First, a confession: I am no expert in qualitative research.

I read a lot of it, and I understand the basic principles, but I've never taken a course to learn the specific methodologies. I know enough to know when I'm looking at good quality qualitative research, to have a few favorite qualitative studies, and to have some things about qualitative research that I just adore.

I know that sounds a little nerdy, but maybe I can make you learn to love qualitative research, too. Here are some things I love about qualitative research, with some examples from the second stage qualitative lit, second stage being the theme of this month's blog carnival, not to mention a well-researched topic among qualitative researchers.

Qualitative studies demonstrate undocumented harms of common obstetric practices.

In a qualitative analysis of videotaped births, researchers documented the number of vaginal exams each woman had in second stage, which ranged from 2 to 17. And although not a single study defines the circumstances, if any, under which second stage vaginal exams are beneficial and indicated, this study suggests that they may be associated with harm - namely, severe, pathological pain.

The researchers reported that both the woman's experience of pain during vaginal exams and the providers' response were markedly different from pain experienced during contractions. During vaginal exams, participants displayed pain with 'unusual behaviors such as screaming, pleading, cursing, crying, arching back, pulling the head backward, and panting' (p. 15-16). Providers did not help women anticipate or cope with the pain associated with vaginal exams, and in fact did not even acknowledge it. In contrast, pain experienced during contractions was directly acknowledged and comfort measures or coping suggestions offered immediately.

Qualitative research finds new things to study:

In the same study documenting the practice of vaginal exams in second stage, the researchers discovered that, 'The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.' The logical next step would be to design a study to determine the safety and effectiveness of vaginal exams to elicit better pushing effort.

Qualitative research tells you the words people actually say.

As someone who cares for women in labor, I always love to know the words other midwives and doulas actually say. We all have our go-to phrases for women who need reassurance or help coping. In a couple of the studies on coached versus spontaneous pushing, researchers looked at what care providers and support companions actually said to the laboring women, then categorized their words as supportive or directive. In a 2007 study in which the researchers watched the videotaped births of 10 women, we again we see that qualitative research documents undiscovered phenomena.

A category of 'supportive direction' (20%) was identified. This care strategy has not been previously reported. It combined direction with support in a way that was supportive rather than overriding the woman's involuntary efforts.

The researchers provided examples from the qualitative data of these 'supportive direction' phrases:

• 'You're doing so good, just push that baby down when you're ready.'
• 'Take in another breath and get in another push, if you have it.'
• 'That's great, if you feel the urge again, then try it again.'
• 'Try it like that and hold your legs.'
• 'Don't forget to breathe.'
• 'Strong and steady.'
• 'Let's try this...,' or 'Do you wanna try...?'
• 'Keep it coming.'
• 'Just relax in between.'
• 'Concentrate on your breathing.'
• 'That's it, push when you feel the urge.'
• 'Don't push unless you feel a contraction, but go ahead if you feel it.' (p. 138)

Qualitative studies have titles that make you feel something.

''You'll feel me touching you, sweetie': vaginal examinations during the second stage of labor

and

'I gotta push. Please let me push!' Social interactions during the change from first to second stage labor.

Qualitative research exposes the paternalism inherent in conventional medical model obstetrics

'I gotta push...' was the first study (to my knowledge) to document the ubiquitous practice of a doctor performing a vaginal exam to 'certify' full dilation. The researchers analyzed videotape of women giving birth and present three cases that illustrate this phenomenon. In the most egregious case, transcripts revealed two nurses and a medical student insisting that the woman not push until a physician could perform the certifying exam, scolding and stalling her for 28 minutes despite her begging to push with her irresistible urge. Although nurses, students, and even women themselves can perform vaginal exams in labor, the official certification came only when the doctor performed the vaginal exam (in fact repeating an exam that had been conducted by the medical student 6 minutes earlier).

Upon certification of full dilation and despite clear evidence that the woman felt a strong spontaneous pushing urge, the nurse immediately 'stated the new rules for the remainder of second stage, 'Push three times on your next contraction, okay?''

Um, no, not okay.

Qualitative research can expose trauma narratives

According to a Listening to Mothers national survey of women who gave birth in U.S. hospitals in 2005, 9 percent screened as meeting all of the criteria for childbirth-related post-traumatic stress disorder. But this condition - and the circumstances and environmental factors that contribute to it - scarcely exist in the quantitative literature. In the qualitative literature, however, such narratives are abundant. One women participating in a sociological study of prenatal counseling and consent recalled this about her birth:

So here I'd been up all this time, in all this pain, and he takes the baby out and what does he tell me? He said, 'Your vagina exploded.' What a thing to tell a woman. 'Your vagina exploded.' What a thing to say!

The study authors go on to tell the epilogue of her story (emphasis mine):

Without the benefit of examining Holly's medical records, it seems as though she suffered extreme vaginal tearing, aggravated, or caused by, forceps, and went through vaginal repair surgery. As a result of this injury, Holly had difficulty post-partum: she suffered from depression, problems with breastfeeding because of her inability to sit and position herself properly, and difficulty with scarring and pain. She never had another child, and this experience left Holly with the sense that she could not risk childbirth again. Of note, the child was healthy, and this birth was considered a 'good outcome [quantitatively speaking].'

Published: March 28, 2010

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