Archive for March, 2010

Six Reasons I *Heart* Qualitative Research

March 29th, 2010 by avatar

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


“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].”

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Calling all bloggers! 5th Healthy Birth Blog Carnival: Get up, stand up!

March 25th, 2010 by avatar

It’s been a while since our last Healthy Birth Blog Carnival.  I thought I’d give everyone a break since there was plenty of blog fodder, what with the NIH VBAC Consensus Conference, an Amnesty International Report on U.S. maternal mortality, and the release of appalling cesarean section statistics from the National Center for Health Statistics.  But when I posted a Fit Pregnancy article about coached versus spontaneous pushing on the Science & Sensibility Facebook page yesterday, it was met with a flurry of comments and was shared widely. It occurred to me that bloggers may be looking forward to something other than cesareans and VBACs to write about.  And readers may be looking forward to something other than cesareans and VBACs to read about.  So without further ado, I hereby announce the 5th Healthy Birth Blog Carnival on none other than the 5th Lamaze Healthy Birth Practice:

Avoid giving birth on your back and follow your body’s urges to push

Anything about the second stage of labor is welcome. Here are some resources from Lamaze to get you thinking.

Participation in the Healthy Birth Blog Carnival is easy:

1. If you are a blogger, write a blog post on the Carnival theme (Avoid giving birth on your back and follow your body’s urges to push). Post it on your blog by Wednesday, April 7. Make sure the post links back to this blog post, to the Healthy Birth Practice Paper, or to the video above. You may also submit a previously written post, as long as the information is still current.

2. Send an email with a link to your post to amyromano [at] lamaze dot org.

3. If you do not have a blog but would like to participate, you may submit a guest post for consideration by emailing it to me.

4. I will compile and post the Blog Carnival here at Science & Sensibility.

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Giveaway: DVD of Lamaze/InJoy Healthy Birth Your Way Videos

March 15th, 2010 by avatar

Last year, Lamaze International and InJoy Birth & Parenting Videos collaborated on the launch of InJoy’s new Mother’s Advocate site. The site offers free video clips and print materials that inform women on how to be active participants in their care to achieve safe, healthy, and satisfying birth experiences.

I’ve met many childbirth educators who love the videos and use them in their educational offerings. But educators who teach in settings without WiFi access (including many hospitals), cannot show web-based videos.

InJoy heard the feedback and now offers all seven videos on DVD. They’re charging customers only for the cost of packaging and shipment, $9.95.  (Remember, the videos themselves can be accessed freely at MothersAdvocate.org, Lamaze.org, or directly from YouTube.) You can see the product details and purchase a copy of the DVD at InJoyVideos.com.

This week we’re giving away a copy of the Healthy Birth Your Way DVD. There are three ways to enter:

1. leave a comment below, sharing something you like about the videos or tell us about how you have used them in your teaching.

2. Tweet or retweet a link to this giveaway (then leave a comment saying you did)

3. Post a link to this giveaway on Facebook (then leave a comment saying you did)

Please leave separate comments for each of your entries.

You do not have to be a childbirth educator to enter. Leave all comments by Sunday, March 21, 2010 at 11:59pm. The winner will be announced by Tuesday, March 23.

Full Disclosure: I was paid a one-time consulting fee by InJoy to draft the content of the videos and accompanying print materials.

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Do women need to know the uterine rupture rate to make informed choices about VBAC?

March 11th, 2010 by avatar

The NIH press release about the VBAC Consensus Meeting includes only a single instance of the phrase “uterine rupture.”  Having spent 2 1/2 days watching the streaming webcast of the event, my strong sense is that this was by design. During the expert testimony, we heard over and over again that uterine rupture is the most feared outcome of a VBAC. We heard in gripping detail what happens when a uterine scar ruptures in labor, and even saw photographs of the devastation. We heard about deaths and hysterectomies and hypoxic injury to newborns that occurred with uterine ruptures.  But after all of that, we heard a rather consistent message that uterine rupture itself is not the issue.

Why’s that? To determine the safety of a practice, it makes sense to look at the death or disability associated with it. Although uterine rupture imposes a high risk of perinatal death, hypoxic injury, and hysterectomy, most uterine ruptures do not in fact result in any of these outcomes. Ruptures are traumatic, devastating, and scary, but they are not in and of themselves “death or disability”. As the lead investigator, Jeanne-Marie Guise said in her testimony to the panel, “uterine rupture is a complex intermediate event.” What women really need to know is, “how will each option affect my health, my baby’s health, and our future?”

This means knowing the likelihood the baby will die or be severely harmed, knowing the likelihood the mother herself will die or be severely harmed, and knowing the long-term consequences of the full range of possible harms. It also, of course, means understanding the benefits of both options. And as obstetrician and bioethicist Anne Lyerly noted in her testimony, everyone applies their own values to the hard data, so two women with the same history and risk factors could make two different choices about mode of birth after a prior cesarean.  These values and preferences were delineated by the panel in it’s statement to the media:

Factors contributing to some women’s desire to attempt a trial of labor include desire for their partner’s involvement in the delivery, belief that labor and vaginal delivery can be deeply empowering, enhanced opportunity for maternal-infant bonding, greater ease in establishing breast feeding, and easier recovery. Conversely, scheduling convenience, the desire to avoid labor pain, fear of failed trial of labor, avoidance of possible emergency cesarean section, and desire for surgical sterilization at the time of delivery may all contribute to a preference for planned cesarean delivery.

All of these are legitimate values, and although as educators and care providers we might explore them with women, we should not ultimately judge them.

Getting back to health outcomes, how did each option measure up? The researchers found that health outcomes for both mother and baby were good in the vast majority of women choosing either option. Maternal mortality and serious morbidity tended to be more common with planned repeat cesarean surgery while fetal/newborn mortality and serious morbidity tended to be more common with planned VBAC. Evidence appeared to strongly favor VBAC when the outcomes in future pregnancies were considered, since life-threatening placental problems and other poor outcomes get more common the more cesareans a woman has had. Many important outcomes, including long-term physical and emotional health, have been studied inadequately or not at all. The panel highlighted multiple critical gaps in evidence and called for more research. For specific findings, you can read the abstract and access the entire systematic review of the evidence here.

Statistically speaking, one of the clearest associations in the data was the small but significant excess risk of uterine rupture in women choosing VBAC. But the excess likelihood of this  “complex intermediate event” doesn’t begin to tell women the whole story. A laser-like focus on this possibility during decision-making obscures the clinically meaningful outcomes that women and their families care about, many of which favor planned VBAC.

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Will the NIH Panelists read the blogs and Twitter feeds? And should they?

March 8th, 2010 by avatar

I spent the good part of today glued to the live webcast of the National Institutes of Health Consensus Develop Conference on Vaginal Birth After Cesarean (VBAC). The agenda was packed with expert testimony on the findings of a systematic review of 35 studies involving over 660,000 women with prior cesareans, prepared by the Agency for Healthcare Research and Quality.

So many important findings were presented that I would not begin to do them justice if I summarized them here. What amazed me as much as the incredibly enlightening science, though, was the remarkable involvement of consumers and consumer advocates, many of whom are very savvy users of social networking tools such as blogs, Facebook, and Twitter.

And another interesting thing happened: the NIH Panel acknowledged the bloggers. Gina from The Feminist Breeder posted this picture of a slide from their introduction…


…right around the time that I was tweeting this:

Screen shot 2010-03-08 at 8.19.39 PM(for the Twitter-naive, FTW is “for the win” and #nihvbac is the “hashtag” for the conference.)

They are right: there is an active blog community on the internet. And we’ve been “actively blogging” about VBAC for several weeks now. The blogging effort was coordinated, too. The International Cesarean Awareness Network pulled together an amazing collection of links to posts all over the internet on the topic of “VBAC as a Vital Option.”

This all got me wondering: have the NIH panelists been reading our blogs?  And should they?

The panelists are supposed to be independent and objective (as we have seen, this is rarely if ever the case). But does independence equate with impartiality? And do the rules of impartiality that govern, say, juries in courts of law (eg, don’t google the case!), pertain to independent scientific panels?

Surely they’ve read somewhat if not extensively in the the scientific literature on VBAC. After all, the NIH would want to choose panelists who would be able to effectively do their job: coming to consensus on VBAC, and doing so requires some familiarity with the research and clinical issues. All of those testifying have affirmed that the available literature for nearly every important aspect of VBAC decision-making is “thin,” “scarce,” or “limited” and that major areas for future research include emotional and mental health outcomes, quality of life, long-term health, and impact on mother-infant bonding and breastfeeding. So if the scientific evidence cannot provide answers, what about asking women themselves? Especially those of us who are eagerly sharing our perspectives and personal stories on blogs and Twitter?

I’m interested to hear others’ thoughts on the role (if any) of consumer advocates, connected via social media, on the scientific panels like the NIH meeting.

I have to end it there to take part in a Blog Talk Radio Show with The Feminist Breeder and Debra Bingham, the president-elect of Lamaze International and the Executive Director of the California Maternal Quality Care Collaborative.  Tune in!

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