All interviews were audio recorded and transcribed in full by the Research Assistant and myself. The Research Assistant, who was fluent in speaking and writing the local languages, transcribed the interviews with community women, which were conducted in regional languages other than Urdu. After the Research Assistant completed the transcription in Urdu, I reviewed the transcript together with the Research Assistant to ensure there were no errors in the verbatim transcription. The Research Assistant transcribed six out of 20 health workers’ interviews, which were in Urdu, and then I rechecked the transcripts against the audio recording to ensure accuracy. I transcribed the remaining health workers’ and key informants’ interviews.
Survey data was manually entered into MS Excel and all entries were double- checked at the time of data entry. Ten percent of the surveys entered were randomly- checked for inaccuracies, and missing values and coding errors were corrected as needed. The cleaned data set was stored as a master file on a Deakin University server and data analysis was performed on the copies of data sets. The final data analyses were conducted using Stata 14.0 software (283) and open-ended responses were entered in a Word document and were analysed as qualitative data.
88 2.9.1 Data analysis
In a mixed-methods convergent study design (see Section 2.3), qualitative and quantitative data are analysed separately by using appropriate analysis methods relevant to the respective strand. Merging of the two analyses occurs in the second stage of analysis through ‘side by side comparison’ or by ‘category theme display’ (225). Category theme display analysis method is useful in studies where sample sizes of qualitative and quantitative data are equal, whereas side by side comparison is used in studies with unequal sample sizes of the two strands, and where the less dominant strand is used to compliment or explain the findings from the dominant strand (225) (see Section 2.3). The most common presentation of side by side comparison analysis involves integrated data from qualitative excerpts complemented by descriptive statistics in results section, followed by the meta inference in the discussion sections (172, 222, 284). I used a similar approach, and the data chapters (Chapters 3-7) provide integrated findings. Meta-inference is drawn on the basis of findings from the mixed- methods study and this is supported by the contemporary literature (see Chapters 8 and 9).
2.9.2 Qualitative analysis
Thematic data analysis technique is applied to identify, analyse, and report repeated views and accounts across all data (285-287). It is a process of encoding qualitative information under a theme and presenting the repeated information in a systematic way that increases its sensitivity and reliability to answer the research phenomena (173). Guest et al. described ‘applied thematic analysis’ as a best combination of all the traditional methodological frameworks, and it can be used to build theoretical models of real world problems (172). The systematic and flexible nature of thematic analysis makes the integration of quantitative and qualitative data much easier. In addition, it is suited to data analysis methods for mixed-methods studies (174).
A theme can be inductively produced from data (288) or deductively identified by previous knowledge or theory (173). In this study, I used an inductive strategy to code the transcripts for all participants’ groups (women, health workers, and key informants). According to Liamputtong’s (249) recommendation for inductive coding, I read at least five transcripts from each participant group to identify recurrent themes
89 emerging from data and develop a coding structure. In the second stage, I used Nvivo software to code the transcripts according to the coding structure, and where appropriate I added new codes and themes to the coding structure which emerged from the data. As the study was conducted as part of my Doctoral Degree research project, I was the only person who coded the data.
Following the identification of main and subthemes, I provided interpretation of themes by including information from the quantitative data to elaborate each theme. The key excerpts from the interviews and workshop were included throughout the analysis chapters, which are supported by graphs and tables. I also made use of field notes and information in my reflective journal, which helped me to personally relate to the participants and the research phenomena (289). Figure 2.6 shows the coding tree model created in Nvivo that plots women’s birthing experiences during floods (right block) and in regular circumstances (left block).
Figure 2.6 Coding tree model – Nvivo
2.9.3 Quantitative analysis
For the quantitative analysis, I obtained descriptive statistics (frequencies and percentage) within 95% Confidence Interval to compare women’s utilisation of health workers across study villages. I also used a chi-square test to determine women’s maternity care utilisation according to age, villages, number of children, relocation stages during floods, relocation places during floods, and birth attendants during floods.
90 2.9.4 Integration
Creswell stated that integration of qualitative and quantitative data can occur at one or more phases of a mixed-methods study (284). The possible stages of integration are ‘data collection’, ‘data analysis’, and the ‘result section’ (284). In convergent parallel mixed design, integration refers to merging data whereby the qualitative and quantitative components are compared, and areas identified that complement each other.
In my study, integration of qualitative and quantitative data occurred after it was analysed separately. After conducting a separate qualitative and quantitative data analysis, I synthesised the data by creating inductive themes and descriptive epidemiology. The qualitative and quantitative findings were combined to answer the overarching research question, which together produced rich data that describes the availability and women’s utilisation of health workers and maternity-care services, and practical solutions to improve the maternal health status in rural Sindh Pakistan during floods as well as in regular circumstances. Figure 2.7 shows the analyses techniques used for the meta-inference of this study.
91
Figure 2.7 Meta-inference of women’s maternity care utilisation
2.10 Ethical consideration
The study received ethics approval from the Deakin Human Research Ethics Committee (DU 2014-181) (see Appendix 5) and the National Bio-Ethics Committee, Pakistan (NBC-161) (see Appendix 6). All participants provided consent (verbal or written) to participate in the study. In this thesis, participants’ names and identity are confidential and pseudonyms are used to protect their identity.
After obtaining the aforementioned ethics approvals, I obtained approval from the District Health Officer, the MNCH Program Manager in Sindh, the Population Welfare Department Officer, and the PPHI District Manager to recruit health workers from their relative programs and departments. All the managers were provided with a copy of the plain language statement, interview guidelines and consent form.
All women who agreed to participate in the study provided verbal consent, as most of them were unable to read and write. Most of the villagers were not willing to provide thumbprints or sign any document out of fear that their signatures could be
92 misused for fraudulent activities. As an outsider, I respected their views, and with the permission of the women, I recorded their consent as part of the ethical requirements. All the health workers and key informants provided written consent to participate in the study.
2.11 Summary
The study used mixed-methods design as an appropriate choice to integrate participants’ perceptions, experiences, and utilisation of maternity-care systems in Pakistan. Data was collected from multiple sources (women, health workers, key informants) by means of interview, survey, and participatory workshop. This chapter has presented the rationale for using a mixed-methods design, and for the process of collecting data and analysing it. The next chapter explores the health workers’ role to deliver continuum of maternity care services in Katcho villages.
93
Maternity-Care
Services
Delivery by Rural Health Workers in the
TMK district
3.1 Introduction
This chapter presents the information about existing roles of different cadres of health workers as maternity-care providers in the TMK district. The focus is on five cadres of health workers who provide maternity-care services at home, at community level, and at public health facilities in different stages of pregnancy. The chapter draws on data from health workers’ interviews, key informants’ interviews, and a participatory workshop with health workers.
3.2 Poor functioning District Health Program Management Teams (DHPMT)