Conversation Analysis & Clinical Encounters, University of Oxford

2 July 2024

Presenter: Clare Jackson

Title: Doing risk surveillance and management during labour 

Abstract: In the UK, midwife-led care is available for low-risk pregnant individuals expected to have a ‘normal’ delivery at full term. Despite midwives’ emphasis on the physiological normality of labour, national guidelines mandate continuous risk surveillance throughout the intrapartum period. NICE Guidelines, for example, require frequent monitoring of fetal heart rate, maternal pulse, blood pressure, and temperature. Despite the low-risk context, this paper explores the situated accomplishment of risk surveillance in interactions between labouring women and midwives using conversation analysis.

The study, based on 37 recorded interactions in two UK midwife-led care units from 2018 to 2019, reveals two ways in which risk surveillance is interactionally routinised. Firstly, midwives implicitly refer to NICE guidelines, incorporating them into routine care. For instance, a midwife might say, “I’ve got to be listening to the baby about every 15 minutes.” Secondly, midwives frequently use presumptive formats to initiate surveillance activities, such as stating, “I need to do your pulse.” 

These activities are presented as taken-for-granted, and as not requiring explicit verbal agreement, although this is commonly forthcoming. Positive assessments may be used to indicate no risk has been detected. However, when risk is detected, it is not generally immediately disclosed and may first lead to rechecking (e.g., following a monitoring, a second midwife says ‘((Midwife’s)) just asked me to count these heart beats…’). The disclosure of risk detection is handled delicately (e.g., Baby’s heartrate’s a little lower than: when you came in…’). This information prompts risk management planning, involving increased observation frequency or changes in assessment methods. In some cases, transfer to obstetric-led care may be recommended.

The study concludes that the seemingly low-risk nature of midwife-led care is contingent on ongoing risk surveillance. Risk surveillance is interactionally produced as both required and routine. Risk detection implicates increased surveillance and/or transfer to obstetric care.

Expert Panel Workshop Centre for Translation Studies, University of Surrey

7th March

Presenter: Ellen Annandale

Title: Midwifery Interactional Practices

Normal Labour and Birth Conference. Grange-Over-Sands

24 April 2023 – 26 April 2023

Presenters: Ellen Annandale and Clare Jackson

Title: Who Makes the Decisions about Pain Relief, and How?

Abstract: Patient involvement in decision-making during birth is enshrined in UK policy and in practice guidelines, and consistently endorsed by practitioners and people giving birth. However, research consistently points to the challenges of translating this aspiration into practice. We address why these tensions persist by analysing how they play out in practice. We present the headline results of a recently completed NIHR-funded study involving video and audio recordings of 37 births captured in real-time, pre- and post-natal surveys of over 100 women in two English NHS midwife-led units. We show that despite midwives’ intentions to engage women in decisions, in actuality, they initiated the majority of decisions and in formats that did not invite participation (beyond consenting). However, the extent of optionality afforded by midwives varied by decision type; women had the most involvement in decisions about pain relief and the third stage of labour. When women initiated decision-making, it tended to be in the form of requests for pain relief, suggesting that this is the arena that they feel most entitled to involvement. Pain relief decisions involved substantial pursuit and negotiation, making them the most complex in our dataset. The presentation will involve the showing of a video dramatization where midwives from the Progress Theatre enact how pain relief decisions were made, alongside the presentation of conversation analysis of interactions and the survey data.

British Sociological Association Medical Sociology Group Annual Conference, Lancaster University 

14 September 2022

Paper 1: Is shared decision-making during childbirth possible?

Presenters: Ellen Annandale and Clare Jackson

Abstract: Patient involvement in decision-making during birth is enshrined in UK policy and in practice guidelines and consistently endorsed by practitioners and people giving birth. However, research consistently points to significant difficulties of translating this aspiration into practice. The tensions between ‘listening to women’, adherence to clinical guidelines concerning risk management and organisational cultures are well-documented and brought to the fore recently with the publication of The Ockenden Report. We address why these perennial tensions persist by analysing how they play out in practice. The analysis draws on a mixed methods study (NIHR funded) involving video and audio recordings of 37 births captured in real-time, pre- and post-natal surveys of over 100 women and 20 semi-structured interviews with practitioners in two English NHS midwife-led units. The analysis (which is completed) shows that despite midwives’ intentions to engage women in decisions, they initiated the majority of decisions in formats that did not invite participation (beyond consenting). Women were afforded limited optionality in decision-making as midwives oriented to guidelines/standard clinical practice in pursuing particular outcomes. However, the extent of optionality midwives varied by decision type; women had the most involvement in decisions pertaining to pain relief and the third stage of labour. Despite limited involvement in decision-making in actuality (compared to pre-natal expectations), postnatal satisfaction was high. We found no relationship between midwives’ use of different formats of decision-making and aspects of satisfaction. However, women’s initiation of decisions, particularly relating to pain relief (e.g., making lots of requests), was associated with lower satisfaction.

Paper 2: Talking cervixes: How time, objects and subjects are made in interactions during labour and birth

Presenter: Siân Beynon-Jones

Abstract: The clock occupies a prominent position in many feminist and midwifery critiques of the medicalisation of labour and birth. Concern has long focussed on the production of standardised ‘progress’ during labour, via the expectation that, once in ‘established’ labour, women’s cervixes should dilate at a particular rate, measurable in centimetres and clock time. Research has emphasised that women’s status as subjects is frequently undone through the measurement and recording of the behaviour of their cervixes. In this paper, we develop this work by exploring some of the complexities involved in constituting people in labour/their cervixes as objects/subjects. Our analysis draws on 37 video and audio recordings of women’s interactions with midwives in midwife-led units during labour in two English NHS trusts. We consider how the relations between women and their cervixes become differently constituted through clocks and measurements of dilation, as well as the role of women and midwives in these processes. It is through such fine-grained analysis, we suggest, that it becomes possible to pinpoint when and how clocks and cervical measurements trouble the positioning of people in labour as decision-making subjects. This study was funded by the National Institute of Health Research (NIHR).

32nd International Confederation of Midwives (ICM) Virtual Triennial Congress (Online)

30 June 2021

Title: The VIP study: Video informed practice & voices in partnership Interactional practices of decision-making during childbirth in two English Midwifery Led Units

Presenters: Helen Baston, Ali Brodrick, Clare Jackson, Tomasina Stacey

Abstract:  This symposium presents the rationale, findings and reflections from a National Institute for Health Research funded study designed to elicit how midwives, women, and birth partners facilitate and negotiate decision-making during labour in two English NHS midwife-led units (MLUs). This NHS ethically approved study is ground-breaking in its analysis of real-time video/audio footage of decision-making during labour and birth. 

Paper 1 – Use of video in labour as a data collection tool: reflections on the journey. Few studies have used intrapartum video/audio recording; hence the willingness of staff to participate, and receptiveness of women and partners to be filmed were largely unknown and difficult to predict. Insights will be shared regarding the initial concerns of staff, recruitment to the study and IT governance requirements, and how these were addressed.

Paper 2 – Reconciling maternity practice constraints with the personalisation agenda: healthcare practitioners’ perspectives. In the midwifery profession, the perceived threat of complaints and litigation has been linked to an erosion of midwives’ autonomy.  Advocating for women may feel challenging and can impact on the way care is offered. Drawing on interview data we show how women’s choices and wishes may be marginalised to avoid professional challenge and to align care with the expected cultural norms and ethos.

Paper 3 – The power of CA:  Identifying situated interactional practices for managing and sharing decision-making during labour. The use of CA enables identification of decision trajectories and exploration of their nature, origin and outcome. We shed light on the interactional strategies used by women, their companions, midwives and obstetricians when initiating and negotiating care. We show whether and how these participants treat decisions as shared (or not). Data extracts demonstrate how approaches change depending on the responses received and emerging clinical context.

Paper 4 – Video informed practice: facilitating learning and practice change using forum theatre. Forum theatre is a dynamic methodology within implementation science and is employed in a workshop format to share VIP study findings. It enables the audience to challenge and shape solutions to real practice scenarios and create a vision of how things could be different. This final part of the symposium will showcase an element of the workshop demonstrating how this methodology can influence change. 

Common focus: This symposium comprises four linked sessions. It uses conversation analysis (CA)- a leading approach to understanding how interaction works in situated practice – to examine how decisions are initiated, by whom, and with what consequences. The analysis is also informed by interviews with midwives and obstetricians exploring the context of care and by data from antenatal and postnatal questionnaires capturing women’s expectations and evaluations of their experiences. Analyses from these data will be shared, including reflections on the use of this methodology.  The symposium will also include footage of the innovative dissemination method ‘forum theatre’ used to accelerate learning from the research findings and support practice change. 

Cohesion between sections: Numerous studies show the nature of the interaction between a labouring woman and her caregivers is key to a woman’s experience. We know communication in labour matters, however, we do not know what practitioners say and do in practice that leads to these appraisals and outcomes. The VIP study addresses this gap in knowledge about what actually happens in labour through: 

1.  One-to-one interviews with midwives and obstetricians 
2. Antenatal and postnatal questionnaires exploring women’s expectations and experiences of birth
3. Video (or audio record if women prefer) of the labours of 30 low-risk women receiving Midwife-led labour care. 
4. Analysis of decisional interactions using CA to inform understanding of how talk works. 
5. Looking at patterns between how satisfied women were with their experience and the decision-making interactions that actually happened during birth. 
6. Sharing findings and facilitating learning using ‘Forum theatre’.

Application to midwifery practice, education or regulation/policy

The study findings elucidate how communication with women is key to the facilitation of decision making in labour. It identifies the key components of interactions in practice and how these are perceived. The symposium draws on implementation science to present innovative ways to support midwifery practice change; through the use of Forum theatre.

International Conference on Communication in Healthcare (Online)

15 April 2021

Title: Conversation Analysis to analyse healthcare communication – from primary care to the operating table

Presenters: Inge Stortenbeker, Chiara Jongerius, Clare Jackson, Mike Huiskes

Abstract: Healthcare related communication is often complex and specific and each interactor has a delineated role. Conversation analysis (CA) can help to understand the means, procedures and methods that people use to structure social actions in natural spoken interactions. Finding its origin in sociology, it can provide in-depth and detailed insights into the characteristics of healthcare interactions, whether this is between patients and physicians or between healthcare providers. In this symposium, four studies will be presented using CA in various clinical settings (e.g., midwifery, orthopaedics), and based in various research methods (e.g. quantitative research, systematic review). The final discussion of this symposium focuses on how CA can be used for in-depth analysis in various settings and disciplines to better understand and improve communication practices in healthcare.

Program

1. The role of language in consultations about medically unexplained symptoms (15 minutes)

The absence of a specific underlying disease challenges patient-provider communication about medically unexplained symptoms (MUS). This systematic review synthesizes evidence from conversation and discourse analytic research about MUS consultations. We describe recurrent linguistic and interactional features, and provide a detailed understanding of the communicative challenges that patients and physicians face during these interactions.

2. Computer use in patient-physician conversations (15 minutes)

Computer use, and in particular use of the Electronic Medical Record, can influence the communication process between physician and patients. This presentation will present a conversation analysis on how physicians’ computer gazing behaviour (assessed using mobile eye tracking data of consultations) relates to their verbal communication. We show that physicians can switch their gaze towards the computer explicitly and implicitly. The latter can cause the conversation to pause. Patients, however, do not experience this as problematic, since they usually finish their sentences.

3. Managing decision making during childbirth (15 min)

Childbirth is a site of longstanding debate about the erosion of choice by medicalisation of practice. However, little is known about how decision-making is managed in real-time during labour. Using conversation analysis of 37 video/audio recordings of intrapartum care in two UK midwifery-led units, we examine interactional practices of decision-making.

4. Communication skills of doctors in the operating room (15 min)

Clinical workplaces bring physicians in training onto the main stage of learning; the place where they meet patients and supervisors. In earlier studies we analysed how residents shape (self-regulate) their learning strategies in the operating room (OR) and identified four strategies residents use to recruit expertise. In a follow-up study we analysed how supervisors regulate entrustment of autonomy (i.e., co-regulate learning). In this study we look at the dynamics of learning in OR. We use conversation analysis to describe how supervisors and physicians in training construct learning in the moment-to-moment, daily practice of the OR.

5. Group discussion: CA in your field (30 minutes)

Interactive group discussion will focus on generating ideas for advancing CA research in healthcare communication. Attendees will be invited to think critically about CA and its advantages and limitations compared to other research methods.

Centre for Maternal and Child Health Research Seminar, City University, London

18 January 2021

Title: Decision making during labour in midwifery-led units: A conversation analysis of women’s involvement

Presenters: Ellen Annandale, Siân Beynon-Jones, Clare Jackson

Abstract: In this paper, we present an overview of some key findings from an NIHR-funded study which sought to explore interactional practices of decision-making that take place during labour in midwifery-led units (MLUs). An understanding of how decisions are made in practice is important because women’s retrospective accounts of birth show that greater involvement in decision-making is associated with greater postnatal satisfaction and well-being and decreased anxiety. Nonetheless, little is known about how decisions unfold in real-time through interactions between health professionals, women and their birth partners. Accordingly, our study drew on video and audio recordings of labour and birth in order to illustrate who initiates decisions, how they are made, and the extent to which women are involved in them. We explore decision-making using Conversation Analysis, which is the leading method for exploring talk in interaction and enables a focus on how decisions are achieved through the micro-level of everyday practice. The paper illustrates i)that decision-making is primarily initiated by midwives ii) that there is a range of ways in which decisions can be initiated which facilitate women’s involvement to greater or lesser extents, and iii) that the topic of a decision impacts on the interactional practices in which midwives engage (and thus, the scope for women’s involvement).

European Sociological Association Conference, Barcelona (Online)

31 August 2021

Presenter: Ellen Annandale

Title: Making Decisions During Childbirth: An analysis of real-time interactions between women and midwives

Abstract: Based on 37 real-time audio/video-recordings within two English NHS hospital midwife-led units, this paper explores how decisions are made during labour and birth for ‘low risk’ women. Drawing on questionnaire data, we explore the associations between women’s antenatal expectations (such as who they think should and who they think will make the decisions during labour, themselves or practitioners) and their postnatal accounts of how decisions actually were made. This analysis is set alongside conversation analysis of recordings which establish how decisions (1,347 across the 37 births) are initiated (e.g via assertion, requests, option-listing, offers and open questions) and followed up, and by whom (women, midwives). We find that while women generally want and expect to be involved in decision-making in advance of the birth, most decision-making is midwife- rather than woman-led and initiated by strategies such as assertion and recommendation, especially at the first decision-point (though this varies by type of decision being made e.g pain relief, vaginal examinations, fetal monitoring). Postnatal questionnaire data also indicate that although women reported being less involved in decision-making than they had anticipated antenatally, they were nonetheless generally satisfied with various aspects of the birth experience. The paper raises questions about the capacity of midwives to offer choice and women to make choices, that is, for ‘shared decision-making’ in a context where national guidelines for intrapartum care exert a strong influence on how birth takes place.

Association of Radical Midwives

November 2019

Presenter: Alison Brodrick

Title: The VIP Study-exploring Interactional practices of decision making in childbirth

Normal Labour and Birth Conference

19 September 2019

Title: Decision-making during childbirth: Contingency and the challenges of ‘choice’ for midwives and obstetricians

Presenters: Ellen Annandale and Clare Jackson

Abstract:

Background: Health policy guidelines in the English NHS place considerable emphasis on patient choice and patient involvement in decision-making about their care. This is nowhere more evident than in maternity care. In this paper, we focus on the quandaries that healthcare professionals (HCPs) face in providing choice to women in two English NHS midwife-led Units.

Objective: To explore with HCPs barriers to, and facilitation of, translation of policy into practice.
Methods: The primary analysis is based on in-depth semi-structured interviews with 20 HCPs (midwives and obstetricians), which is part of a larger study of decision-making in childbirth funded by the National Institute of Health Research (NIHR). The analysis is supported by conversation analytic examination of real-time recorded interactions between labouring women, their birth partners and HCPs in situated practice in two maternity units.

Findings: We show how decision-making is rendered contingent and complex by the contexts in which labour and birth take place. We explore the situations where HCPs feel promoting choice is straightforward and those where is it more difficult. We focus particularly on the challenges of reconciling clinical protocols surrounding birth with the ideal of including women and birth partners in decision-making. Such challenges show that this often calls for women to flex between passivity and assertion and to embrace an open attitude to the changing and unpredictable clinical circumstances of labour and birth. Drawing on our recordings, we show how these challenges play out interactionally in the labour room. For example, in one example, a midwife invokes guidelines and ‘need’ in the lead up to a decision to break waters by saying, ‘I know that it sounds very textbook but according to that guidelines you’re supposed to be seven centimetres. So if it’s okay with you: what I need to do now uhm so that we are knowing what you’re doing. And how to help you in terms of bladder and progress is I’ll examine you now. An::d and see where we are. And if we are round about same six or seven centimetres then I need to break your water’

Conclusions/implications: The constant tension between guidelines that promote both particular expectations around clinical practice and women’s choices has consequences for women’s engagement in decision-making.

British Sociological Association Medical Sociology Group Annual Conference

12 September 2019

Title: Managing risk versus choice: The case of fetal heart monitoring in midwifery-led care 

Presenters: Lyn Brierley-Jones and Clare Jackson

Abstract: Potential tensions between guideline-driven care (Kotaska, 2011) and personalised care – the risk-choice paradox (Symon, 2006) – are particularly relevant in the context of childbirth; a site of a longstanding debate about the erosion of choice by the medicalisation of practice. However, little is known about how this apparent paradox is managed in real-time during labour. In this paper, based on NIHR-funded conversation analysis of 23 video/audio recordings of intrapartum care in two UK midwifery-led units, we take fetal heart monitoring (FHM) as a case study to examine if and how risk and choice are oriented to in interaction between a woman and her carer. NICE guidelines state that women at low risk of complications in established labour should be offered intermittent fetal monitoring and that this should be conducted every fifteen minutes during the active first stage of labour.  Guidelines also state that such monitoring can be conducted via Pinard stethoscope or Doppler ultrasound.  However, in our data, there is only one instance of Pinard use and there is no discussion about the two different technologies. Our findings demonstrate the normalisation of Doppler ultrasound and its apparently non-optional status vis-a-vis labouring women.  Occasionally, data show midwives conducting monitoring without verbal discussion. More commonly, midwives state their intentions to monitor in ways that expect agreement. When women (rarely) resist such moves, midwives orient to risk in pursuit of agreement. Far from a risk-choice paradox, the practices of FHM enact this as a routine technique of risk management during labour. 

European Sociological Association Conference

21st August 2019

Title: Decision-making during childbirth: the challenges of “choice” for midwives and obstetricians

Presenter: Ellen Annandale

Abstract: Health policy guidelines in the English NHS place considerable emphasis on patient choice and patient involvement in decision-making about their care. Nowhere is this more evident than in maternity care. In this paper we focus on the quandaries that healthcare professionals (HCPs) face in providing choice to women in two English NHS midwife-led Units. The analysis is based on in-depth semi-structured interviews with 20 HCPs (midwives and obstetricians) which is part of a larger study of decision-making in childbirth funded by the National Institute of Health Research. We show how decision-making and choice are rendered contingent and complex by the contexts in which labour and birth take place. We explore the situations where HCPs feel promoting choice is more straightforward and those where it is more difficult. We focus particularly on the challenges of determining women’s capacity to make informed choices (such as when in pain) and HCPs’ preferred approach for women and their birth partners to take during labour and birth. Such challenges show that this often calls for women to flex between passivity and assertion and to embrace an open attitude to the changing and unpredictable clinical circumstances of labour and of birth.  The consequences for women’s engagement in decision-making about their care are explored.

Department of Sociology, Drexel University, USA

10th April 2019

Title:  Decision-making during childbirth: contingency and the challenge of ‘choice’ 

Presenter: Ellen Annandale: Department of Sociology, Invited seminar

Abstract: English NHS policy guidelines place considerable emphasis on patient choice and patient involvement in decision-making. This is nowhere more evident than in maternity care. I will explore the quandaries that healthcare professionals face in providing choice to women based an ongoing study, Interactional Practices of Decision-making During Childbirth in Maternity Units interviews funded by the UK’s National Institute for Health Research. The study is based on two English NHS midwife-led Units and data include video/audio recordings of labour and birth and in-depth interviews with midwives and obstetricians. I will present preliminary findings from which suggest that decision-making and choice are rendered contingent and complex by the contexts in which labour and birth take place and explore situations where practitioners feel promoting choice is more straightforward and where it is more difficult. I will focus particularly on the challenges of determining women’s capacity to make informed choices (such as when in pain) and healthcare professionals’ preferred approach for women and their birth partners to take during labour and birth. Such challenges show that this often calls for women to flex between passivity and assertion and to embrace an open attitude to the changing and unpredictable clinical circumstances of labour and of birth. The consequences for women’s engagement in decision-making about their care are explored.

Society for Reproductive and Infant Psychology Conference

12 September 2017

Title: Interactional practices of decision-making during childbirth in maternity units

Presenters: Lyn Brierley-Jones and Jo Green

Abstract: Numerous studies have indicated that the nature of the interaction between a labouring woman and her caregivers is key to a woman’s experience, with a systematic review (Hodnett, 2002 p.171) concluding that

‘influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviours of the caregivers’. However, these studies are largely retrospective so that very little is known about the details of interaction that lead to women’s appraisals. Understanding interaction practices between women and their caregivers is particularly important if shared decision-making (SDM) is to be implemented in the maternity setting (DH, 2016a) as in other areas of health (DH, 2016b). Birth plans increase women’s sense of control and satisfaction (Kuo et al., 2010) whilst during birth shared decision-making over birthing position increases womens sense of control and well-being (Nieuwenhuijze et al., 2013). General satisfaction with intrapartum care and the birthing experince is related to more positive post-natal psychological functioning (Michels, Kruske and Thompson,2013). However, to date, there is little evidence indicating how SDM might be most effectively achieved during labour.

Aim and Objectives: A real-time study of interactional practices during labour to better understand what behaviours lead to satisfactory encounters.
Method: 

• Video (or audio record if women prefer) the labours of 50 low-risk, full-term women in two Midwifery-led units in Yorkshire.
• Analyse how decisions are discussed using Conversation Analysis (CA)
• Women will complete questionnaires ante- and post-natally, allowing us to explore patterns between women’s appraisals of their experience and the decision-making interactions observed during birth.
• We will also conduct one-to-one interviews with selected midwives and doctors to ask about what they think is helpful and unhelpful in giving women choice.

31st ICM Triennial Congress

18 June 2017

Title: Using conversation analysis to study decision-making in talk between women and healthcare practitioners during labour

Presenter: Helen Baston

Abstract: UK maternity policy emphasises women’s participation in decisions about their during labour, but clinical guidelines tend to offer only generic advice about how practitioners might nurture shared decision-making in practice. We illustrate the benefits of studying real-time recordings of interactions that occur during labour. In support of the ethos of making a difference through supporting women’s and girls’ rights, we report the findings of a conversation analytic (CA) study of women’s requests made during labour. Interactions between 26 women, their birth partners and health care practitioners (HPCs), predominantly midwives, were transcribed from the British reality television show, One Born Every Minute (Dragonfly productions for Channel 4). Using CA, a method for studying how speakers accomplish social actions (e.g. requesting pain relief) in and through talk, we identified how decision-making is enacted in talk. In these data, based on interactions in large maternity units, HCPs tend to initiate decision-making in ways that vary women’s optionality. For example, the use of ‘we need to…’ sets up an expectation of agreement (which women often give). In contrast, women tend to initiate decision-making by making requests (e.g. ‘I wanna epidural, I can’t do this’). HCPs then grant, defer or deny these requests. We show how women’s requests are managed and negotiated in ways that either attend or disattend to their agentive rights to decide. We argue that close attention to real-time interaction provides important insights into how policy on shared decision-making can be translated into practice by detailed attention to how women make requests and how HPCs respond.