Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill

3.4 Conclusions

There is no single ‘right’ way to do any research, but different approaches fit different research questions and generate different findings (Green and Thorogood 2014). A qualitative approach was chosen as best fitting the aims of the study; qualitative research is largely about understanding different perspectives, rather than explaining ‘reality’, in this case about late booking. It is about producing rich data for thoughtful and scrupulous analysis, insights from which may expose unexpected layers of complexity, rather than final answers (Ziebland and Wright 1997). Qualitative methodologies have the potential to generate sophisticated data on beliefs and behaviours in relation to healthcare use, and provide useful information to inform policy making and sensitise professionals to the views of health service users. This is essential if antenatal care is to become more responsive to the women it is designed for, and to influence the acceptance of personal and public pregnancies discussed in chapter two.

Green and Britten (1998) argue that the value of qualitative methods lies in their ability to pursue systematically the kinds of research questions that are not easily answerable from a quantitative perspective or more positivist epistemologies. The inductive, qualitative methodology chosen for this study rejects positivism for a more empathetic understanding (interpretivism) of late booking, and emphasises how pregnant women interpret and create their social world, and how this is constantly changing (constructivism) (Bryman 2008). The main features of the methodology reflect the need for honesty, flexibility and a partnership between researcher and researched. They acknowledge the influence of cultural and social contexts on both sides, whilst adopting strategies for maximising rigour and credibility during the collection, analysis and presentation of data (Bowling 2009). These are discussed further in chapter four.
Chapter 4: Methods used in the qualitative study

4.1 Introduction

Chapter three has considered the rationale for choosing a qualitative methodology to explore late booking for antenatal care among pregnant women, and the influences on this. This chapter provides a detailed consideration of the methods applied to the study. The methods chosen were systematic and rational, suitable to meet the aims of the study and to generate adequate and relevant information of sufficient quality (Holloway and Wheeler 2010). All qualitative research requires the skilful application of such methods, and an explicit and systematic approach, as Pope and Mays (2006) comment:

“qualitative research involves the application of logical, planned and thorough methods of collecting data, and careful, thoughtful and, above all, rigorous analysis… requires considerable skill on the part of the researcher” (p8)
An iterative process of concurrent sampling, data collection and analysis was undertaken during the study, with each ‘stage’ serving to refine and support the others. Methods reflected the theoretical background to the study, and aimed to address challenges presented during the research. The term ‘participant’ is used throughout to express the collaborative and equitable relationship between myself the researcher and the women researched, that was strived for during the study. Morse (1991) suggests this is in contrast to the passive response suggested by ‘respondent’ or ‘subject’. Qualitative methods are aligned with the health promotion (and feminist) ideology of empowerment (Sword 1999). The term participant reflects feminist influences on the research and better represents the active role played in such social encounters, emphasising a more egalitarian and reflective process for all involved (Holloway and Wheeler 2010). Fundamentally, the methods used aimed to generate rich insights from lay perspectives, in order to answer the research question “what perceptions and beliefs do late booking women express about the delayed initiation of antenatal care?”, rather than produce statistically significant or generalisable information (Bowling 2009).

4.2 Background to the study

4.2.1 Referring for antenatal care in Sheffield

The Jessop Wing, part of Sheffield Teaching Hospitals NHS Foundation Trust (STH), is Sheffield’s only maternity unit, and approximately 7000 babies are born in the unit each year (NHS Sheffield 2010). The hospital offers both midwifery-led and consultant-led care antenatally, postnatally and during labour. It has a large neonatal care unit and feto-maternal medicine unit, and acts as a tertiary referral centre for complex pregnancies throughout South Yorkshire. The hospital has specialist multi-disciplinary teams working with women with complex medical needs such as endocrine, renal and cardiac disorders, as well as complex social and psychological needs, such as teenagers and substance misusing women. These teams work collaboratively with other medical and social care practitioners. Community midwifery teams, largely based in children’s centres, provide low and high risk care, working in conjunction with hospital-based services, GPs, health visitors, family support workers and social workers. There are some specialist community midwives, for example working with homeless and asylum women.
At the time of the research women were referred to the Jessop Wing by their community midwife or occasionally by their GP, by fax or letter, completed as part of their first ‘booking’ appointment at their local children’s centre, GP practice or home. This first appointment represents the initial pregnancy risk assessment (STH 2012a,b), when women are categorised into low risk (midwifery-led) or high risk (consultant-led) care, based on medical, psychosocial or obstetric history. Screening and lifestyle considerations are discussed and the initial completion of the woman’s handheld maternity notes is undertaken. As a result of the referral, women are sent an appointment to attend for the second part of their booking appointment, at the Jessop Wing, with a target date of 12 completed weeks of pregnancy for this appointment. At the time of the research, this first hospital appointment involved women having a dating ultrasound scan, antenatal screening tests including serum screening for infectious diseases, blood group and antibody testing and haemoglobinopathy screening, and the assessment of Body Mass Index (BMI) and smoking status. For high risk pregnancies this visit also includes attendance at an obstetric-led clinic to plan care for the pregnancy. All women are offered a detailed anomaly scan between 20 and 22 weeks gestation.
Some women booking after 20 weeks gestation are categorised as high risk, primarily because of other risk factors such as age, medical history or substance misuse. There are no criteria for late booking women with no other risk factors to be routinely defined as consultant-led pregnancies, and if a placental localisation scan at 32 weeks gestation is normal women are returned to midwifery led care. However some are categorised as higher risk and offered extra monitoring, partially as a result of the inability of later scans to accurately determine gestation. As with women who do not attend for multiple antenatal appointments, midwives are required to complete a Common Assessment Framework (CAF) assessment for the unborn baby with women who book after 20 weeks gestation (STH 2012c). This is shared with the woman’s GP and Health Visitor, and the city’s Multi Agency Support Team (MAST), who provide preventative and supportive services for vulnerable families, and may result in a referral to social care services.