Tina Miller

How can systematic reviews incorporate qualitative research? A critical perspective

Systematic review has developed as a specific methodology for searching for, appraising and synthesizing findings of primary studies, and has rapidly become a cornerstone of the evidence-based practice and policy movement. Qualitative research has traditionally been excluded from systematic reviews, and much effort is now being invested in resolving the daunting methodological and epistemological challenges associated with trying to move towards more inclusive forms of review. We describe our experiences, as a very diverse multidisciplinary group, in attempting to incorporate qualitative research in a systematic review of support for breastfeeding. We show how every stage of the review process, from asking the review question through to searching for and sampling the evidence, appraising the evidence and producing a synthesis, provoked profound questions about whether a review that includes qualitative research can remain consistent with the frame offered by current systematic review methodology. We conclude that more debate and dialogue between the different communities that wish to develop review methodology is needed, and that attempts to impose dominant views about the appropriate means of conducting reviews of qualitative research should be resisted so that innovation can be fostered.

Finding qualitative research: an evaluation of search strategies

BackgroundQualitative research makes an important contribution to our understanding of health and healthcare. However, qualitative evidence can be difficult to search for and identify, and the effectiveness of different types of search strategies is unknown.MethodsThree search strategies for qualitative research in the example area of support for breast-feeding were evaluated using six electronic bibliographic databases. The strategies were based on using thesaurus terms, free-text terms and broad-based terms. These strategies were combined with recognised search terms for support for breast-feeding previously used in a Cochrane review. For each strategy, we evaluated the recall (potentially relevant records found) and precision (actually relevant records found).ResultsA total yield of 7420 potentially relevant records was retrieved by the three strategies combined. Of these, 262 were judged relevant. Using one strategy alone would miss relevant records. The broad-based strategy had the highest recall and the thesaurus strategy the highest precision. Precision was generally poor: 96% of records initially identified as potentially relevant were deemed irrelevant. Searching for qualitative research involves trade-offs between recall and precision.ConclusionsThese findings confirm that strategies that attempt to maximise the number of potentially relevant records found are likely to result in a large number of false positives. The findings also suggest that a range of search terms is required to optimise searching for qualitative evidence. This underlines the problems of current methods for indexing qualitative research in bibliographic databases and indicates where improvements need to be made.

“Is This What Motherhood is All About?” Weaving Experiences and Discourse through Transition to First-Time Motherhood

This article focuses on transition to first-time motherhood and explores the experiences of a group of women as they anticipate, give birth, and engage in early mothering. It illuminates how these women draw on, weave together, and challenge dominant strands of discourse that circumscribe their journeys into motherhood. Using qualitative longitudinal data, prenatal and postnatal episodes of transition are explored. The analysis and juxtaposing of these data reveal the different ways women anticipate and gradually make sense of becoming mothers. While there is a disjuncture between expectations and experiences for these new mothers, this article draws attention to the different ways women discursively position themselves through transition. It reveals how birth experiences can act as a discursive turning point and underscores the obduracy of some strands of dominant discourse. These findings contribute to a subtler and more nuanced understanding of the dynamic interplay between personal experience and gendered discourses.

Falling back into Gender? Men’s Narratives and Practices around First-time Fatherhood

This article explores men’s articulations and practices of gender through transition to first-time fatherhood. Using qualitative longitudinal data, men’s antenatal intentions and postnatal practices are explored in this study which replicates earlier research on motherhood. The contemporary context in the UK is one where paternity leave, discourses of caring masculinities and more public displays of fathering involvement appear to offer new possibilities for men. But data analysis shows that whilst opportunities to disrupt gender norms are initially imagined, longer term practices can confirm ‘patriarchal habits’. The findings illuminate gender being done and undone, at times simultaneously, as the exhaustion and hard work of new parenting is encountered. A retreat into normative behaviours can be a path of least resistance as experiences unfold in an arena where men are found to have available to them a wider repertoire of discursive storylines. Optimistically, some changes in fathering involvement are discernible.

Losing the Plot: Narrative Construction and Longitudinal Childbirth Research

This article seeks to explore the ways in which theories of narrative might be significant in the study of childbearing. The event of childbirth and the process of women becoming mothers have major significance for individual biographies and are publicly defined. The medicalization of childbearing and the placing of a natural event into a pathological illness model has repercussions for the ways in which women experience and make sense of the event. The complex interweaving of public and lay narratives that surround this period of transition can lead to bafflement and the eventual construction of personal counter narratives. The context in which narratives are managed is explored.

Mapping men’s anticipations and experiences in the reproductive realm: (in)fertility journeys

This paper examines mens experiences of fertility/infertility against a backdrop of changing understandings of mens role in society and medical possibilities. It presents findings from two qualitative research projects on mens experiences of engagement with reproductive health services as they sought to become fathers and anticipate impending fatherhood. The findings from both projects provide insights into mens experiences of (in)fertility and their engagement with services set against cultural ideals of masculinity. Discussions of reproduction have historically focused most centrally upon womens bodies and maternal processes, leaving little space for consideration of mens experiences and perspectives. While womens experiences of infertility/fertility have been characterized in relation to productive or faulty biological processes, male infertility has been largely invisible and male fertility typically assumed. This context provides a difficult terrain for men in which to contemplate the potential of not being able to father a child. The findings discussed in this paper illuminate the ways in which men talk about and make sense of their reproductive journeys. In doing so, it challenges current understandings of masculinity and reproductive bodies and highlights the need to rethink how men are treated in reproductive spheres and how services to men are delivered.

Increasing the use of skilled health personnel where traditional birth attendants were providers of childbirth care: a systematic review.

Background Improved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked? Methods and Findings We systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care. Conclusions The interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist.

Going back: ‘Stalking’, talking and researcher responsibilities in qualitative longitudinal research

This paper explores the process of going back in qualitative longitudinal research (QLR) to gather later accounts of unfolding personal experiences. The design of interview-based QLR is usually premised on collecting data, over-time, around an unfolding experience or event. This design facilitates the establishment of an on-going research relationship and ‘rapport’ and the accessing of fluid and time-sensitive accounts of individual experiences, leading to more nuanced understandings of temporal subjectivities. However in practice maintaining a sample in QL research, which may span a number of years, can be challenging and the process of going back, complicated. This paper reflects on issues and responsibilities which can arise when researchers try to access and go back to participants, especially where experiences once optimistically narrated and future-oriented have unfolded in unplanned and personally unwelcome ways. Using researcher experiences and the data from later phases of two UK based QLR studies on transition to first-time motherhood and first-time fatherhood, the practical steps of maintaining contact, reconnecting with participants and going back are documented. How does the passage of time and changes in participant’s lives alter research relationships, interpretations of data and researcher responsibilities?

Shifting perceptions of expert knowledge: transition to motherhood

In all societies reproduction and childbirth are more than a biological event: they are shaped by the cultures in which they are experienced. In post-industrialized societies transition to motherhood involves women in interactions with experts and normative practices as professional management, screening and monitoring increasingly become features of caring for women becoming mothers. At the same time, womens experiences of transition to motherhood are mediated through interactions with professionals and expert bodies of knowledge. The implications of this are that womens expectations of who provides support and who is the expert around childbearing shift as transition is experienced. In this paper, data from a qualitative study is used to focus on womens narrative accounts of first-time motherhood and the shifts that occur in perceptions of expert knowledge as experiences of transition unfold. The findings of this research demonstrate the difficulties of matching formal care to individual needs whether in relation to information giving in the antenatal period or support in the early postnatal period.

Balancing caring and paid work in the UK: narrating ‘choices’ as first-time parents

Paid work is generally accepted as an important dimension of hegemonic masculinities and mens identities, which can become heightened when they become fathers. Changes in global economies together with educational shifts and other demographic patterns mean that paid work has become a significant feature of many womens lives too. Increasingly across Europe women who are mothers combine caring, domestic chores, and paid work. Using data from a qualitative longitudinal study on womens experiences of transition to first-time motherhood in the UK, this paper will explore how women narrate and reconcile their decisions either to return to paid work or not to, following the birth of their first child (Miller 2005). These findings are considered alongside a companion study on mens experiences of transition to first-time fatherhood (Miller 2011). The comparison shows that women articulate work and caring decisions in narratives which convey a sense of ‘guilt’, whilst the men are able to talk more freely – and acceptably – about ‘career progression’ and the importance of work to their identity and their new family. Even though recent research points to some changes in mens involvement in caring and womens increased activities in the work-place, particular aspects of these arrangements remain seemingly impervious to change.