The use of an egalitarian paradigm in a qualitative research project entitled midwifery practice in the third stage of labour
Tina Harris
Paper presented at the Qualitative Evidence-based Practice Conference, Taking a Critical Stance. Coventry University, May 14-16 2001
Introduction
Slide 1
My presentation focuses on the use of an egalitarian paradigm in a qualitative research project entitled “Midwifery Practice in the third stage of labour”. It sounds a bit of a mouth full doesn’t it? Essentially I want to share with you the difficulties I have had fitting my research project into an existing qualitative research paradigm and the decision I came to in adopting a pluralistic approach based on the requirements of the project and my beliefs as a researcher.
1. Introduction to study
Slide 2
The third stage of labour is defined as the period of time from the birth of the baby until the placenta and membranes are delivered (Morrin 1997). During this time the midwife is concerned with at least three things:
· The baby’s adaptation to extra uterine life
· The first and important meeting between mother and child
and
· Ensuring completion of the childbirth process with delivery of the afterbirth.
It is this last aspect that I have been particularly interested in as Midwives can adopt a number of approaches when managing delivery of the placenta and membranes.
Whilst I am not going to talk in detail about the research, I thought it would be useful to share with you how I became interested in the third stage of labour and the essence of the research.
Slide 3
As you may know, there are two universally accepted ways of managing the third stage of labour Enkin et al (2000). An active approach which normally includes clamping and cutting the umbilical cord, giving a drug to make the uterus contract and then the midwife pulling the placenta out of the uterus by cord traction. The alternative is an expectant approach where the woman is not subjected to any of the above interventions, but births her placenta naturally usually by standing up, giving a little push and the placenta falling out.
Slide 4
Now over the last fifty years active management with drugs and cord traction has become the treatment of choice (Garcia and Garforth 1989) as it is said to reduce the risk of excessive bleeding in the woman (Enkin et al 2000). As in many other aspects of practice, this intervention became popular based on recommendation rather than upon research findings and it was not until active management was firmly entrenched in practice within the UK that comparative studies sought to provide scientific evidence of its superiority.
In the last fifteen years there have been a number of large randomised trials namely in Bristol, Dublin and Hinchingbrook (Prendiville et al 1988, Begley 1990, Rogers et al 1998). Their results all point to reduced blood loss in women having active management compared to the expectant approach, though some side effects of the treatment have been noted. Whilst this evidence appears conclusive, there has been significant critique of these studies (Gyte 1994, Harris 2001) and midwives continue to question whether active management is appropriate for all women experiencing normal birth (WHO 1999, Harris 2001).
Whilst I have followed the active versus expectant management debate with interest, the emphasis for my study has been on variation in practice within these two approaches. This has stemmed from my personal experiences in practice and comments made to me by students. Personally I became aware of differences between my practice and other midwives ways of practising in relation to the third stage of labour. I was also told by students (first here in Coventry) that midwives practised in a variety of different ways during the third stage and their role as students was to adapt to the practice of the midwife with whom they were currently working.
I then began to think. If there was such variation in practice how reliable and valid were the results of the published comparative studies. How can two forms of care be compared when there may in fact be ten or twenty or thirty ways of managing the third stage of labour? I also began to question how this variation in practice had evolved. And so the project was devised.
3. Project aims What I set out to do
The project aims were as follows:
Slide 5
· To identify and explain the variety of ways midwives manage the third stage of labour
· To see if there were characteristics associated with different third stage management practices
· To identify and explain models of midwifery care in labour
· and
· To identify and explain how midwives develop expertise in managing the third stage.
In simple terms I was interested in:
Slide 6
What are we doing? Where does that practice come from? and why are we doing it?
2. Choosing positivism or subjectivism - Starting the project
So I began to look for a research approach that would meet the needs of the project.
At this time I was a relatively newly qualified midwife teacher with to be honest a rather superficial understanding of research methodology. Whilst I had a working knowledge of quantitative and qualitative research, I had never studied the underlying principles on which these approaches were based. This came in the first year of my PhD when I took some research methodology courses and learnt about the philosophical underpinnings of the various traditions and the dominance of positivism within health care research. So I began to see the need to align myself with a research paradigm on which values and beliefs the research project would be based, and which would guide the way I designed and carried out collection and analysis of data. Kuhn defines a paradigm as
Slide 7
“A set of beliefs, values and techniques which is shared by members of a scientific community and which act as a guide or map dictating the kinds of problems scientists should address and the types of explanations that are acceptable to them”
(Kuhn 1970:175).
Sarantakos (1998) suggests that that there is no complete agreement about the use of this term and though the definition given here is widely accepted it can be interpreted broadly
Slide 8
(as in referring to any of a number of approaches (phenomenology, symbolic interactionism, feminism, postmodernism, ethnography, critical realism) or narrowly (referring to only 2 perspectives: the positivist and postpositivist schools of thought). As a result for some researchers there are as many paradigms as there are groups of like-thinking individuals, whilst others use this concept to describe the major theoretical directions in the social sciences. For the novice researcher, and I count myself as one, this is where things get rather confusing. Taking the narrow definition of a paradigm it seems relatively easy. I can adopt one of two ways of researching. Slide 9
The positivist perspective based upon principles of following a defined set of rules and regulations to collect quantifiable data from an objective standpoint seeking to explain behaviour based upon universal laws or principles (Streubert and Carpenter 1995, Sarantakos 1998). Or I can use the post positivist or subjectivist approach which offers the opportunity to find answers to questions that centre on social experience, how it is created, and how it gives meaning to human life (Streubert and Carpenter 1995, Denzin and Lincoln 1994). The approach emphasises the subjective experience within a social context. Accordingly quantitative methodology is associated with the positivist school and qualitative with the subjectivist approach. Whilst I struggled a little with the suggested polarity of these two philosophical standpoints when comparing the two it became apparent that this project would best be explored from within the subjectivist school which most clearly met the perspective I wished to adopt as a researcher. Whilst a positivist approach could be adopted elsewhere, to explore the lived experience of midwives during the third stage of labour, I needed a subjective approach which explored holistically, the multiple realities of participants within a social context. I did not want to test a predetermined hypothesis and seek to explain behaviour through a cause and effect relationship. I wanted to understand the processes of a midwife’s decision making in third stage events through the exploration of the individual and unique.
So I chose an approach – one which lies within the subjectivist paradigm based upon a qualitative methodology. Simple. Well, not quite.
3. Choosing between subjectivist paradigms
If we adopt a broad interpretation of the word paradigm a new researcher then has to tip toe through the plethora of approaches within the subjectivist tradition and choose one. And that for me, was a difficult task. Having accepted that I had found it difficult to choose between two apparently diverse approaches, to choose between approaches which shared similar values and beliefs was challenging to say the least.
Initially I plumped for an ethnographic approach (Hammersley and Atkinson 1983, Spradley 1980),
Slide 10
the intention being to explore the culture of midwifery through discussions surrounding the third stage of labour. Using multiple methods of data collection: interviews, observation, and field notes, I wanted to create a picture of the third stage through the eyes of midwives and generate theory from the data to develop understanding as to why midwives make the choices that they do.
Slide 11
However, whilst some of the principles of ethnography were ideally suited to the exploration of midwifery practice in the third stage, such as the use of multiple data collection tools, looking holistically at practice within context, I could not collect data by living within the confines of a delivery suite for a protracted period of time. I only had one research day per week. Also whilst ethnography wishes to understand people in their social environment, the emphasis is on description of culture, when the focus for my study was on understanding how midwives practice within the culture of midwifery rather than the culture itself. Also I struggled with the concept of entering the research field without any preconceived ideas about what I might find. I was a midwife with a number of years experience in midwifery. I already had an idea of what I might find ie variation in practice, though no understanding of where it originated. In addition whilst I valued the concept of objectivity to a point, and avoiding the principle of “going native”, as a midwife exploring midwifery practice I felt that my contribution to interpretation and analysis of data would essentially create a unique picture where I played a key role. And so I came to realise that ethnography did not fit.
To be honest I did not wholly come to this decision myself, but was guided by my research supervisors. When you think you have everything clearly worked out and you think you know where you are going, it’s a hard lesson to be told that what you thought you were doing was not in fact the case.
And so having already developed a fairly clear picture of what I wanted to do and how I wanted to do it, I had to seek out a paradigm that would help to illuminate why midwives practised in the way they did during the third stage of labour.
I reviewed a number of paradigms and in fact continue to in the hope that one day I can say, yes that approach will fit what I am seeking to achieve, an understanding of midwifery practice But no single paradigm offered this. And so l took a leap of faith. I could clearly identify where I was coming from philosophically and how I wanted to conduct the research process based upon the aims of the project. Whilst my approach did not fit neatly into one paradigm it was underpinned by the subjectivist tradition
as outlined here
Slide 12
Values of subjectivism
· Belief in multiple realities
· Commitment to identify approach to understanding that will support phenomen being studied
· Commitment to participants point of view
· Conduct of inquiry that does not disturb the natural context of the phenomena of interest
· Acknowledged participation of researcher in research
· Conveyance of understanding of phenomena by reporting in a literary style rich with participant commentary
and the approach I adopted was one drawn from a number of existing paradigms. Therefore I created my own pluralistic approach, which for want of a better word I called “egalitarian”. I did not want to create another paradigm as such, one which everyone would follow to the letter. I wanted to draw attention to the fact that as a practitioner investigating practice within a social context, I felt confined by following the guidelines of one specific paradigm and that by choosing elements from paradigms within subjectivism may enhance the scope of the project to achieve its goals.
So what does this paradigm look like?
6. What the project look like
Slide 13
I wanted to explore the richness and diversity of midwifery practice in the third stage of labour using a qualitative approach where my role as a midwife researcher is acknowledged and plays a unique role in the collection and analysis of data. I recognise that there is no single reality but reality is context and time based and influenced by the researcher. I want to seek to provide an enhanced understanding of midwifery practice at this point in time in this context. The flexible nature of the approach will allow me to explore new and interesting avenues as they emerge rather than being restricted by setting out what I intend to do at the outset. To this end I will use purposive sampling and complete data collection when saturation has been achieved. Whilst I plan to generate theory from the data, I am seeking to identify commonalities rather than being prescriptive about how practice is derived. However I am not conducting this project only for the experience of researching, but to provide midwives with new knowledge about what they do during the third stage of labour and why they do it. So that this can inform practice development and add to the debate about how the third stage of labour should be managed. In addition by exploring with midwives their practice it is hoped to give individuals the opportunity to reflect and see their practice in a different light based upon a deeper understanding of their own decision making process and on what this is based.