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Traditionally, clinical guidelines rely on objective evidence from quantitative research, largely derived from Randomized Controlled Trials (RCTs) of specific interventions in a defined healthcare area. Findings from qualitative research tend to be under-represented or overlooked because qualitative studies are more subjective, relatively small in scale and contextually bound. They may, however, contain important information about how a particular intervention works or doesn't work as well as relevant insights concerning the experiences, values and beliefs of key stakeholders with regard to the intervention or healthcare area. In recent years some novel approaches have been developed to address the lack of qualitative data within clinical guidelines. The most popular of these approaches is 'qualitative synthesis', a method that brings together the findings from isolated qualitative studies exploring the same or similar phenomena with a view to eliciting new, more abstract findings such that the whole is greater than the sum of the parts. More recently, techniques derived from qualitative synthesis have been adapted and used to inform global guidelines in the field of maternity care. Recognition that the findings from qualitative synthesis constitute a form of 'evidence' represents a major breakthrough for qualitative research generally but the newly emerging field is a highly contested area. There are internal tensions relating to the nature of qualitative synthesis itself, including the methodological and philosophical basis of the approach, as well as wider tensions relating to the incorporation of interpretive findings into the positivist frameworks associated with clinical guidelines. By referring to eight publications I have either authored or co-authored I will explore the qualitative synthesis landscape from its roots in the interpretive paradigm to its current application in guideline development. I will start by placing qualitative synthesis within the wider context of qualitative research and introduce the most commonly used synthesis technique, meta-ethnography. I will go on to examine some of the methodological, terminological and philosophical tensions that continue to challenge the credibility of this approach and highlight how I have addressed some of these issues by referring to several qualitative syntheses I have published. I will explain how the findings from these syntheses have been incorporated into clinical guidelines in maternity care and highlight some of the compromises that have been made to accommodate this endeavour within the wider context of Evidence Based Medicine (EBM). I will draw on some of the writings of the German philosopher, Jürgen Habermas, and explore how Habermas' concept of colonization might be applied in this context to illuminate some of the areas of contestation. By developing some of Habermas' theoretical discourse I will suggest that the method of qualitative synthesis is evolving in an 'interference zone' where competing claims for integrity strive for priority. I will juxtapose this position with a more utilitarian view of qualitative research and suggest that the findings from qualitative synthesis reflect a wide range of views, beliefs and experiences and represent a collective voice that can be utilized by guideline panels and policy makers. Finally, I will draw on the work of Carl Rogers, psychotherapist and pioneer of the 'person centred care' model, to illustrate how a patient led approach to guideline development, using qualitative-synthesis as a method, might represent a shift in global healthcare strategy towards more authentic and inclusive guidelines.

Birth is an important time in a woman’s life. While the journey into motherhood can be a transformational and liminal experience, unfortunately, this is not the case for every woman. It is estimated that approximately 30 % of women experience childbirth as a traumatic event, with up to 4% of women in community samples developing Post Traumatic Stress Disorder (PTSD) following childbirth. It is also highlighted that women who are vulnerable and disadvantaged, due to complex life situations such as poor mental health, poverty and social isolation, are more likely to experience birth trauma and PTSD onset. Recent research highlights that women’s subjective experience of birth is one of the most important factors in determining birth trauma, and that negative interactions with health care professionals are a key contributor to its development. The aim of this study was to develop and evaluate a training programme for maternity care providers to raise awareness of birth trauma amongst disadvantaged and vulnerable women. A critical pedagogical approach was adopted so that the design of the programme would aid reflection, critical thinking and conscientization. This study includes a meta-ethnographic review, empirical interviews and the design and delivery of a tailored educational programme within an NHS Trust. Firstly, a meta-ethnography was undertaken to explore disadvantaged and vulnerable women’s negative experiences of maternity care in high income countries. Noblit & Hare’s (1988) meta- ethnographic approach was used and four themes were identified through the synthesis of eighteen studies; ‘Depersonalisation’ ‘Dehumanisation’, ‘Them & us’ and ‘No care in the care’. Secondly, ten local disadvantaged and vulnerable women in North West of England were recruited and interviewed, exploring their negative experiences of birth. A framework analysis was used to interpret the data, identifying key triggers for birth trauma, focused on interpersonal interactions with maternity healthcare professionals. These findings were then compared against studies included in the meta-ethnography. Following these stages an innovative educational programme focused on birth trauma and PTSD was developed and evaluated. Key findings from the meta- ethnography and the empirical interviews informed the content of a filmed childbirth scenario that was embedded within a critical pedagogical framework. The scenario was delivered to participants’ using virtual reality (VR) technology, forming part of a 90- minute educational programme, in which maternity professionals view the scenario from a first-person perspective. Other elements of the education programme involved providing statistical evidence on birth trauma and PTSD, a presentation of qualitative data collected during empirical phases, critical reflections and the development of actionable practice points to change/influence care practice, for self and others. Ten maternity professionals participated in the evaluation, with pre/post questionnaires and a follow-up session used to assess participants attitudes, knowledge and experiences prior, during and following attendance. Findings suggest the immersive educational programme increased participants understanding and knowledge of birth trauma and PTSD, with the use of VR as a tool for knowledge translation found to enhance critical reflection and facilitate praxis. While further research to test the efficacy of the educational programme on women’s birth experiences is needed, simulated first person realities, embedded within a critical pedagogical framework, offer a unique and innovative approach to addressing interpersonal care in maternity and wider health-related contexts of care.

Inequalities in UK breastfeeding initiation and continuation rates exist whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and consequently third sector breastfeeding organisations are commissioned to deliver UK BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, and a key evidential gap concerns understanding interaction between context and intervention. This study explored how and why these organisations have developed BPS services within socio-economically deprived contexts. The study was completed in two phases. During phase one an exercise was undertaken to establish background information about the four main UK breastfeeding organisations. Semi-structured interviews with BPS organisation strategists and representatives (n=7) were undertaken, complemented by a meta-synthesis of published literature. Phase two constituted case studies of two BPS services in different areas of deprivation in England. Semi-structured interviews were undertaken with: mothers who had (n=10) and had not engaged (n=9) with the BPS services, peer supporters (PSs) (n=9), community health professionals (n=5), infant feeding co-ordinators (n=2), third sector organisation managers (n=3), and public health commissioners (n=2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse data. One over-arching theme and four main themes were constructed. The over-arching theme ‘the transcending influence of society’ explains how the combination of funding availability and data sharing arrangements, determined service operation and PSs access to women. Although commissioners required that more support be given to the target group of women, this was not always achieved. The acceptability of the peer support role, operating at the individual, social group, and community levels was captured by ‘the role’ main theme. The second main theme, ‘access,’ concerns developments to improve the access of target women. The third main theme, ‘embedding’ describes the community-professional connections for supporting access. The final main theme, ‘service management’ captures issues of funding and the relationship with time, communication, and reporting. Findings suggest that organisational practices do not facilitate the discussion, collection, and use of contextual knowledge to inform ongoing development of BPS services. Recommendations include development of a theoretical tool to facilitate the use of contextual knowledge.

This thesis presents the findings of an original study that explored NHS midwives practice of facilitating women's alternative physiological birthing choices - defined in this study as 'birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth'. The premise for this research relates to dominant sociocultural-political discourses of medicalisation, technocratic, risk-averse and institutionalisation that has shaped childbirth practices in the UK. For midwives working in the NHS, sociocultural-political and institutional constraints can negatively impact their ability to provide care to women making alternative birth choices. A meta-ethnography was carried out, highlighting a paucity of literature in this area. Therefore, the aim of this study was to generate practice-based knowledge to answer the broad research question: 'what are the processes, experiences, and sociocultural-political influences upon NHS midwives' who self-define as facilitative of women's alternative birthing choices'. Underpinned by a feminist pragmatist theoretical framework, a narrative methodology was used to conduct this study. Professional stories of practice were collected via self-written narratives and interviews to understand the processes of facilitation (the what, how, why), their experiences of carrying out facilitative actions (subjective sense-making), and what sociocultural-political factors influenced their practice. Through purposive and snowball sampling, a diverse sample of 45 NHS midwives from across the UK was recruited. A sequential, pluralistic narrative approach to data analysis was carried out, and a theoretical model was developed using the whole dataset. The findings were subjected to three levels of analysis. First, 'Narratives of Doing' highlight how and what midwives did to facilitate women's alternative choices. The sub-themes reflect the temporal nature of a wide range of actions/activities involved when caring for women making alternative birthing decisions. The second analysis; 'Narratives of Experience' - highlighted the midwives polarised experiences captured as 'stories of distress', 'stories of transition,' and 'stories of fulfilment'. For the third level of analysis, a theoretical model of 'stigmatised to normalised practice' was developed using notions of stigma/normal, deviance/positive deviance. A six-domain model was developed that accounted for the midwives sociocultural-political working contexts; micro, meso, and macro. The implications of this research related to a number of identified constraints, protective factors, and enabling factors for midwifery practice. Key barriers included negative organisational cultures that restricted both midwives' and women's autonomy. Disparities between the midwives' philosophy and their workplace culture were highlighted as a key stressor and barrier to delivering woman-centred care. Protective factors related to the benefits of working in supportive, like-minded teams that mitigated against their wider stressful working environments. Facilitating factors included positive organisational cultures characterised by strong leadership where midwives were trusted and women's autonomy was supported. Therefore, this study has captured what has been achieved, and what can be achieved within NHS institutional settings. Through the identification of both challenges and facilitators, the findings can be used to provide maternity professionals and services with insights of how they too can facilitate women's alternative birthing choices.