Cross- cultural surveys:
Experiences from the field
Ans Luyben, PhD PGDE RM, R & D Midwifery
Overview of presentation and workshop
Experiences of doing a cross- cultural doctoral
study:
1. What was done before I did it?
2. Why I did what I did?
3. What happened when I did it
4. And what I learnt….
Cross- national background
 Born in the Netherlands 1961, trained and worked as a
midwife
 Emigration to Switzerland in 1989, worked as a midwife and
teacher
 PhD study Scotland 2001- 2008- looking for a topic for
study;
 Doubt about content of (Dutch) antenatal care
Existing knowledge about antenatal care
Doctoral thesis Heringa (1998), based on study of Hall in
Aberdeen (1985)
Experiences of care providers in practice
Studies on effectiveness
 Effectiveness and satisfaction in antenatal care
 Effective care in pregnancy and childbirth
 Cochrane Library, for example Villar 2001
 Other studies, particularly those carried out in Europe
Summary existing knowledge
 1920s: Introduction of antenatal care in Europe
 Effectiveness determined based on traditional statistical
outcome (mortality, morbidity)
 1950s: Introduction of confidential enquiries
 1989: Effective care in pregnancy and childbirth
 2000s: Assessments of content still inconclusive
 Women‘s complaints hardly changed
Primary research question
What is effective content of antenatal care in
Europe?
Existing cross- national studies
Comparative surveys and studies in Europe
 WHO 1979- 1984
 HSRC of EU: Heringa & Huisjes 1988
 Barriers and Incentives to Prenatal Care 1994
 EuroNatal Study 1996
 PERISTAT 2003
Several others, like:
 ESS, OECD, EMA
 Haertsch, Langer
 Villar et al.
WHO Study 1979- 1984
Questions:
 What is known about women‘s and children‘s health around
childbirth?
 What health care services are available?
 How big is the gap between what is known and what is
being done? (or not being done)
Included: 23 countries
Methods:
 Systematic literature review
 Two surveys (organisation/ content, psychosocial)
 Observations of experiences in care
WHO Study 1979- 1984
Some results:
 Wide variety of programmes with similar MMR or PMR
 Antenatal care should be improved by a better combination
of medical and social care
 Effectiveness of risk selection should be assessed
 Role of primary provider should be reconsidered
 Interventions, including risk selection should be better
evaluated, eg. in RCTs
 Evaluation should include the role of the client/ provider
relationship
 Women should be empowered by determining their health
needs, planning and evaluating their care
Heringa and Huisjes 1988
Health Services Research Committee EU 1986:
- Aiming for harmonisation of systems
- Evaluation of efficacy, effectivenes, costs and
psychological and social impact
Heringa & Huisjes 1988:
Evaluation of existing screening procedures:
 Literature review
 Survey in 67 tertiary hospitals, questionnaire with closed
questions (30 procedures)
Heringa and Huisjes 1988
Results:
 Wide variation of 11 to 24 routinely performed screening
tests between as well as within countries
 Only 5 tests in common: blood pressure, glycosuria,
weight, blood group/ Rhesus and fundal height
 Effectiveness for many procedures was lacking
 „Benefits of routine screening are probably overestimated
and disadvantages undervalued“
„Barriers and Incentives“ 1994
 Premise: Uptake of antenatal care improves pregnancy
outcomes
 Aim: Studying the utilisation of antenatal care, in particular
under- or overutilisation
 Included: 17 European countries
 Multi- study design, included:
- attendance of antenatal care
- incentives
- organisation related to utilisation and PMR
„Barriers and Incentives“ 1994
Results:
 No relationship between incentives and attendance of
antenatal care
 Variety in attendance, but women‘s reasons for non- or late
attendance were not studied
 Large variety in services, equally effective in regard to PMR
 More information needed about relationships between the
players and characteristics of the systems
EuroNatal Study 1996
 Aim: Determining the validity of PMR as an outcome
indicator for the quality of antenatal and perinatal care
 Assumption: PMR can be reduced by 25% by improved
standards of care
 Included: 11 countries
 Design:
- investigation in different registration practices
- investigation of risk factors influencing PMR by auditing
individual cases
EuroNatal Study 1996
Results:
 1619 anonymous cases of perinatal death between 1995
and 1998
 Linked to prevalence and clinical guidelines
 715 cases of suboptimal care
 Major factors: failure to detect and treat intra-uterine growth
retardation and maternal smoking
 Recommendation:
- improvement of quality of care
- identification of determinants of quality of care
PERISTAT 2003
 Aim: Develop indicators for monitoring and describing
perinatal health in Europe
 Included: 15 countries
 Process:
- review of existing international and national perinatal
health indicators by experts
- Delphi consensus process with a scientific committee in
order to determine indicators
- feasibility study in involved countries as to assess their
use in practice
PERISTAT 2003
Results:
 Four categories of indicators: fetal/ neonatal health,
maternal health, sociodemographic associated with health
outcomes and health services
 Few lacking indicators in regard to women, eg. „support to
women“ and „maternal satisfaction“
 Feasibility: some indicators were not available, some had
different definitions and demographic differences
influenced their values
Villar et al. 2001
Aim: Prove evidence of effectiveness of an antenatal
programme with a reduced number of visits and reduced
content in four developing countries
Setting: Argentina, Cuba, Saudi Arabia and Thailand
Design:
 Systematic literature review
 Randomised controlled trial with cluster randomisation,
including compliance and process outcomes (service use)
 Cost- effectiveness
 Women‘s and provider‘s perceptions
Villar et al. 2001
Results:
Routine antenatal care can be provided with a reduced number
of visits and content without affecting its medical
effectiveness
 Primary and secondary clinical outcomes similar, although
rates of pre- eclampsia higher in new model
 Health care costs similar, or even less in new model
 Care providers were satisfied as long as modifications „did
not limit their clinical control“
 Women were „satisfied“ with new model, but…
 Provision of support should be provided by other means
than „formal encounters with medical providers“
Concept analysis of effectiveness
Perspectives
Women
Biological/
Other(s)
epidemiological disciplines
Antecedents/
Aims
Becoming a
mother; own and
family health
Reduction of
PMR, MMR and
morbidity
Quality,
satisfaction,
experience
Clinical
effectiveness
Terminology
varying e.g.
evaluation
Consequences/
Indicators
(Dis-)
Satisfaction,
experience
Biomedical/
epidemiological
outcome
Variety- little
available and
comparable
Evaluation
methods
Surveys,
qualitative
interpretive
Quantitative,
deductive
RCTs
Depending on
agent and
perspective
Attributes
Variety
Research question
What is effective content of (Westeuropean)
antenatal care from women‘s points of view in
the Netherlands, Scotland and Switzerland?
Methodology and methods
Several considerations:




Top- down or bottom- up approach ?
Deductive or inductive ?
Descriptive or analytic ?
Access and availability ?
 Methods ?
Methodology and methods
 Constructionist epistemology
 Interpretive ontology
 Grounded theory
 Symbolic interaction
 Interviews, and possibly other material
Settings and access
Cross- national or - cultural
Three languages
Three health care systems
What is culture?
„A set of explicit and implicit guidelines which
people learn from a particular society and which
informs them on how to view the world, how to
experience it emotionally, and how to behave in it
in reaction to other people, to the supernatural
and to the natural environment.“
(Helman 2007, p. 2)
GT considerations in regard to culture
 Symbolic interaction:
Culture is the self- defined social world of the participants
based on joint meanings of symbols
 Meanings are a consequence of the research process; they
can not be defined in advance
 The field is addressed as one unit, and every variable has
to earn ist place in the theory based on the relevancy for
women
 Need for cultural neutrality and sensitivity (familiarity)
What is language?
 Symbolic interaction:
Joint meanings of symbols created through interaction with
the social world (Mead 1967)
 Coding in Grounded Theory:
Translating language into a secret set of symbols (Dey
1999)
 Minimal translation (Barnes 1996, Strauss and Corbin 1998)
 This meant that meanings had to be created (coding) with
women in one language, before creating meaning (coding)
between all languages
Design: Grounded Theory with Units
Continuous comparison
Theoretical sampling
Maternity care in the 3 countries
Care
Switzerland
Holland
Scotland
Place
Private
practice or
hospital
Midwifery
practice or
hospital
Health care
center or
hospital
Persons
Gynaecologist Midwife
(Midwife)
(Obs/ Gyn)
Content
KVG, varies
Interprofessio- Framework for
nal guideline
Scotland NHS
Philosophy
Decentral
organisation
and choice of
care provider
Maintenance
of divisions of
echelons
Shared care
Health care for
all in need
Gaining access and ethical approval
-
Knowing the system
Having some relevant informants
Speaking the language, knowing the culture
„Being there“ or „having been there“
Recruiting and sampling
 Information and consent forms in 3 languages
 First sample convenience sample (variation)- clear
communication about sampling if more persons involved
 Other samples: theoretical samples
12 women
14 interviews
10 women
12 interviews
10 women
12 interviews
Data collection and field experiences
 Organisation of units of interviews, planning in advance
 Semi- structured one- to- one interviews by one researcher
in women‘s own languages, tape recorded, minimum
interview guideline
 Excellent way of „meeting“ the context
 Differences in set up of meetings
 Field notes, role of field notes
 Collection of information in practices and hospitals
Data analysis
 Transcription in own language
 Coding in own language
 Categorising; primarily in own language, then into the
overall unit, using the distinction between an „etic“ and
„emic“ dimension (Brislin et al 1973); what fits and what is
different ?
 Four memobooks; one in Dutch, Swiss- German and
English and one for the overall unit
 Theoretical sampling; looking for largest variation
 No software used for qualitative analysis
Coding and categorising „live“
Netherlands
Scotland
Results after analysis first sample
Category
Scotland
Switzerland
Netherlands
Responsibility
X
X
X
Autonomy
X, „control“
~, not content but X, also „letting
organisation
go“
Confidence
X
X
X
- Information
X (++)
~
X
- Environment
X
X
X (+)
- Baby
~
~, partly
X
- Care provider
~
X
X
Results I: Model of Effective Maternity Care
Results III: Model of Content of Care
Conclusions and implications
Effective maternity care needs:
•
•
•
•
•
Mentorship model of maternity care
Choice of an experienced care provider
Sharing woman- care provider partnership
Women- and process- orientated content of care
Continuity of care and carer; from beginning of pregnancy
to about one year after giving birth
• Involvement of women‘s social environment
Reality in the three countries
Category
Scotland
Switzerland
Holland
Being experienced
+
+
+
Providing a familiar
environment
~
~
+, if bond
Guidance (care)
~, access/ attitude
~, attitude/ bond
+, attitude/ bond
Raising awareness
+
+
+
Sharing awareness
~
~/+
+
Closing awareness
+, self
~/+
+
Being there
+/ ~
~/+
+
Support
~
~/+
+
Releasing
~
~
+/~
Results III: Creating a bond with a care
provider
„Someone who is always there for me..“
Finding access
Approaching
Being familiar
Reality in the three countries
Category
Scotland
Switzerland
Holland
Someone who
is always there
for me
Shared care
Gynaecologist
Midwife
Gynaecologist
Finding access
Hospital
Health center
Private practice
Private practice
Hospital
Approaching
Midwife
Gynaecologist
Known ???
Gynaecologist
Midwife
Midwife
Gynaecologist
Being familiar
?
?
Midwife
Reality in the three countries
Effective care: what happens if not continuous?
Category
Expert/Reference
Information/ Raising
awareness
Sharing
Support
Guidance
Releasing
Netherlands
Switzerland
Scotland
Some points of experience
One size does not fit all….
„English speaking empirialism“ in literature
Underpinning philosophies of systems are very important
Language= not language, even in English
Words are not always what they seem. Dialectical
construction of meaning is an extremely valuable tool
 Competence of multi- cultural, multi- language researchers
(vs. translators eg. Squires 2009) is underestimated
 The biggest issue in qualitative research done this way is
not bias of the researcher, but her loss of reference, which
might be a reason why most prefer deductive approaches





Some open questions
1. Is what we do important?
2. Do we do what we think we do?
3. Are we measuring what we want to measure?
(according to Heringa 1998)
Thank you !