Interviews

Interviews are integral to ethnography. As Fetterman (2010, p.40) states “interviews explain and put into a larger context what the ethnographer sees and experiences”. The main aim of conducting interviews was to gain the perspectives and in-depth accounts of participants‟ experiences and opinions on the OptiBIRTH package of care.

Interviews were performed with women participating in the trial, clinicians who were caring for these women and the OOL and MOL employed to advocate for VBAC and to implement and deliver the OptiBIRTH intervention. The interviews were semi-

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structured in nature, which ensured that throughout the ethnography the areas that I believed were important were being captured while simultaneously allowing

participants to forward their own ideas and thoughts (see Appendix 14and Appendix 15 for interview guides for women and clinicians).An example of this would be the

relationship between doctors and midwives and the unfolding power struggle over the aims of the OptiBIRTH intervention (see section 8.4.1). Bryman (2008) claims that semi-structured interviewing allows the participants freedom to reply in their own way and also allows questions that may or may not be on the interview schedule to be asked if needed to probe an issue further. The advantage of using this type of interviewing was that the participants can select what they perceive as personally important. For example, during the interview process, the subject of clinicians not discussing birth options with the women was a frequent theme that arose. Subsequently this area was then

investigated through interviews with clinicians to ascertain their viewpoint on the subject of discussing birth options with OptiBIRTH participants (see Appendix 16 for modified interview guide). Semi-structured interviews also allowed for a great deal of flexibility (Kvale, 1996). This was important as the ethnography progressed with the intervention, whereby different social processes and phenomena might have emerged as the trial progressed. In this sense, it was important that the interviews were semi-

structured to facilitate gathering of these changes in views and understandings over time. These interviews were also held at different time points during the intervention, for example, after the first and second OptiBIRTH antenatal classes, before giving birth and soon after finishing the intervention. This meant that if any changes occurred during the intervention, these could be captured at each time point for each participant.

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between 20-25 minutes. Written informed consent was obtained before each interview and a duplicate copy of the consent form was given to the participants for their records (Appendix 10). All of the participants who were interviewed for this ethnography were given the opportunity to read their interview transcripts, which were transcribed

verbatim. This aided in making sure that the representations of their views and experiences are true representations, and, limited the risk of researcher bias and subjectivity. I also made notes after the interview had ended, to record non-verbal response and body language (Brewer, 2000). All interviews were recorded and participants were informed of this on the consent form provided.

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Sample Women Clinicians (staff

participating in OptiBIRTH)

Clinicians (OLs as part of OptiBIRTH)

Observation Antenatal Clinic

OptiBIRTH antenatal classes

General observation Interactions between women and health care providers

Antenatal Clinic and labour ward

OptiBIRTH Clinician Information Session General Observation Interaction between staff and OptiBIRTH women

Antenatal Clinic and labour ward

OptiBIRTH Clinician Information Session General Observation

Interaction between OLs and staff as well as OptiBIRTH women

Interviewing Women participating in OptiBIRTH 1-3 interviews depending on uptake and interest Staff participating in OptiBIRTH Intervention – clinic and labour ward 1-3 interviews depending on uptake and interest

MOL and OOL

2-3 interviews throughout intervention

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4.7

Data Analysis

“The important thing to recognise is that, order to produce an ethnographic study that is equally rich in data and concepts, it is not merely enough to manage and manipulate the data. Data are materials to think with” (Hammersley & Atkinson, 2007, p.158)

Ethnography involves deep immersion in the research process. This is emphasised even further during the process of analysing collected data whereby the researcher must immerse him/herself in the data to discover, understand, and interpret the gathered information so as to gain a sense of the culture and ensure accurate representation of that culture. Bernard (2013) suggests that, during the process of data analysis in

ethnography “you tell a story, as you see it, of how the themes are related to one another and how characteristics of the speakers account for the existence of certain themes and the absence of others” (p.393).

There are various different types of data analysis that can be applied to the ethnographic context, such as discourse analysis, grounded theory and hermeneutics. When choosing the method of data analysis, a number of factors must be considered. These include the theoretical perspective taken, the methodology employed and the research aims and objectives of the study. As the researcher and the person conducting the data analysis, I believed that the use of a thematic analytical approach was best suited to this

ethnography. Thematic analysis is deemed appropriate in the ethnographic method as it supports an interpretive view whereby data are organised into categories, sub-categories and patterns (Lindlof &Taylor, 2011) and therefore, the social context of the

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participants in a study can be understood in a meaningful way (Lacey & Luff, 2001). Thematic analysis allowed me to systematically work through the data to represent a view of reality by identifying recurring patterns through the linking of categories that have similar meanings.

I aimed to collect and analyse the data concurrently, as Hammersley & Atkinson, (2007) have stated that, through familiarisation with the data, emergent issues will guide later data collection. The process of analysis is not a distinct stage in ethnography, but rather a part of the data collection stage. This process was difficult to maintain, as Kleinman & Coop (1993) note that due to the time constraints of data collection, much of the in- depth data analysis is delayed until data collection has been completed. To compensate for this, I maintained on-going analytic memos and a journal that recorded emerging insights and themes of particular interest through re-reading and familiarising myself with the data already collected.

This process of coding and sorting data developed into three major periods of analysis. From the beginning, the period of becoming extremely familiar with the raw data that have been collected was undertaken. This included first impressions that were noted, categories that were identified as well as key concepts emerging (Patton, 2002). Themes and categories were then identified in the interviews and field-notes that helped to generate codebooks (See Appendix 17). This stage of data analysis allowed me to interact with the data that I had collected and dissect it from a more analytical perspective.

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This study‟s raw data took the form of interview transcripts and field-notes (see

Appendix 18 and 19 for interview transcripts). The interviews allowed me to hear from the participants and gain their understanding and interpretation of their participation in the intervention. The field-notes that I had accumulated then allowed me to give context to the interviews that had been conducted and to understand the setting and its

relationship with the intervention. All field-notes were kept in a chronological order, with separate folders detailing the month and day and times in which they were taken. In this way, I had a clear idea of what was occurring throughout my time in the field so that I could keep a detailed record of the field-notes. Individual components pertaining to the intervention, such as the antenatal classes and clinician information sessions, were also kept separately.

Coding data is a form of qualitative analysis, which Patton (1990, p.381) suggests as the “process of identifying, coding, and categorizing the primary patterns of data”. The procedure for coding involved reading through the transcripts and field-notes generated over a period of 16 months. As I encountered data that illustrated a particular code, specific words or sentences would be highlighted and assigned a code. This process was very basic in looking for indicators of categories in both events and behaviours; for example, „power plays‟ or „socialisation‟ in certain situations. These are general codes to mark that an event has occurred that is of interest.I moved through the interviews and field-notes, assigning all codes that applied to the data. Material quotes corresponding to all issues that had been raised in the literature were extracted using the participant‟s words. In addition, new ideas and issues that had arisen directly from the participants‟ narratives were explored and analysed. I then reviewed all codes to assess the

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commonality and differences between the interviews and notes. This open coding process then moved to the more analytic stage of selective coding. Selective coding is more focused and categorises the data more precisely (See Appendix 20 for example). “Selective coding provides a more abstract and comprehensive conceptual handle in the data than open coding. These focused codes not only serve to synthesise large amounts of data, but also to organise earlier codes into a coherent framework” (Charmaz

&Mitchell, 2001, p.167). This coding involved exploring the consistencies between open codes that were generated in the first analytic stage, and refining them down to specific events and developing sub-categories. This process helped to generate understanding of the nature of the issues raised by the study participants. The codebooks allowed for critical data to be extracted and analysed, thus allowing for meaningful findings (See Appendix 17).

Once the data had been analysed literally and coded, interpretive analysis to understand the data and what was common across all data was reconstructed into categories and subcategories to create patterns, emerging themes. This was achieved though memo- making. Memo-making brought the ideas emerging from the data analysis together and where I recorded any ideas I had about the data. It helped me to make explicit

comparisons between the categories that I coded which then aided me in discerning any patterns. These became central textual codes that facilitated links for the development of broader concepts and theoretical frameworks. These patterns in the data were able to describe any actions that played out in a social situation and how these actions affected the actors that were involved. This analysis of the patterns then developed into themes

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that can be described by the categories that have been created from the analysis of the data.

I have provided a diagram to illustrate the process of data analysis for this ethnography:

Figure 2: The process of data analysis and the relationship between each stage

Through this process, a clearer framework of the data began to emerge and refining of the categories gave way to an interpretive analysis and the themes in this ethnography. This was achieved through an integration of the sub-categories with similarities into one main category that provide an explanation for the phenomena that were observed. An example of this can be seen in Chapter Six with the theme of Identity. Through the sub- categories generated from the data (the de-brief, language, and success stories) I was able to link the sub-categories as a pattern and interpret them under the main category of Identity. To further illustrate this process, I have provided a sample table of the codes and categories and how they refined to the themes of this ethnography:

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Table 6: Example of how the analysis progressed through codes, categories, to themes.

Code Categories Theme

Talking about previous birth 1. Language

2. Success Stories

Changing Identity

Encouraging VBAC

Interaction between women

OOL anecdotes Language used

Other doctors’ practice

OOL Influence 1. Power Position

2. Levels of Risk

Power Plays in the field Differing Opinions’ of doctors

Uterine Rupture Risk of VBAC/CS

The outcome of the analysis process described above is presented in the findings

chapters of this thesis. The analysis process was integral to the findings of the thesis and I have presented them in this way as the data analysis and development of the findings occurred as a concurrent process. I believe that the presentation of the findings in this way shows the shape of the ethnography and the data collection process. By presenting my findings as part of the data analysis process it will give the reader a clearer image of the ethnography and how the data shaped the story of the intervention. The process of data analysis is an interpretive process and, using pattern recognition from field-notes and interviews as well as my reflexive diaries, I reconstruct the data to a more abstract

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level of thought that provides a discursive order of the categories that were identified during the coding phase.

As well as this, ethnography is an interpretive process by the researcher of the data that have been collected. Due to my experience of data collection and the data analysis process, I felt that by presenting the findings in this way, this would be representational of the process that I experienced as the researcher and would have provided a rationale for the relationship between the data and the concepts developed. Ethnography is the telling of a story and the experiences within that story and I feel that the presentation of findings of cultural change when implementing the intervention in the field-site gives the reader a sense of this story and the sense of change that occurred in the field-site.

This ethnography can be seen as a consideration of the themes of ritualization, identity, authoritative knowledge, and power that affected the cultural dimensions of the field- site when it came to mode of birth after CS and its relationship with the OptiBIRTH intervention. These themes will be presented in the subsequent findings chapters and as part of the intervention with which they are associated.