Ethnographic Research in Maternal and Child Health

Fiona Dykes, Renée Flacking

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317647928
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

A unique and innovative resource for conducting ethnographic research in health care settings, Ethnographic Research in Maternal and Child Health provides a combination of ethnographic theory and an international selection of empirical case studies.

The book begins with an overview of the origins and development of ethnography as a methodology, discussing underpinning theoretical perspectives, key methods and challenges related to conducting this type of research. The following substantive chapters present and reflect on ethnographic studies conducted in the fields of maternal and child health, neonatal nursing, midwifery and reproductive health.

Designed for academics, postgraduate students and health practitioners within maternal and child health, family health, medical sociology, medical anthropology, medicine, midwifery, neonatal care, paediatrics, social anthropology and public health, the book will also illuminate issues that can help health practitioners to improve service delivery.

1
Introducing the Theory and Practice of Ethnography

Fiona Dykes and Renée Flacking

Introduction

Ethnography is a well-established qualitative research method that involves the researcher being immersed in a community of people and observing people’s activities, listening and asking related questions. Ethnography originates from anthropology; it was the methodology utilised for observing and writing about specific remotely-based cultural groups. The studies of Malinowski (1922, 1929) in the Trobriand Islands (now Papua New Guinea) are commonly referred to as ground-breaking anthropological research. The anthropologist would generally spend long periods of time living in the community in a participant observer role, watching and asking questions; making extensive hand-written field notes which would then be collated and written up as an in-depth description of the tribe or situation being studied.

As the twentieth century progressed, sociologists started to utilise ethnographic methods to study local communities and organisations. There has also been an increasing use of ethnography to study health care situations both in community settings and in organisations such as hospitals. Neyland (2008) documents the more recent development of ethnography in the field of management research, although, as he notes, its origins stem from the earlier Hawthorne studies in the 1920s and 1930s in which workplace practices were observed and documented. In this context, Neyland refers to two distinct types of ethnography: ethnography ofinvolving academic/scholarly studies of an organisation or ethnography for anorganisation, i.e. carried out for or on behalf of an organisation.

In this chapter, we focus upon the range of theoretical underpinnings that have influenced ethnography, associated methodological approaches and the practicalities of conducting ethnography.

Theoretical underpinnings

Clearly, the ethnographic approach may vary considerably according to the ethnographer’s epistemology, ontology and theoretical perspective. Crotty (1998) provides definitions: epistemology is the “the theory of knowledge […] a way of understanding and explaining how we know what we know” (p. 3); ontology is the “the study of being […] concerned with ‘what is’, with the nature of existence, with the structure of reality” (p. 10). One’s theoretical perspective may be described as “the philosophical stance” informing the methodology and thus providing a context for the research process (Crotty 1998, p. 7).

Most ethnographers embrace a constructionist epistemology, in contrast to an objectivist epistemology. Berger and Luckmann (1966) in their classic text The Social Construction of Realityfocused particularly on “reality” as it is perceived and experienced by “ordinary members of society” in their everyday lives (p. 33). In this way, they argue, meaning is constructed by people as they engage with the world. Crotty (1998) defines constructionism as the:

View that all knowledge and therefore all meaningful reality as such is contingent upon human practices being constructed in and out of interaction between human beings and their world, and developed and transmitted within an essentially social context […]. Meaning is not discovered but constructed. (p. 42)

Crotty (1998) makes an important distinction between social constructionism and the rejection within other approaches, to include post-structuralism and postmodernism, of the “existentialist concept of humans as beings-in-the world” (p. 43). In this way, the social constructionist holds on to the notion that “experiences do not constitute a sphere of subjective reality separate from and in contrast to the objective realm of the external world” (p. 45). This closeness to the immediate external world is emphasised by Berger and Luckmann (1966):

The reality of everyday life is organized around the ‘here’ of my body and the ‘now’ of my present. This ‘here’ and ‘now’ is the focus of my attention to the reality of everyday life. (p. 36)

Social constructionism, as defined here, differs fundamentally from constructivism. Constructivism focuses upon the individual’s mind and meaning-making related to phenomena, while the social constructionist perspective relates to the collective shared constructions of meaning and ways of knowing (Crotty 1998). Social constructionism thus emphasises intersubjectivity and the shared experience of culture (Berger and Luckmann 1966, Hammersley and Atkinson 1995, Crotty 1998).

To some extent these differences relate to the degree of relativity embraced. Crotty (1998) describes the social constructionist position as firstly epistemologically relativistic:

Social constructionism is relativist. What is said about ‘the way things are’ is really just ‘the sense we make of them’. Once this standpoint is embraced, we will obviously hold our understandings much more lightly and tentatively and far less dogmatically, seeing them as historically and culturally effected interpretations […]. This means that description and narration can no longer be seen as straightforwardly representational of reality. It is not a case of merely mirroring ‘what is there’. When we describe something we are in the normal course of events, reporting how something is seen and reacted to, and thereby meaningfully constructed, within a given community or set of communities. When we narrate something […] the voice of our own culture – its many voices in fact […] are heard in what we say. (p. 64)

However, social constructionism is at the same time ontologically realist, in that it acknowledges that there is a world out there and the way in which we interpret and socially construct meaning provides us with an experience that is indeed a reality for us. Thus social constructionism rejects the epistemologically realist/objectivist notion that “meaning exists in objects independently of any consciousness” (Crotty 1998, p. 10). It also rejects the ontologically relativist/idealist position of constructivism that reality is simply “mind created” (Murphy et al. 1998, p. 66).

This relationship between ontological realism and epistemological relativism provides a balance or middle position that prevents what is referred to as “naive realism” by Hammersley and Atkinson (1995, p. 17). This position asserts that there is a definitive knowledge simply “there” and awaiting discovery independent of interpretation. On the other hand the “middle position” treats with caution the extreme forms of relativism seen in constructivism which emphasise that human reality is simply created by the individual mind or the notions within post-structuralist theory whereby discourse constructs, inscribes and creates.

Culture and enculturation are important concepts in constructionism and are absolutely central to anthropology and ethnography. These concepts are defined by Helman (2007) who states that:

Culture is a set of guidelines (both explicit and implicit) which individuals inherit as particular members of a society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment. It also provides them with a way of transmitting these guidelines to the next generation – by the use of symbols, language, art and ritual. To some extent, culture can be seen as an inherited ‘lens’ through which the individual perceives and understands the world that he inhabits, and learns how to live within it. Growing up within any society is a form of enculturation, whereby the individual slowly acquires the cultural lens of that society. Without such a shared perception of the world, both the cohesion and continuity of any human group would be impossible. (pp. 2–3)

Spradley (1980) defines culture as “the acquired knowledge people use to interpret experience and generate behaviour” (p. 6). However, as Spradley argues, we should avoid cultural determinism, that is, the notion that individuals are simply programmed by their culture. He argues that culture should be viewed as a “cognitive map” acting as a reference and guide; it should not be seen as constraining the person to adopt only one course of action. Nevertheless, he acknowledges that culture does create in the person a taken-for-granted view of reality and, in this sense, individuals are somewhat “culture bound” (Spradley 1980, p. 14). In this way humans are able to exercise agency within their cultural parameters. This balance between enculturation and agency assists in understanding the differences between “tacit knowledge”, a knowledge that remains largely outside our immediate awareness, and “explicit knowledge”, a form of knowledge that people may communicate about with relative ease (Spradley 1980, p. 7). As Spradley argues, what we see represents “only the thin surface of a deep lake; beneath the surface, hidden from view, lies a vast reservoir of cultural knowledge” (p. 6).

Naturalism

Hammersley and Atkinson (1995) chart ethnography’s journey from a more descriptive and naturalistic discipline, to diversifying to embrace other theoretical perspectives ranging from interpretivism, critical inquiry and postmodernism. In its naturalistic form, ethnography rejected positivism which had previously dominated in the early twentieth century by emphasising that human behaviour was complex, based on social meanings and continually constructed and reconstructed. The aim of the ethnographer was to enter a relatively unknown (to him/her) community as an outsider and document, in detail, the cultural norms, beliefs, codes of behaviour and social rules. However, the naturalistic approach to ethnography itself came under criticism in that it attempted to understand social phenomena as existing independently of the researcher that could be described and even explained in some literal fashion.

Interpretivism

Interpretivism emerged through the thought of Weber who became concerned with notions of understanding rather than explaining (Weber 1949). Interpretivism stems from the social constructionist epistemology discussed above; it offers a critique of naturalism, seeing it as being aligned to an epistemology of objectivism. The interpretivist view acknowledges that the ethnographer’s interpretations are influenced by her/his own culture and the context of the research and thus the findings are inevitably influenced by the researcher’s perspective. As Hammersley and Atkinson (1995) argue, once the ethnographer her/himself is seen in any way to be involved in constructing there is incompatibility with the assumptions that underpin naturalistic ethnography.

Critical inquiry

Critical inquiry offers a challenge to both naturalistic and interpretivist perspectives in that it emphasises the influence of power, ideology and control upon the researcher, the researched and uses of the research findings. This perspective is generally associated with the Frankfurt school of critical inquiry and a range of political theorists to include Marx (1970), Gramsci (1971) and Freire (1972). The definition proposed by Kincheloe and McLaren (1994) of a researcher or theorist embracing a critical theory perspective, is useful in illustrating the key tenets of this perspective:

We are defining a criticalist as a researcher or theorist who attempts to use her or his work as a form of social or cultural criticism and who accepts certain basic assumptions: that all thought is fundamentally mediated by power relations that are social and historically constituted; that facts can never be isolated from the domain of values or removed from some form of ideological inscription; that the relationship between concept and object and between signifier and signified is never stable or fixed and is often mediated by the social relations of capitalist production and consumption; that language is central to the form of subjectivity (conscious and unconscious awareness); that certain groups in any society are privileged over others […] that oppression has many faces. (pp. 139–140)

Ethnography underpinned by a critical perspective is described as critical ethnography. Thomas (1993) describes critical ethnography as a:

Type of reflection that examines culture, knowledge and action. It expands our horizons for choice and widens our experiential capacity to see, hear and feel. It deepens and sharpens ethical commitments by forcing us to develop and act upon value commitments in the context of political agendas. Critical ethnographers describe, analyse, and open to scrutiny otherwise hidden agendas, power centres, and assumptions that inhibit, repress, and constrain. (p. 3)

These definitions point to the centrality of ideology, power and control in the research process, analysis and theoretical conceptualisations.

Hammersley and Atkinson (1995) emphasise the need for balance between the impact-less ethnography which allows the “world to burn” and the ethnography which is underpinned by a clear political agenda (p. 20). The latter may lead to a filtering out of information, thereby simply corroborating the political point making, with resulting compromise of the data.

Critical medical anthropology

In health care research the critical ethnographer is closely aligned theoretically to the discipline of critical medical anthropology. Csordas (1988) sums up the essence of the critical medical anthropology perspective:

It takes positions on the medicalisation of everyday life in contemporary society, which it opposes; on biomedicine as a form of power, domination, and social control, which it also opposes; and on mind–body dualism, again in opposition. Its intellectual debts are to Marx, Gramsci, the Frankfurt school of critical theory, phenomenology and political economy. Its agenda includes critique of medicine as an institution, cultural criticism focused on the domain of health, analysis of capitalism in the macro-politics of health care systems and the micro-politics of bodies and persons, addition of historical depth to cultural analysis, and critique of allegedly non-critical medical anthropology. (p. 417)

Singer (1990) summarises the balance between the macro and micro perspective in that it seeks:

To add the traditional anthropological close-up view of local populations and their lifeways, systems of meaning, motivations for action, points of view, and daily experiences and emotions,...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of illustrations
• List of contributors
• Foreword and introduction
• 1 Introducing the theory and practice of ethnography
• 2 Ethnographic fieldwork as teamwork
• 3 Work practice ethnography: video ethnography in maternity settings
• 4 Writing of one’s own culture: an auto-ethnography of home birth midwifery in Ireland
• 5 A mirror on practice: using ethnography to identify and facilitate best practice in maternity and child health care
• 6 Cross-national ethnography in neonatal intensive care units
• 7 Night-time on a postnatal ward: experiences of mothers, infants, and staff
• 8 Fathers’ emotional experiences in a neonatal unit: the effects of familiarity on ethnographic field work
• 9 Evaluative ethnography for maternal and child nutrition interventions
• 10 Challenges of organizational ethnography: reflecting on methodological insights
• Index