1

Qualitative Article Critique

Rachel Neale

Pennsylvania College of Health Sciences

IPC 511

Dr. Cynthia Castaldi

March 20th, 2022

2

Introduction

Women face a difficult decision when trying to figure out if they are in spontaneous labor

and need to arrive at the hospital. Edmonds et al. (2018) notes that “being admitted during the

latent phase of labor is associated with increased risk for clinical interventions, including

cesarean birth” (p. 455). These researchers wanted to explore through qualitative analysis what is

the thought process and/or decision-making behind arriving at the hospital for both women

admitted in latent labor (less than 4cm dilation) and those admitted in active labor (4cm dilation

or higher) (Edmonds et al., 2018).

Research Design

The researchers reported an ethnographic research tradition, which aligns well with their

method of data collection in the form of in-person interviews. Many ethnographic studies involve

researchers spending time in the culture in order to best observe it, but this is not feasible with

this kind of patient culture; the patients needed to be sought out and interviewed postpartum

(Polit & Beck, 2021). The amount of time spent with study participants was not mentioned,

which would have enhanced the trustworthiness. Researchers reported using field notes and self-

reflections to prevent interpreter bias, both of which are adequate forms of reflexivity (Edmonds

et al., 2018, p. 456).

Sample and Setting

The group of interest, low-risk nulliparous women who arrived in spontaneous labor,

were described adequately, with the eligibility criteria being specified in detail. This was

especially important as many women are not medically able to labor at home, including those

with medical conditions for induction, or women who were group-beta streptococcus positive

and needed antibiotics prophylaxis. The setting was described in sufficient detail, the researchers
3

specifying that interviews were conducted in a hospital on the postpartum floor with the

participants being at least 12 hours postpartum but prior to discharge from in-patient stay

(Edmonds et al., 2018, p. 456). The sample was generally described, demographics of the sample

being described in a table on p. 457.

The sampling method seemed appropriate for information richness, as every eligible

patient was approached to participate in the study, and out of the 25 women approached

postpartum, 21 consented to the study. The sample size was considered adequate as the

researchers felt a “convergence of consensus” on the participants’ decision-making process for

when to arrive at the hospital for labor (Edmonds et al., 2018, p. 456). This is a different way of

saying they had reached data saturation, as both phrases mean that more data would not have

produced new information.

Data Collection

Data triangulation, according to Polit & Beck (2021), is using several sources of data in

order to support the conclusions, and can include time, space, and persons (p. 572). Appropriate

methods were used to gather the data, exclusively through medical records and in-depth

interviews, but this would not be considered triangulation due to the medical records not giving

data with regards to the research question (Edmonds et al., 2018). This does hurt the study’s

overall credibility; the study would have been stronger with participants over a longer period of

time (such as including different seasons of the year where travel could have impacted their

decision-making) or interviewing participants at a different hospital site.

The data received from the participants was detailed and rich, providing much insight as

to how they made their decisions to arrive to the hospital. The researchers demonstrated this with
4

several quotes from their participants that show the quality of the responses (Edmonds et al.,

2018).

Procedures

Data collection and recording procedures appeared appropriate, the researchers utilizing a

professional transcriber as well as collecting demographic and medical history from the medical

records (Edmonds et al., 2018). The researchers attempted to minimize bias by utilizing

reflexivity, but bias cannot be completely ruled out as the researchers were not blinded to the

participants. To their credit, the researchers reported over 20 years of “experience with the

sample population and with in-depth interview techniques” (Edmonds et al., 2018, p. 456).

Enhancement of Trustworthiness

The researchers did use effective strategies to enhance the trustworthiness of the study,

specifically maintaining an audit trail of the data analysis (Edmonds et al., 2018, p. 456). This

audit trail improves the confirmability of the results. Polit & Beck (2021) say that confirmability

is proven when findings “reflect the participants’ voice and the conditions of the inquiry and not

the researcher’s biases or perspectives” (p. 570). Trustworthiness is overall improved if

confirmability is strong.

The level of description of the participants and the context was high, enough to support

transferability to an extent, though not necessarily generalizability, per the researchers. Edmonds

et al (2018) commented on the study’s transferability with regards to “ongoing work in this area

and applicable to developing content” for prenatal and triage phone calls (p. 459).

As mentioned previously, the researchers stated over 20 years combined experience with

the patient population and with in-depth interviews, which improves the credibility of the study,
5

as the researchers were more likely to ask the right probing questions for deep, meaningful data

(Edmonds et al., 2018, p. 456).

Results

According to Polit & Beck (2021), ethnographic researchers are “continually looking for

patterns in the behavior of participants, comparing one pattern against another” (p. 545) which is

exactly what Edmonds et al. (2018) did in this study. They spent a rigorous amount of time

reading and rereading the transcriptions of the interviews and coding them based on similarities

and patterns. They utilized a coding software called HyperRESEARCH that helped organize the

information and develop themes, though they specifically mentioned using a deductive approach

in creating the codes (Edmonds et al., 2018, p. 456).

Findings

The findings were presented in a clear and effective manner while still presenting several

excerpts of participant interviews and demonstrating the richness of the data retrieved. The data

showed six main criteria that women use for deciding when to arrive at the hospital for labor, and

the researchers gave quotes in each section for better description of the participants’ thoughts

(Edmonds et al., 2018, p. 457-459). The results covered many influences in a woman’s life that

would impact her thoughts and decisions and seemed quite thorough a depiction of the

phenomenon being evaluated. The six main decision-making criteria the researchers found were:

1) labor onset recognition, 2) pain tolerance/coping, 3) provider advice, 4) social network

influences, 5) distance/travel concerns, 6) perception of childbirth risk (Edmonds et al., 2018, p.

458).

Theoretical Integration
6

The themes that came about from the data analysis made sense and were organized in a

way that was simple to understand: trends of women who were admitted in latent labor vs. trends

of women admitted in active labor. These trends within the themes tended to oppose each other,

which gave a clearer picture on the ethnographic groups being studied, two obviously different

cultures of women whose decision making processes were similar in themes but opposite in

conclusions (e.g. high pain tolerance in active group vs. low pain tolerance in latent group)

(Edmonds et al., 2018).

Discussion

The researchers made sure to compare their results to other studies, commenting that the

results aligned with those of related studies regarding women’s decisions to arrive at the hospital

for labor (Edmonds et al., 2018). They did not specifically mention the social/cultural context,

but did state that these results could not necessarily be generalized because of different cultural

impacts elsewhere (Edmonds et al., 2018).

Interpretations were not totally consistent with the study’s limitations, as the researchers

went into detail about improvements that could be made to provider-patient triage calls, but the

researchers did not actually know what was communicated through the phone calls, only the

perspective of what the patient heard (Edmonds et al., 2018). This is a limitation in that providers

may be telling the patient one thing and the patient is not processing it correctly. Further studies

could be helpful in determining what the providers are saying and comparing it to what the

patients believe they are hearing to support these researchers’ interpretations.

The study addressed transferability and applicability in its limitations sections as noted

previously, the researchers claiming the results are both transferable and applicable to future

research and performance improvement (Edmonds et al., 2018).

7

Summary Assessment

Healthcare providers should have confidence in the truth of these results due to the data

saturation, reflexivity, experience of researchers involved, and the credibility of the study. That

being said, the clinical implications section seemed to make more assumptions than may be

actually true, and more studies would be needed to determine if there is miscommunication

between providers and patients in antenatal and triage call settings, or if the providers truly need

to change their approach in educating their patients on signs of active labor (Edmonds et al.,

2018). The data is, ultimately, helpful in directing future education and research based on what

women who go into spontaneous labor at home tend to think and feel about when to arrive at the

hospital for admission.

Conclusion

Edmonds et al (2018) collected ethnographic data about women’s decision-making

process about hospital arrival for labor onset. They did so in an effective manner, and analyzed

the data appropriately. Their themes were thorough and provided a detailed picture of the culture

being studied. However, they came to some quick conclusions with regards to antenatal

education and triage phone calls with providers that may not be as trustworthy due to

participants’ recall bias (Edmonds et al., 2018). Future studies should hone in on these two

results to see in what ways they truly impact when a women chooses to arrive at the hospital in

labor, to maximize the active labor admissions vs. latent labor, and hopefully decrease clinical

interventions and cesarean delivery rates.

8

References

Edmonds, J.K., Miley, K., Angelina, K.J. (2018). Decision making about hospital arrival among

low-risk nulliparous women after spontaneous labor onset at home. Journal of Midwifery

and Women’s Health 63(4), p. 455-461. Doi: 10.1111/jmwh.12741

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for

nursing practice. Wolters Kluwer.