Observation

Participant observation was the main method of data collection in this ethnography, as I spent the majority of my time in the field observing in a variety of settings (antenatal clinics, antenatal classes, clinician information sessions, consultant rooms, canteen) and it provided a large amount of data. Extensive observation as the researcher and

„stranger‟ to the field-site is paramount in order to note any interesting patterns that may have been a unique feature to the field-site, and also help to discern any patterns of interaction that may arise, and their significance, as well as ascertain whether there was a recurrence of certain phenomena or whether it was a once-off anomaly. Lengthy observation allows for valuable data to be gathered on the field-site and document any significant events or cultural changes that may have occurred during the data collection phase of this study.Observation involves engagement in the daily lives of individuals in their natural setting; “watching, observing and talking to them in order to discover their interpretations, social meanings and activities” (Brewer, 2000, p.59). It allows for rich, detailed description and provides opportunities for either participating in or viewing unscheduled events, which can help to describe and interpret people‟s “behaviours, intentions, situations and events as understood by one‟s informants”(DeMunck & Sobo, 1998, p.43). Participant observation can also allow for the researcher to experience native activities directly, to get the feel for the events that are occurring and to record his/her experiences and perceptions (DeWalt &DeWalt, 2002; Spradley, 1980).

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Observation data collected throughout the study helped to inform questions and topics to explore further over the course of the ethnography. For example, through the process of cross-checking between observations and interviews, questions were added to interview guides for use in later interviews, and observation also became more focused on certain areas that were arising. For example, observing and listening to the language used by consultants when they were discussing the OptiBIRTH intervention helped me to realise that many of the clinicians were not familiar with or knowledgeable of the various components of the intervention that were available to the women, and, as a result of this, perhaps, they did not discuss OptiBIRTH with the women, rather simply informed them that VBAC was an option.

The observation was conducted using specific guiding principles for how observations should be, and were subsequently, performed. These were:

 the definition of what was to be documented in the observation and in every case;

 descriptive observations that provided an initial, general presentation of the field;

 focused observations that concentrated on aspects that were relevant to the research question;

 selective observations that were intended to purposively grasp central aspects;  the end of the observation, when theoretical saturation had been reached, which

meant that further observations would not provide any further knowledge (Flick, 2009).

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General observations were conducted in the clinical environment in two main settings; i) the antenatal clinic and ii) a room where the OptiBIRTH antenatal classes and clinician information sessions, as part of the OptiBIRTH intervention, were held (sections 5.2 and 6.2 provide full descriptions of these areas). General observation involved observing the interactions that occurred between women that were

participating in the trial, health care providers caring for these women, midwives in the antenatal clinic who provided eligible women with the study information and the OLs, as a component of the study intervention. Observation began when a midwife found the OptiBIRTH screening form in the woman‟s chart if it was her first booking visit, or if the midwife found „OptiBIRTH‟ written on her chart. The screening form or note was placed in women‟s charts who were booking into the clinic by midwives each morning before the clinic began. The midwife would then tell me when a woman was eligible for OptiBIRTH and I would observe from my position, how the midwife and woman interacted. This included observing the language used by midwives to describe the intervention, the woman‟s response to this information and whether the woman had any questions for the midwife about the intervention, including the nature of these questions and the midwife‟s response. Although the midwives, for the majority of the observation period answered women‟s questions, at the time if a woman wanted further detailed information on the intervention, the midwife would direct her over to me. I would discuss the trial further and answer her questions as best as I could, either in the main clinic area or obtain the use of the CMM‟s office. On many occasions throughout the recruitment phase, the MOL was present in the clinic and would manage the recruitment of women to the study, which I also observed. I recorded observations through field-

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notes, including noting what clinic staff said and did between themselves and between them and myself, and the non-verbal interactions that occurred with each other. Prior to commencing the study, staff in the clinical setting were fully informed (written and verbal information) of my embedded ethnography and that this required general observations of them in their work environment; that said, all staff had the option of excluding themselves from direct observations. None of the staff voiced any objection to the observation and all were agreeable in taking part. Furthermore, all staff, from the outset of the study, were informed that I am not a healthcare professional and that I was only present and observing in the capacity of researcher and doctoral student. I wore university identification and introduced myself as a researcher who was exploring views, experiences and thoughts on, in addition to any cultural change surrounding, the OptiBIRTH package of care. I was in the field for approximately four alternating days per week, and present in the antenatal clinics for 3 to 3 ½ hours per day for the

observation period. Any greater length of time would have been detrimental and challenging to my memory and recording process ability (Patton, 2002).

The site MOL or OOL, or other midwife/obstetric staff member who were aware that a woman who was attending the clinic was participating in OptiBIRTH, acted as

gatekeepers and introduced me to these women. Women were aware, having been previously informed in the OptiBIRTH trial „Study Information Leaflet‟ (Appendix 9), that observations were taking place as part of the OptiBIRTH study. Women who wished to take part in OptiBIRTH, but did not want to be observed could opt-out of these observations by informing either the staff midwives, the MOL or myself. Where this occurred, observational data were not collected on these women. Observation data

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were recorded through field-notes, which consist of “fairly concrete descriptions of social processes and their contexts and which set out to capture their various properties and features”(Walsh, 2012, p.255).

Clinicians and OLs were also generally observed as part of the ethnography. These observations were conducted in the antenatal clinic, the antenatal classes and during the clinician educational information sessions, which are facilitated by the OLs, as part of the OptiBIRTH trial. Observing these components was deemed important as they were designed to inform clinicians on the risks and benefits associated with VBAC and on the intervention. As such they had the potential to influence a change in clinicians‟ thoughts on VBAC in general. In addition, attending these sessions facilitated observing how the OLs interacted with their colleagues. These interactions and the portrayed views of the OLs had the potential to impact on how clinicians view this information and, subsequently, how they relate this information to women participating in the trial; an important aspect of exploring cultural change.

Participant and non-participant observation was used interchangeably in the field-site depending on the situation. For the majority of my time in the antenatal clinic, non- participant observation was the method employed unless I was specifically asked to help in the clinic. This was the same for the antenatal classes and the clinician information sessions.

Following observation in antenatal clinic, antenatal classes, and clinician information sessions for a significant period of time and in conjunction with interviews, my

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observation then changed to a more focused observation of interactions that were relevant to my research question. This meant observing how OptiBIRTH was portrayed to participants in the field-site, how OptiBIRTH was discussed between participants and observing as to whether the conversation around VBAC changed through language and interaction between women and clinicians.