Non-Malificence

Beauchamp and Childress (2013 p.150) state that ‘the principle of non- malificence obligates us to abstain from causing harm to others.’

Harm in this research could have caused to the participants in four ways described by Richards and Schwartz (2002) which are: anxiety and distress, exploitation, misrepresentation and identification of the participants in presentations and published papers. Each of these was addressed in this research by measures described in the following sections.

Anxiety and distress can be caused by all types of research, but qualitative research has the potential to cause harm particularly when participants are asked to recall intimate and potentially traumatic experiences (Creswell 2014; Bryman 2012; Bahn and Weatherill 2012; Parahoo 2006). During the consent process, all participants in this research were made aware of their right to stop during any data collection and withdraw any information given. Several

women became tearful when recounting previous traumatic birth experiences at which point the data collection was stopped and only continued at the participant’s expressed request. The long intervals between data collection points during the women’s (phase three) part of the research also held the potential for me to cause them anxiety or distress by contacting them without being aware of any complications or poor outcome in the intervening weeks. This scenario was addressed by ensuring that consent was given by each woman for me to access her medical records via a clinical stakeholder (their midwife at the CMU) before any contact was made.

Exploitation was guarded against in this research by ensuring that the opportunity to recruit stakeholders and women, and to obtain data did not take precedence over the participants’ needs, wishes and rights. Participants were not introduced to me until their first booking clinical consultation had been completed and they were comfortable to discuss their opportunity to participate. My observation of clinical encounters at the second booking appointment took place only after consent was reconfirmed with the participant and the clinician, and on one occasion this was given but I discontinued the observation when the participant was feeling unwell and it became inappropriate to observe her examination and distress. The interviews and focus groups were all held at the time and place requested by the

participants and the comfort and appropriateness (for example clinical activity and privacy) and remained a primary concern throughout.

82

Participants may disclose information as part of a relationship of trust between the participant and researcher (Bowling 2009). For example in this study a disclosure of domestic abuse was made, which had not been revealed to the participants’ midwife. In this circumstance the wellbeing of the woman required me to encourage the woman to inform her midwife of this abuse, which she did. The woman was made aware that if she had not informed her midwife, action would have been taken on my part to safeguard the

participant by revealing this disclosure to her midwife (ICM 2014). The safety of the woman took precedence over the research objectives even if this subsequently caused a breakdown in the trusting research relationship. All participants were made aware of my priorities should circumstances arise where women or stakeholders disclosed information, or I observed behaviour, that required action from me in order to protect a participant and this was stated in the participant information sheet (Appendix 10), before each participant gave consent to take part.

Misrepresentation may have occurred in this research if the participants felt that I had misinterpreted them, leading to an apparent incorrect

representation of their views, beliefs or experiences (Miller and Bell 2012). When participants were asked to validate abbreviated findings of the research, or transcripts of their interviews or focus groups, apparent misrepresentation of their views may be revealed. Participants may also feel that their views have been ignored or subjected to an alternative agenda for which they had been unwillingly used (Parahoo 2006). A short summary of the findings of the research was sent, with an accompanying letter explaining the summary related to general themes from the overall research, to all the participants in this study. Whilst all the vast majority of the responses were positive in that the participants could recognise their views within the analysis, one participant found that the summary of the findings did not place enough emphasis on her strongly held views on the value of one aspect of care at the CMUs. Further communication and clarification allowed the participant to appreciate that I had understood her contribution, which resolved her initial anger at the apparent misinterpretation within the necessarily abbreviated findings.

Harm caused by the identification of participants (Hardicre 2014) was a particular concern for this study and whilst I took measures to protect their confidentiality (as described in the justice section), the anonymity of research sites and thus the participants could not be completely guaranteed within a contextually detailed case study. The research sites were anonymised in this research by the allocation of pseudonyms (Cherrytrees and Seaview), and these have been consistently used in any presentations or publications

resulting from this research. It was also recognised, and potential participants informed, that the small sample size in the qualitative phases of the study, even with the use of anonymised quotes to illustrate the participants’ views, could potentially lead to identification of the participants.