Midwifery 30 (2014) e157–e165

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Midwifery journal homepage: www.elsevier.com/midw

The joy at birth: An interpretive hermeneutic literature review Susan Crowther, MSc, BSc, (Hons), RM, RN, PhD Candidate (Senior Lecturer in Midwifery and Caseload Midwife)a,n, Elizabeth Smythe, PhD, RN, RM (Professor)b, Dr Deb Spence, PhD, RN, RM (Senior Lecturer)b a b

AUT University, Auckland, New Zealand School of Health Care Practice, AUT University, Auckland, New Zealand

art ic l e i nf o

a b s t r a c t

Article history: Received 2 August 2013 Received in revised form 18 November 2013 Accepted 19 January 2014

Objectives: this literature review examines the experience of joy at birth and what that joy means. The premise is that the whole of the birthing experience has not been fully explicated in the literature and that something of significance remains unexplored and unspoken. It is argued that a hermeneutic phenomenological approach to reviewing literature provides unique insights and leads to deeper understandings about birth and the experience of joy that attunes at that moment. Methodology: the philosophical underpinnings informed by Heidegger and Gadamer are central to this review and therefore the process of reviewing literature hermeneutically is described. Heideggerian phenomenology is used as the method to ask the questions of the literature in order that concealed and hidden experiences of joy at birth are made visible where they are gleaned from the literature. A hermeneutic lens is used to uncover relationships within the phenomenon of joy at birth and meaning. Findings: although a vast birth literature was reviewed joy at birth was often ignored, hidden or covered over. Reviewing the literature on relationships, professional presence, place of birth, birth satisfaction studies and birth as peak and spiritual experience provides glimpses of the phenomenon ‘joy at birth’. Conclusion: it is argued that joy at birth remains largely neglected as a phenomenon worthy of consideration. Plausible interpretations are presented that suggest that joy at birth points to something significant and meaningful. Spiritual and sacred meaning is alluded to in the papers reviewed yet the majority of papers that investigate birth leave this meaning unspoken. The review highlights a need for further thinking and questioning about birth that would direct on-going investigation. & 2014 Elsevier Ltd. All rights reserved.

Keywords: Attunement Birth Joy Sacred

Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodology of review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reviewing as questioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heidegger's phenomenology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gadamer's hermeneutics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth as satisfying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth as unsatisfying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Being-with-others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professional others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Midwives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Obstetricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

n Correspondence at. AUT University, Department of Midwifery, School Health Care Practice, Faculty of Health and Environmental Studies PB 92006, Auckland, New Zealand. E-mail address: [email protected] (S. Crowther).

http://dx.doi.org/10.1016/j.midw.2014.01.004 0266-6138 & 2014 Elsevier Ltd. All rights reserved.

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Intimate others at birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birthplace and birth space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth as a self-actualising and peak experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological explanations of shared attunements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spiritual experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sacred possibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Introduction Something special attunes at birth that makes the occasion different from other daily experiences. Birth experiences are culturally determined, enmeshed in the context and culture of society (Selin and Stone, 2009; Clarke, 2012; McIntosh, 2012). Thus birth can be viewed as social metaphor reflecting interpretation according to the dominant social context (Crouch and Manderson, 1993). At times this has become confrontational rhetoric. Odent (2002) argued that the industrialisation of society mirrors the industrialisation of human birth; a story of controlling and disturbing. He contends that modern maternity practices serve to disrupt the physiological processes of birth denuding its innate power. Yet, there is danger inherent in a one dimensional way of interpreting birth. It is important to remember that the prevalent western technocratic medical model of birth is only one birth culture amongst many in a vast historical and evolving cultural context. This is not to argue that modern westernised birth approaches are deficient but it raises the question of whether significant aspects (dimensions) of birth are being hidden in the medicalised environment. Birth arouses the imagination and provides a sense of mystery that speaks to us all (Forbes-Rogers, 1966). The unique mood or attunement at birth alludes to something important and perhaps mysterious. Yet the frequently experienced sudden joy at birth is relegated in the scientific birth literature to an occasional passing comment thus silencing the phenomenon. Joy is a word that conjures many unique interpretations: great delight or happiness caused by something exceptionally good or satisfying; it can be a keen pleasure; elation, delight, something greatly valued or appreciated, an expression or display of glad feeling, a state of happiness, felicity and cherished contentment (Parse, 1997; Harrison, 2010). One can feel joy; be glad and rejoice. Joy appears to be a cross cultural phenomenon (Maslow, 1964). This hermeneutic literature review seeks to attune thinking and dialogue to the phenomenon named ‘joy at birth’. In order to attune to this way of reviewing literature examination of methodological notions is essential.

Methodology of review Hermeneutic phenomenological research is suited to childbirth due to its focus on context, lived-experience and surfacing of meaning from such experiences (Thomson et al., 2011; Miles et al., in press). Hermeneutic scholarship requires an interpretive lens and way of attuning that invokes both creative and scientific thinking. This review provides alternative findings and conclusions that challenge readers to think beyond more conventional approaches to literature reviews. Smythe and Spence (2012) argued that ‘Engaging hermeneutically with literature is distinctive’ (p. 23) and different from quantitative and other qualitative reviews. In a hermeneutic review ‘there are few rules to follow; rather a way to be attuned’ (Smythe and Spence, 2012, p. 23). The philosophical underpinnings attune thinking. Interpretive

hermeneutic literature reviewing is not about predicting or providing final definitions through pooling, assembling, summarising findings and critiquing the analyses. Neither is the intention to focus on developing defined themes that lead to a theory. It is more about how one is attuned philosophically as one engages with the literature. Hermeneutic and phenomenological philosophical notions from the works of Heidegger and Gadamer were thus pivotal to this review. Reviewing as questioning To review hermeneutically is to question, remaining engaged and open to what could be revealed; ‘The essence of the question is to open up possibilities and keep them open’ (Gadamer, 1960/ 1975, p. 298). Questions and answers became a dialectical play. Thus, the literature was questioned: what is silenced regarding the mood at birth? What is concealed and unsaid about the joy at birth? How is the joy at birth announced? How is this joy meaningful? Attuning questioning in this way deepened understanding, clarified and sharpened our focus. There is a lot written about birth but little of the joy or the something ‘special’ at birth itself. Reviewing the literature presented the paradox of having so much to read yet only being rewarded with occasional glimpses and rare ‘that is it’ moments. Background taken-for-granted aspects of the phenomenon revealed hidden unspoken meanings within and between words. Searching for the phenomenon of joy at birth in the literature was challenging and required a ‘willingness to be surprised’ (Smythe and Spence, 2012). Heidegger's phenomenology The meaning of a phenomenon is essentially withdrawn and hidden, forgotten, covered up, and even disguised. It lies hidden in the background familiarity of experiences. Thus phenomena remain unintelligible to us in this form. A phenomenon can, however, be partially revealed and made explicit through sustained reflection and questioning. A pre-reflective background can be brought to light and languaged through the process of phenomenological interpretation. Phenomenology is thus a method for uncovering phenomena through a particular approach. Interplay of the Heideggerian notions of withdrawal, appearance, announcement and semblance were integral to the process of this review (Heidegger, 1927/1962). In withdrawal the phenomenon plays hide and seek; at times silenced and leaping out when least expected. In some articles rich descriptions were provided about the lived experience of being at birth that spoke of the shedding of ‘tears’ at the birth of an infant. Yet tears are an appearance of joy, not the joy itself. Appearances can conceal the heart of phenomena while revealing something else on their surface. The tears revealed the phenomenon as ‘appearance’ which is as close to the thing in itself as is possible.

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Some authors attuned to the phenomenon when qualitative data announced birth as joyful: ‘The awe of birth has never diminished…the spirituality of the moment, the tears in my eyes, and the lump in my throat’ (Doherty, 2010, p. 100). Thus the phenomenon of joy was announced in the stories but rarely interpreted further. Another way phenomenon was hidden was through semblance, a façade that seemed to be joy but was not. Semblance is not the whole phenomenon itself; tears for example can represent both joy and grief, or even a mix of both. There is always some hint of semblance in appearances as the heart of appearance does not totally show itself. There was a paucity of literature describing the taken-forgranted everyday doing and experiencing in the world of birth. The back-grounded familiar lived-experience of being-there at birth remained often invisible, withdrawn and silenced. The hermeneutic lens sought to reveal that which was disguised and hidden in this often unnoticed circumspective background at birth. Heidegger's phenomenology is therefore focussed on pointing out the background or familiarity of birth and our understanding/ interpretation of being at birth that seems so distant but is paradoxically so near. The focus of this review was to seek that which lay within and between the words that concealed the phenomenon joy at birth and bring it visibly nearer.

Gadamer's hermeneutics Authors attuned to the same phenomenon become dialogical partners through thinking and raising questions. Hermeneutics explores relationships seeking to reveal hidden meanings of an interconnected world. The primacy of hermeneutic interpretive work is the ability to listen to what is read and prioritise questioning of texts and how they pose questions to us as readers (Gadamer, 2008/1967). Hermeneutic work informed by Gadamer recognises that who and what ‘I am’ is part of the enquiry and plays a significant role in the interpretive process. Preconceptions are always inherent in the process of reviewing literature, contributing historically effective consciousness or past experiences and pre-understandings.

The process The lead researcher (named as ‘me’ and ‘I’ in this section for it was a very personal process) spent long hours in libraries and book shops glancing often in unrelated shelves for a glimpse. I surveyed friends, work colleagues and family book collections. I scrutinised the references used by and suggested by others. Surfing the net for hints of the phenomenon was absorbing. I was constantly noting moments of inspiration that leapt out. The search became endless. Some articles inclined towards ‘me’ as ‘I’ inclined towards them provoking more thinking (Smythe and Spence, 2012). There were articles and books that intrigued me, pulled me in repeatedly as I exclaimed ‘yes that is it!’ Conversely some papers left me bereft ‘Tell me what is really going on – what does this mean?’ The process over years, generated a vastness of data. The review journeyed from the most prevalent and dominant notions in the literature to a narrowing of focus that comes closer to the phenomenon sought. It examined birth satisfaction studies and the influence and experience of others at birth. The influence of birth location and distinguishing between space and the place where an infant is born was explored. The review included descriptions of peak experiences, self-actualisation, spiritual and sacred experiences at birth. Finally, possible meanings of the birth

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experiences evident in the literature were examined through asking further questions. The phenomenon of joy at birth is always in a dialectical play between whole and part understandings, yet to begin a hermeneutic enquiry a place of departure is required. I started with the assumption that there may be a link between ‘joy’ and ‘birth satisfaction’. Birth as satisfying The literature on satisfaction spans several decades but the precise way of measuring and assessing experience of satisfaction continues to elude. Britton (2012) examined factors that influence satisfaction at birth and how these are measured. The variables chosen to measure satisfaction reduced the lived-experience of birth to produce standardised results. Psychometric scales and quantifiable questionnaires were employed to measure birth satisfaction (Martin and Fleming, 2011; Larsson et al., 2011) leaving much of the experience unexplored or silenced. Most birth satisfaction research focuses on negative experiences and the interventions that mitigate such experiences. However measuring and assessing ideal birth or positive birth is context driven, multidimensional and always influenced by the differing expectations, beliefs and responses of those involved at birth (Christiaens and Bracke, 2009; Martin and Fleming, 2011; Sawyer et al., 2011). Cultural and ethnic influences are seldom evident in satisfaction surveys and, as would be expected, there were times when birth was not satisfying. Birth as unsatisfying At times the literature revealed both grief and joy. The birth of an infant is usually expected to bring joy and happiness and be a defining moment in women's and families' lives, yet it is also a time of unhappiness, hardship, distress and fear of harm (Sawyer et al., 2011). Negative experiences at birth were multifaceted. How women attuned at the moment of birth in adverse situations remains unclear. Nilsson et al. (2012) longitudinal study highlighted how women's perception of negative birth experience explained subsequent fear of childbirth more than mode of childbirth. Harris and Ayers (2012) found that interpersonal difficulties and complications with the neonate increased the chances of developing postnatal emotional and psychological morbidity. Yet the association with intervention and negative experience also remains unclear. There are assumptions that traumatic births decrease satisfaction. Care giver support and attitude is often highlighted as contributing more to increased satisfaction than exposure to obstetric interventions. Størksen et al. (2013) found previous subjective negative birth experiences had greater influence over perception of the experience than obstetric interventions alone. In other words it was fear of birth, not interventions that influenced future fears associated with birth. They found that the majority of women experiencing interventions did not report overall lack of satisfaction with the birth. Harris and Ayers (2012) concluded that reducing interpersonal difficulties, providing support and reassurance lessened traumatically experienced births. It is now well established that continuity of care provided in labour and birth enhances satisfaction (Hodnett et al., 2011). Trusting relational continuity has been found to enhance positive birth experiences that can also potentially open the possibility of family empowerment (Hunter et al., 2008; Halldorsdottir and Karlsdottir, 2011; Dahlberg and Aune, 2013). Experience of joy at birth in these papers was not reported. Interpretations of satisfaction of births were based solely on the influences of interventions and midwife presence.

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Emotional morbidity following unsatisfactory birth experiences has been repeatedly demonstrated (Creedy et al., 2000; Blom et al., 2010). Yet it remains unclear in the literature whether technology and interventions alone disrupt the joyful atmosphere at birth or if attitude of care affects atmosphere. Kirkham pointed to the distinction between technology and technical care. She argues that care is connected to relationships: The privileging of technology over care is evident throughout health care and much of the discourse of modern nursing and midwifery demonstrates how status comes with technical rather than caring work. If time is limited, it is the technical rather than the caring work which must be done. (Kirkham, 2009) It would seem counter intuitive to believe that interventions and others there at birth do not attune to birth in a particular way. Can interventions and others at birth prevent the experience of joy at birth? Perhaps technology covers some things up but paradoxically reveals others. Perhaps a dysfunctional or unknown relationship at birth similarly both covers up and reveals something at birth. Emotional response to unsatisfactory experiences at birth can provide opportunity to see what is often covered up when things go smoothly (Crowther et al., in press). These distinctions are not explicit in the literature on satisfaction and joy at birth remains unspoken and silenced. Being-with-others Being-with-others at birth emerged strongly in the literature as impacting the mood at birth. Although models and theories of midwifery care have been explored in depth (Pairman, 2010; Halldorsdottir and Karlsdottir, 2011; MacLellan, 2011; Berg et al., 2012) they do not reveal the experience of birth mood itself when midwives were present or absent. Reciprocal relationships between women and midwives seem key to the atmosphere at birth in the literature (Berg et al., 2012). Berg et al. define reciprocity as presence, affirmation, availability and participation and argue that positively construed reciprocal relationships with others at birth can safeguard the birthing atmosphere. The notion of atmosphere, interpreted as attunement, is thus disclosed as something worthy of protection. To safeguard something implies that there is something to safeguard. Hunter et al. (2008) also argued that it was the quality of relationships that was central to birth ‘the warp threads that hold it all together, but which are hidden in the final work’ (p. 136). Although an atmosphere at birth is glimpsed the moment of joy at birth continued to be poorly seen and understood. If relationships with others at birth are fundamental then how are ‘others’ faring at birth? They too experience something and are attuned at birth. Do their experiences reveal more of the phenomenon of joy at birth? Professional others Other literature focuses on the notion of good midwife/bad midwife (Powell Kennedy et al., 2010), good doctor/bad doctor dichotomies (Odent, 2008). Doctors are sometimes portrayed as perpetrators of violence (Kitzinger, 2006) whereas midwives are often viewed more positively but are still part of a hegemonic system. In contrast non-institutionally connected doulas are presented as providing better outcomes (Hunter, 2012). These of course are improbable generalisations. The point is there are ‘others’ at birth. ‘Others’ are often called to birth for different reasons and are significant to the gathering. Their various labels serve to cover up what is happening in the uniqueness of human encounter at each birth experience.

Midwives Examining times of breakdown at birth provides potential to reveal how midwives attune at birth. Midwives can experience emotional stress as they attempt to straddle two opposing ideologies; biomedical model versus a physiological and social model (Davis and Walker, 2011; Rice and Warland, 2013). McCourt and Stevens (2009) found that reciprocity between the mother and midwife increased job satisfaction and decreased stress in midwifery. Conversely Rice and Warland (2013) found that distress in midwives was magnified by their sensitivity to events unfolding and empathy for the mother. Rice and Warland described how a shared attunement arises at birth revealing that midwives are not separate from others at birth. Midwives participating in their study appeared to vicariously attune to the traumatisation. The authors connected this to potential burnout, job retention and satisfaction and emotional exhaustion. If this emotional work threatens reciprocal relationships does attuning at birth become more difficult? Deery (2009) argued that the emotional work of midwives can adversely affect their ability to be there fully in their work. These papers reveal the notion of shared communication at birth through attunement yet the potential for shared joy at birth remains hidden. The focus is on breakdown and distress not on the joy itself. For there to be a breakdown in something there has to be a mode that works well that can breakdown. A pre-reflective taken-for-granted familiar mood in the background at birth remains unreported and thus left silenced.

Obstetricians There is a paucity of literature about the lived-experience of obstetricians at birth. Yoon et al. (2010) reported links between obstetrician burnout due to emotional exhaustion and continual clinical decision making. Interestingly another study highlighted the lack of personal connection with women as strongly correlated to obstetrician emotional exhaustion, burnout and depression (Govardhan et al., 2012). Lack of personal connection with recipients in their care coupled with professional responsibility and workload demands reduced job satisfaction. Scully (1994) used the term ‘distancing’, to describe the phenomenon by which obstetricians become detached from the affective aspects of birth. However the work of obstetricians is unique at birth; their experience tempered by their professional focus. Often obstetricians hold beliefs of birth as potentially unsafe until proven to be normal in retrospect (Lokugamage, 2011). They are constantly called to emergencies and problems requiring medical intervention. Thus their worldview could be construed as significantly different from midwives. They are rarely focused on building reciprocal relationships unless in private practice. Their risk-averse professional experience would appear less attuned to the joy at birth. What are obstetrician's livedexperiences at the moment of birth? How obstetricians attune at birth remains largely absent in the literature except for one recently published paper from our own study in which obstetricians tell of how special being at birth can be (Crowther et al., in press).

Intimate others at birth How others attune can influence the mood at birth overall. However, it was not the remit of this review to focus on the merits and rationale of intimate others at birth but rather to explore the literature for evidence of experiences of joy at birth. The presence of fathers at birth has become more common in western birthing yet their experiences in the birthing room have only been

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researched in the last decade. The reported experiences have not always been positive or healthy. Father's experiences have been shown to range from feelings of distress to wonder, some even leading to post traumatic stress disorder symptoms (Dellman, 2004; White, 2007). KunjappyClifton (2007) identified themes of fear, disempowerment and helplessness amongst fathers at birth. The intense emotional responses can be connected with mode of birth and care giver attitudes (Johansson et al., 2012). It appeared that fathers were experiencing a roller coaster of overwhelming emotions and attuning at birth somehow in ‘an interwoven process pendulating between euphoria and agony’ (Premberg et al., 2011). Johansson et al. (2012) found that most fathers experienced birth as positive despite the uncertainties and challenges. The degree of satisfaction with birth was also found to be age related (Schytt and Bergström, 2014). Yet at the moment of birth Premberg et al. (2011) found fathers experienced an avalanche of emotions with tears of joy and happiness that was mutually shared with the mother. Fathers appeared to experience a shared joyful attunement at the moment of birth. However such tears are not necessarily joy itself; they could also be a semblance of something else such as sheer relief. The tears nevertheless reveal an unfolding of something significant that fathers may experience. Longworth and Kingdon's (2011) phenomenological study captured the experience of joy at the moment of birth, ‘It was like everything! It was just relief, joy… everything!’, ‘…it was pure joy, didn't know whether to laugh or cry’ (p. 591). Perhaps surprisingly this effusive joy announced itself despite the circumstances of labour and birth. The male stoic façade was difficult to maintain at the intensity of the moment (Premberg et al., 2011). In Lahood's (2006) study a father described birth as ‘the most amazing experience I have ever had…I cried for the first time in years’ (p. 39). How fathers experience the moment of birth has begun to be revealed. Single sex couples and non-gestational parents are also experiencing being at birth from differing perspectives and concerns (Bergum and Van Der Zalm, 2007; Goldberg et al., 2011). For example a non-gestational lesbian mother speaks of her joy: ‘I was there for the whole thing, right by the midwife, and it was a miracle, seeing him born … and thinking that he was ours’ (Renaud, 2007). We also recognise there are emotional experiences of surrogate mothers; another complex perspective (Teman, 2010), as well as other intimate others including friends, siblings of the mother and/or infant, grandmothers and other relations. Yet the effect intimate others have on the attunement at birth was poorly shown overall. Like mothers and health care professionals, intimate others are attuned somehow at birth. Is birth a shared experience with everyone gathered? The next aspect of birth explored in the literature was where birth takes place and whether this contributes to the joy at birth. Distinctions between birth places (physical locations) and the notion of birth space are evident in the literature. Birthplace and birth space Birth place is referred to in terms of physical structures such as personal residence, hospital or birth centre. The notion of birth space or atmosphere is the feeling dimension of place, an attuned space not necessarily connected to physical places. Berg et al.'s (2012) model of midwifery was the first where the notion of atmosphere at birth is explicitly included. Berg's model speaks of radiating calmness, quiet presence, trust, sense of safety and support for normalcy. These attributes overlap with reciprocal relationships and personal and professional knowledge that is grounded and embodied. The midwives in Berg's study attuned to a sense of coherence and meaningfulness. They promoted a

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birthing atmosphere balancing between competing ideologies. The midwives sought to create a sympathetic space to birth that promoted a sense of homeliness and familiarity. Initial engagement with women at birth has been revealed as something worthy of consideration pointing to special ways midwifery presence attunes (Goldberg, 2005). Yet how maternity institutions enables or constrains midwifery presence at birth has been questioned (MacKinnon et al., 2005). Place of birth has been shown to be an aspect of what makes for a positive birth experience (Hodnett et al., 2009; Foureur et al., 2010; Laurel Merg and Carmoney, 2012). Public hospitals are accused of perpetuating the industrial model vanquishing the intimate social nature of birth (Walsh, 2006; Walsh, 2007). Davis (2010) examining what keeps birth normal found that the hospital environment often determined how birth was managed. Davis (2010) found that the place in which birth occurs is often influenced by the discursive spaces that influence ways of being and behaviour. Places and spaces can play out polarising ideologies yet tell nothing of how those at the moment of birth attune. It is plausible that birth space can be full of fear and feel impersonal. Smythe et al. (2014) described how a New Zealand rural birthing centre worked to honour birth as amazing and safe creating a birth space that is positively filled. This is congruent with Bergum's (2007) hermeneutic phenomenological findings on how there is a relational engagement at birth which included all there at birth and extended to feelings of connection with the environment. Yet how birth attunes in varying locations remains unclear. Is there less joy at the moment of birth in a highly technological hospital than in a birth centre or home birth setting? Arguably how others are attuned within this space influences satisfaction with the experience at birth. There have been many attempts to improve institutional birth environments and make them more gentle and welcoming (Gaskin, 1977; Leboyer, 1991). Changes to ambient environment in hospitals demonstrated a reduction in medical interventions (Hodnett et al., 2009), but the mood at birth remained withdrawn. The place of birth was often related to safety concerns and the reassurance of being in the security of technological environments (Bedwell et al., 2011). This raises questions. Does this reveal a common attunement of anxiety and mistrust in nature or desire to control a biological process? Does the concrete environment and use of technology matter to attunement at the moment of birth? How birth attunes those there in varying locations remains hidden. Does the attuning of those there at birth open a joyful space regardless of the physical birth place? The mood of maternity institutions and how they are managed has been examined. Hunter and Deery (2009) discuss the ways in which individuals and managers can influence the tone of institutions and organisations. Volmer (2012) advised managers to be aware of their own mood because emotional contagion affects the tone of the workspace. She argued strongly that positive moods create positive affective states in the workforce. Do the working patterns of maternity health care providers facilitate positively attuned spaces at the moment of birth? Workloads and increasing acuity were found to place demands on Australian midwives adversely influencing their affective wellbeing and attitudes to work (Paterson et al., 2010). The notion of emotional contagion and institutional attunement thus points again to shared mood or atmosphere yet something ineffable at that moment of birth continues to be unmentioned. The experience of being at birth as extraordinary and meaningful remained hidden. Birth as a self-actualising and peak experience The notion of ideal joyful birth in the literature involves an experience of self-actualisation and/or peak experience connected

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to a meaning central to birth itself (Fahy et al., 2008; Hall, 2010; Parratt, 2010; Thomson, 2010). Birth as rite of passage is also described as a powerful self-actualising experience manifesting an array of deepening insights (Cheyney, 2011; Lokugamage, 2011). Birth often provides fulfilment of purpose for women. Schneider (2012) described women as bearers of miracles with a deepened sense of unity with others especially women. Maslow (1964) coined the term ‘peak experience’ as moments of joy in everyday experience. Peak experiences do not have a lineal progression as the movement to self-actualisation does. This is a key distinction. They appear to have the capacity to catapult one into different awareness recognisable to self and others. Described as the happiest moments in life, peak experiences have been found to involve a shared joy wherein individual experiences unify with others (Hoffman et al., 2012). This again points to the potential for a shared quality of mood at birth. Maslow was concerned with how peak experiences opened perception to layers of reality not normally experienced. He found that peak experience was common around the world and at different times. This is akin to Heidegger's notion of shared attunement in which experience is revealed and understood through attuned mood. Heidegger (1927/1962) contended that understanding is always attuned somehow and that attunement is a shared phenomenon of our being together. The literature is beginning to reveal biological explanations for this shared phenomenon. Biological explanations of shared attunements The emerging science in neurophysiology regarding mirror neurons and empathy provided physical evidence of shared encounters (Häusser, 2012; Oztop et al., 2013). In childbirth, neuro-hormonal processes have been shown to influence affective states for the mother at birth producing ecstatic and peak experiences (Buckley, 2005; Dixon, 2011). Yet for Maslow how a person arrived at peak experiences is secondary to what is revealed as deeper knowing when experienced. This distinction highlights the repeated call to return to the experience and note the ontological differences. In phenomenology brain imaging and behavioural testing do not reveal the experience itself. Neither do the biological explanations give voice to these experiences as meaningful. The moment of birth would appear to harbour an excess of meaning that is barely glimpsed in westernised maternity services. Spiritual experiences The experience of attuning at birth would seem to open to spiritual and sacred possibilities. ‘Spirituality is a personal search for meaning and purpose in life, which may or may not be related to religion’ (Tanyi, 2002). Tanyi's definition reminds us of significant distinctions between religion and spirituality. There is little scientific literature that addresses this aspect of birth. Although non-rational non-dichotomous experiences are often unexplainable they may paradoxically be the most meaningful and important. Childbirth as a spiritual meaningful experience is evident in the literature (Hall, 2012). The atmosphere or attunement at birth as spiritual or sacred atmosphere at birth is beginning to be recognised and acknowledged. Midwives have described their spiritual experience at birth, ‘… the awe of birth has never diminished…Birth never ceases to amaze me. The spirituality of the moment, the tears in my eyes, the lump in my throat, and the prayer of thanksgiving are always there for me’ (Doherty, 2010). In Linhares's (2012) study midwives also announced birth as spiritual, ‘The spiritual experience of birth

is seeing that baby crown and emerge, and start crying…that is the most spiritual moment to me’ (p. 169). Midwives in these studies unsurprisingly speak of ways of enhancing the spiritual quality at birth such as relationships, environment and attitudes. There is a sense of connective knowing that grows as reciprocal trusting relationships are formed. The midwives all acknowledged spirituality at birth as opening possibilities for harmony, trust and love in the families with whom they worked. In addition some of the literature pointed to a sense of ‘other’ as constitutive of the experience of being at birth that further enriched the atmosphere. Ólafsdóttir (2009) found that some Icelandic midwives felt the presence of ‘other’ providing inner strength, of ‘not being alone’ (p. 196). She highlighted an inner knowing learned through being present with women. The notion of inner or intuitive knowing surfaced in the midwife stories as attuned ways of being at birth, ‘…the wholeness of the experience of inner knowing…appears not so much in words as in atmosphere’. One midwife described how the power of birth changed atmosphere, ‘she can sense if the baby has already been born when she arrives, as the home changes’ (p. 206). Something significant fills or opens the space in and around birth as attunement at birth begins to be revealed. These experiences were also reported by mothers. Gray (2011) found mothers experienced joy at birth and a connection to a sense of an unknown past stretching back in time. The same study reported that even following a caesarean section a woman reported awe filled spiritual experiences. The joy at birth, even in times of intervention, is a recurring theme (Thomson, 2011; Crowther et al., in press). The overwhelming nature of the moment invoked physical responses despite birth circumstances in Gray's study: ‘It made me cry, simply the miracle of it’. One woman in Lahood's study described a peak experience at birth as ‘the ultimate spiritual orgasm’ (2006). Spiritual experiences at birth are evident across cultures. ClarkCallister and Khalaf's (2010) review of anthropological studies reported birth as sacred and spiritually transforming experience rich in meaning. Some women connected deeply with their religious beliefs. A mother recalls, ‘…right as she [baby] was born… It felt honestly like a moment frozen…it was one of those moments when the spirit is there’ (p. 18). Another woman recalls the mood ‘…there was something holy around me, something beyond the ordinary, a feeling, a spirit about being part of God's creation of a child’ (p. 18). The attunement at birth is made present through these mother's stories. The experiences were also across genders. Fathers in Lahood's (2006) study spoke of spiritual experiences at birth ‘I would put it on par with a spiritual experience where your mind stays out of your body’. However little was found that revealed the spiritual experience of obstetricians at birth other than the Crowther et al. (in press) study. The voices of obstetricians remain unheard. Sacred possibilities A sacred experience at birth stirs at the edge of the unspeakable in the literature. Something extraordinary is happening at the moment of birth. Everyday life can become something sacred. Sacred experience is based in reverence, in awe and love for creation, valuing it for its own sake, in its own right as a living presence. It is based in the emotions – zest, joy, passion – that help life process flow as opposed to the stuck unexpressed emotions that may distort experience (Reason, 1993). Does a biomedical technocratic orientation to birth hold the birth experience in reverence? Does the contemporary model of western birthing turn from the spiritual and sacred attunement at birth obstructing the flow of life's process? The moment of birth appears to provide an opportunity for a peak joyful experience.

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Gaskin (2011) speaks of birth as sacred; that the experience is special and that those involved need to attune in the right way. Can such a special experience open a moment of vision revealing meaning and purpose to life? Leboyer (1991) described such a mood, ‘Birth may be a matter of a moment. But it is a unique one’ (p. 99). Yet the sacred moment at birth when joy attunes for all those present remains largely unannounced and invisible.

Discussion The whole truth about birth has not been understood. Truth is not mere agreement or/and correctness but an unconcealment of what lies hidden, covered up and forgotten (Heidegger, 1927/ 1962). The papers have indeed revealed something of the joy and sense of sacredness in and around birth but they have also allowed the phenomenon of joy to withdraw or be silenced. Some parts of phenomenon always remain hidden that is phenomenon's nature. We argue that although the joy at birth remains hidden in many papers it is not because we have not yet discovered it or have simply forgotten it but because it is too close and familiar for us to notice it. It has been taken-for-granted within maternity service protocols and institutions, tradition and cultural interpretations of birth as risky and fearful. This may be obscuring the mystery of what birth ‘is’ by reducing it to aspects that are visible and measurable. Biological and scientific explanations add to the epistemological understanding at birth but provide little insight into how joy is experienced and understood or how it is meaningful. Parts of the phenomenon, such as relationships and place of birth, have been examined but the whole remains unknown. The nearest and most familiar dimensions are thus overlooked. There are dichotomised and polarised themes in the literature. Authors' research questions, methodology and interpretation of findings always arise from their unique historical and traditional perspectives. These preconceptions are not often made explicit in published work. The historicity of researchers and writers remained hidden or only partially seen. This omission in the literature treats birth as an object for investigation and denies the value of context that includes the pre-understandings of investigators. Most authors remained invisible in the literature so that their findings and possible alternate plausible conclusions remained partially hidden. Some papers focus on the special mood at birth more than others. To bring experience and feelings to words was minimal in most cases. Often it was only a quote, a conclusion or way of drawing a reader into the significance of birth. The joy although glimpsed was not explored and the meaning of that joy at best left superficially interpreted. There was a sense that joy at birth is a cliché that does not require further exploration. How the joy was experienced and how it was meaningful remains silenced. Often papers spoke of creating the experience through actions such as place of birth, relationships, professional expertise and education. There was a sense that joy at birth could somehow be manufactured. Yet from personal experiences, joy at birth seems far more than is currently visible in the literature, and beyond anything that could be engineered. Questions remain: Is it possible to create joyfully attuned birth experiences? Are purposeful mood interventions worthwhile? Some literature pointed to sacred experiences at birth that were ineffable, transformative and significant. Yet spiritual significance at the moment of birth was often hidden in political rhetoric and polarised, dichotomised accounts of positive and negative experiences. Addressing spiritual dimensions and acknowledging birth as a shared sacred experience allude to another way of being at birth. The experience of joy at birth as a shared phenomenon has not been adequately researched. The

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ontological implications at the moment of birth have largely been left unspoken and await our engaged thoughtfulness. This review journeyed from the epistemological understandings of birth towards an ontological understanding of joy at birth. It was not about winning an argument or proving others wrong. The intention was to review the literature in search of experience and meaning. The purpose was to invoke thinking and open a dialogue. It can be argued that the process of this review is subject to bias that supports our view of the world, one which yearns to protect and preserve whatever joy emerges. Yet leaving aside presuppositions of authors, past and present history, culture and life experience is not possible. They come with us and are inherent in all human endeavours. In addition it is likely that using a more conventional systematic methodological approach would have led to different literature being reviewed and altered interpretive findings. The question posed to the literature demanded an approach that was orientated to interpretive analysis more than critique. The task was to engage with published literature in order to present plausible interpretations revealing the phenomenon joy at birth while acknowledging that any phenomenon can never be fully revealed (Heidegger, 1927/1962). The possibility of every birth being significant and joyous would seem to be important. How we attune at birth and the meaning that holds for human beings has important consequences related to the well-being of all those involved and will help reconnect with the meaning that birth has collectively. This raises questions. Has something of experiential importance become conspicuously absent in daily western maternity practice? Have the reviewed papers provided evidence of a special joy at birth? Have birthing practices become increasingly secular, if so what does this mean? There is a need to explore and clearly articulate the hidden yet significant experiential aspects of birth beyond the type, place and outcome of birth alone. We contend that joy at birth is constitutive of the shared birth experience as a whole and provides opportunity for greater professional sensitivity and tact at the moment of birth. What would be the effect of joyless birth for all involved including the newborn? Beginning parenthood with joy would perhaps nurture the beginnings of positively attuned parenthood and have future outcomes yet to be realised and known. Making visible and addressing joy at birth may optimise and benefit the health and well-being of all those at birth physiologically, psychologically and spiritually in ways not yet understood. It is possible that the quality of personal relationships for all would benefit from more positively attuned and meaningful birth experiences. Fuller understanding of the experience at the moment of birth and acknowledgement of its significance and meaning may have important consequences. This requires further investigation.

Conclusion This literature review began with as a call to seek out the meaning and experience of joy at birth remembering that ‘… sacred inquiry will start with awe and love rather than suspicion, scepticism’ (Reason, 1993, p. 278). The challenge in a world of scientific certainties is to remain openly attuned to possible forgotten understandings and embrace the sacred dialectical nature of birth. Use of an interpretive hermeneutic approach was able to reveal gaps in the scientific literature related to the notion of shared attuned joy at birth. Many of the papers reviewed provide glimpses of a mood at birth signalling its presence and possibility. Such a search is never complete. It is ‘not definitive… not all-encompassing’ (Smythe and Spence, 2012, p. 14). Previously reviewed articles will, in future readings, reveal other understandings and interpretations, with different questions arising

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from changing horizons. Joy in the lived-experience at the moment of birth attunes, inspires, beckons, and invites us to respond. To bring this usually silenced and little understood phenomenon to language will prove eternally insufficient, yet the quest in itself begins to safeguard that which is precious.

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