Transcript Maternal Mortality - I research for Birth

Cross-cultural comparative
research methods
workshop
Kuopio, Sept. 2011
Prof. Edwin van Teijlingen
www.bournemouth.ac.uk
Is cross-national research
possible?
“Holland differed enormously from other countries …. also in
its arrangements for childbirth… It is difficult, given
these factors, to find bases for comparison.
In
attempting to explain such differences, we are also drawn
inevitably into an analysis of Dutch society and economy,
educational provisions ... the culture surrounding childbirth
…”
Lieburg van M.J. & Marland, H. (1989) Medical History 33: 296-317
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Overview
Traditional approaches to
comparative research /
cross-national studies.
Decentred Comparative Research
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Strengths comparative
research
• You learn to question your own ways of doing
things from observing the “strange” ways of others.
• You can (may) study approaches which have not
been considered in certain countries, for example,
“looking at the problems from a different angle,
questioning present practices, raising warnings as
to possible negative effectiveness”
(Collins et al. 2000: 97).
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Traditional approaches
Types of comparisons:
• Over time;
• Between geographical areas;
• Between populations within a
community / society
• Between countries / cultures
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Comparisons over time
Expected age at death
Figure 1. Average life expectancy
90
80
80.4
80
70
60
50
66.5
62.9
80.5
81.3
69.3
73.3
69.1
83.7
80.5
76.3
61.6
54.2
47.2
40
Birth
1
15
Age of woman
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45
65
1888
1930
1999
Comparisons by sub-group
in population
Girls in developing countries are generally
disadvantaged in the education system:
• less likely in secondary education than boys;
• those in rural areas are particularly
disadvantaged;
• but, today’s adolescent girl is 2 to 3 X more
likely to receive an education than her mother.
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Comparing at different levels
Example I
comparison between countries
Example II
comparison between regions
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Problems with
epidemiological data
• Data sets differ between areas;
• Data are collected for a different reason, often they do no
exactly address our research question;
• Definitions of topic under research vary between areas;
• Cultural differences in interpreting survey questions
introduces differences in the data sets;
• Data sets are incomplete/ missing data;
• Response rates to survey underpinning data sets varies;
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Overview
Traditional approaches to comparative
research / cross-national studies.
Decentred Comparative
Research
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Introduction / aim of BBD
The main goal of this international
project was to bring together
researchers located on both sides of
the Atlantic, who, until that time, had
almost exclusively focused on
issues pertaining to maternity care
within their own academic
disciplines and national boundaries.
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Shaping a Network
of Local Researchers
BBD brought together researchers from two
continents and 9 countries;
while some had done two-country comparisons,
BBD involved comparisons of up to four
countries at a time;
examining everything from the training of
maternity care providers to public policy, to
attitudes of women about desirable care.
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Culture & Society
?
What is main task of the
state in the provision of
maternity care?
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Main task of the state?
Americans replied: "To ensure that individual women
have freedom of choice” and "to make choice
available for childbearing women".
Europeans: "to ensure that the poorest women in
society have access to a reasonable quality of
maternity care" and "to ensure that all women
have access to good maternity care".
... we were talking from our own culturally colored
perspectives.
(DeVries et al. 2000: xvi)
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Cause or effect?
“We
do not wish to discount the role of clients
in the creation of maternity care systems, but
we are keenly aware that opinions about
health care are as much a product as a
cause of that care.”
DeVries et al. (2001) ‘What (and why) do women want?’
In: Birth by Design, Routledge, NY, p. 244.
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Comparative studies in
maternity care
Structural:
• organisation of health care, welfare state, politics,
law, economy, etc.
Cultural:
• attitudes, general views, expectations of a
population, ‘the way things are done here’, etc.
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Lessons BBD
• When we began our work together, our
natural inclination as sociologists was
to look for structural explanations for
the variation we discovered – the
tradition in the field of medical
sociology is to use differences in social
structures to explain varied health care
delivery systems.
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Lessons BBD
• Structural explanations were insufficient:
they simply push the question back one
level. For example, our research
uncovered important differences in the
power of professional groups to influence
health care policy – differences that had
significant influence on how maternity
care was delivered.
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Problematising Terminology
Comparing like with like?
• Trained nurse-midwife
• Direct-entry midwife (NB: UK vs US meaning)
• Midwifery assistant / maternity care assistant
• Maternity benefits
• Economic migrant
• etc.
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Comparative
research
Comparative studies
•
•
Cross-national research helps one to look at
problems from a different angle, questioning
current practice, warn against side effects, etc.
I.e. there exist ways of doing things which have
not been considered in the UK (or Germany or
Finland or …..) .
Cognitive psychology recognises that cognition
is a situated process and that knowledge is a
collaborative, culture-bounded effort.
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Decentred method I
key aspects:
•
•
•
add context to seemingly context-free concepts.
challenge ethnocentrism in cross-national research.
all contexts are perceived as problematic & in need of
explanation.
•
team of scholars rooted in multiple communities.
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Decentred method II
BBD used decentred method to fashion a multilevel
Macro
Meso
Micro
framework that used meso level of organization
(i.e., health care organizations, professional groups
and other concrete organizations) as an analytical
point. Our method departs from traditional
comparative health systems research that is mostly
conducted at the macro level.
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Decentred method III
Decentred comparative research – addresses the often
unacknowledged ethnocentrism of traditional comparative
research. Decentred cross-national research draws on the
socially-situated and distributed expertise of an international
research team to develop key concepts & research questions.
Decentred method IV
“International collaboration, if pursued more
systematically, is a strategy for individual
researchers to become more cosmopolitan in their
reflexivity….”
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Recent example
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Salway et al. (2011) I
Salway and colleagues adopted:
“… frameworks that encompass both
national-level contextual specificity and
universal patterns or trends [Hantrais
1999; Wrede et al. 2006].”
“We adopted approach that did not seek to
impose standard concepts or measures
(something we felt was neither
conceptually nor operationally feasible)
but rather to work with the national
peculiarities of our three countries.”
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Salway et al. (2011) II
• We worked “with and against the established
discourses …to understand …migrant/minority groups
and the implications for maternal health. Such an
approach offered potential for important new insights.
• BUT moving beyond accepted concepts and terms
may create problems at a country-level. We … need to
engage with local stakeholders and to generate
research products that were meaningful and
applicable to these actors; suggesting the importance
of employing familiar concepts and terminology.”
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Final Note: Culture
Sharing a culture does not mean people
are in agreement on specifics, only that
they possess a similar understanding of
how the world works.
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References
Benoit et al., 2005, Understanding the social organisation of maternity care systems, Sociol Health Illness
27: 722-37.
Collins et al. (2000) NHS reforms in UK & learning from developing country experience. J Man Med, 14: 8799.
DeVries, R, et al. (eds..), 2001, Birth by Design: Pregnancy, Midwifery Care & Midwifery in North America &
Europe, NY: Routledge. [ISBN 0-4159-23387]
Galtung, J., 1981, Structure, culture, and intellectual style, Soc Sci Information 20(6): 817-856.
Hantrais L (1999) Contextualisation in cross-national comparative research. Int J Soc Res Meth 2(2):93-108
Lieburg van MJ & Marland, H, 1989, Midwife regulation, education, and practice in the Netherlands during the
Nineteenth Century. Medical History 33: 296-317
Lupton, D, 1994, Medicine as Culture: Illness, disease & the body in Western Societies, London: Sage
Payer, L., 1990, Medicine & Culture, London: Victor Gollancz Ltd.
Wrede, S., et al. (2006) Decentered Comparative Research: Context Sensitive Analysis of Health Care, Soc
Sci & Med, 63: 2986-2997.
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Cross-cultural comparative
research methods
workshop
Thank you!
Edwin van Teijlingen
www.bournemouth.ac.uk