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PLOS ONE logoLink to PLOS ONE
. 2022 Jan 26;17(1):e0260277. doi: 10.1371/journal.pone.0260277

Decision-making during obstetric emergencies: A narrative approach

Gabriel M Raoust 1,2,*, Johan Bergström 3,#, Maria Bolin 4,#, Stefan R Hansson 1,5
Editor: Bernadette Watson6
PMCID: PMC8791468  PMID: 35081113

Abstract

This study aims to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies. Childbirth is considered safe in the wealthiest parts of the world. However, variations in both intervention rates and delivery outcomes have been found between countries and between maternity units of the same country. Interventions can prevent neonatal and maternal morbidity but may cause avoidable harm if performed without medical indication. To gain insight into the possible causes of this variation, we turned to first-person perspectives, and particularly physicians’ as they hold a central role in the obstetric team. This study was conducted at four maternity units in the southern region of Sweden. Using a narrative approach, individual in-depth interviews ignited by retelling an event and supported by art images, were performed between Oct. 2018 and Feb. 2020. In total 17 obstetricians and gynecologists participated. An inductive thematic narrative analysis was used for interpreting the data. Eight themes were constructed: (a) feeling lonely, (b) awareness of time, (c) sense of responsibility, (d) keeping calm, (e) work experience, (f) attending midwife, (g) mind-set and setting, and (h) hedging. Three decision-making perspectives were constructed: (I) individual-centered strategy, (II) dialogue-distributed process, and (III) chaotic flow-orientation. This study shows how various psychological and organizational conditions synergize with physicians during decision-making. It also indicates how physicians gave decision-making meaning through individual motivations and rationales, expressed as a perspective. Finally, the study also suggests that decision-making evolves with experience, and over time. The findings have significance for teamwork, team training, patient safety and for education of trainees.

Introduction

Childbirth is generally considered to be safe in the wealthiest parts of the world but also show some puzzling variations between countries in both intervention rates and outcomes [1]. These international variations may be explained by differences in maternal and perinatal characteristics as well as healthcare systems [25]. However, unexplained variations persist between different maternity units within high-income countries with standardized care, universal coverage and after adjusting for differences in the population [68]. It has been suggested that variations in outcome rates within a country may indicate an inappropriate use of interventions [3, 7, 9]. Indeed, as interventions may prove important in preventing neonatal and maternal morbidity [10], they may also cause avoidable harm if performed without medical indication [1, 11, 12]. Traditionally, the justification for an appropriate course of action in obstetric care is often grounded in an evidence-based approach [1, 10, 13]. The implementation of evidence is seen in best practice guidelines and checklists [1416]. Furthermore, two other views originating in the decision-making and safety science research are slowly being incorporated into obstetric practice and physician training: a psychological view and/or a ‘teamwork view’ [1719]. One view, borrowed from different schools of psychology, sees physicians as autonomous agents and focuses on the tools that can reduce errors and improve decision accuracy, or even practitioners’ (i.e., obstetricians and gynecologists, and midwives) attitudes [2023]. Training individuals in uncovering their biases (i.e., underlying affects and patterns of thinking) or ‘risky attitudes’ are implementations of such a psychological view of the problem [14, 2022]. The other view puts more emphasis on teams and teamwork [2428], and teams have been described as resilient, defined as Complex Adaptive Systems (CAS) [29]. Team performance is the result of interactions, relations and coordinative strategies among individuals connected to the team, rather than the result of “correct decisions” from a single person [27, 30]. This view is in support of team training and improved interpersonal communication [31, 32]. However, none of these approaches has yet been able to adequately resolve the existing problem of variation. As a new and complementary approach in trying to understand variation in interventions, we wanted to explore first-person perspective on decision-making; particularly those of physicians who hold a central role in the obstetric team as they are assumed to make key decisions before and during childbirth, especially during emergency situations. The purpose of this study is to explore how physicians make sense of and give meaning to their decision-making process during obstetric emergencies [33]. We believe that stories told by obstetricians and gynecologists to justify their decision-making process might enable us to interpret variation in terms of decision-making strategies and perspectives.

Materials and methods

Study design

A narrative approach using individual in-depth interviews ignited by the retelling of an event and having art images as associative stimulation, was chosen for this study. Narrative analysis provides a unique possibility to understand how individuals give meaning to the complexities of their experience through stories [3438]. Using a thematic narrative analysis outlined by Riessman, and further influenced by Czarniawska’s interpretation, the intent was to eventually render disparate stories into a coherent whole through a dialogical process [34, 39, 40].

Ethical considerations

The study was approved by the regional ethics review board (Lund University, permit number LU 2018/198). The participants gave their written consent after being informed about the study and the voluntary nature of their participation. Participation could be terminated at any time. The interviewees were also assured of their anonymity and the strict confidentiality in handling interviews and results. Because retelling an obstetric emergency can bring back difficult memories, efforts were taken by the interviewer to create a compassionate and empathetic atmosphere during interviews [41, 42]. Considering some memories could be of traumatic nature, collaboration with a psychotherapist was established during the study. No interviewee expressed a need for special counseling.

Childbirth in Sweden

Intrapartum care in Sweden is institutionalized and publicly funded. There are 40 maternity units, and about 115.000 to 120.000 births per year serving a population of 10,2 million (2019) [43]. Pregnancy, labor, and childbirth are first and foremost considered natural processes. In 2020, 88% of births were so called normal births. Normal births are births without greater intervention: no Caesarean sections (CS) or no vacuum extraction (VE)/forceps, postpartum bleeding below 1500 mL or no need for blood transfusion, no sphincter rupture, no Apgar score below 7 at 5 minutes [43]. The care is standardized by national and local guidelines. Trained and autonomous midwives follow most of patients during pregnancy and assist during labor and childbirth. Midwifery is a university degree constructed around the medical sciences and modern medicine, and a previous degree in nursing is required. Physicians, trainees or specialists in obstetrics and gynecology are primarily involved in the care of patients with complicated pregnancies or when complications occur during labor and childbirth. Physicians take over the medical responsibility from the midwife when getting involved during pregnancy, labor, or childbirth. Historically, a non-interventionist ideal, i.e., wait and see rather than intervene, has guided practice for both midwives and obstetricians in Sweden [44]. The relationship between physicians and midwives in Sweden has also been characterized by considerably more teamwork rather than conflicts [44].

Sampling and study population

The study was conducted at four maternity units in the southern region of Sweden. The maternity units used similar guidelines, routines, and practices. A combination of purposive and by referral sampling of obstetricians and gynecologists actively working with delivery care was used. Contact was established by e-mail. The selection of participants aimed at being representative of gender, work experience and preference for either obstetrics or gynecology. In total, 16 specialists and one trainee, of which 7 men and 10 women, were included. Another three physicians were asked to participate but declined. The most junior physician had worked 3 years and the most senior 31 years (mean age: 45 years ± 8.7 years, mean years of experience: 15 ± 9.4 years). Ten of the participants were working predominantly with obstetrics, 2 with gynecology and 5 had yet no preference. Inclusion stopped when no new data was generated by further interviews, defined as obtaining saturation [45, 46]. The interviewer and participants were known to each other on a professional level after having worked together to various degrees over the years.

The interviewer

The interviewer, the first author (GMR), is board certified specialist of obstetrics and gynecology since 2009 and a senior consultant in perinatology since 2014.

Data collection

The first author conducted all interviews, from Oct. 2018 to Feb. 2020. The time and location for the interview was agreed upon together with each interviewee (secluded places at the hospitals, research labs or in private homes). All interviews were carried out in a co-creative narrative form [41] (i.e., interviews were constructed and given meaning jointly by interviewer and interviewee), and divided in two parts. The first half was prompted by the question: “can you recall an obstetric emergency situation that has left a memorable impression?” The second half was initiated after the interviewees had glanced through randomly selected books depicting images of various works of art. The interviewees were requested to find one or several images speaking to them about decision-making during obstetric emergencies, more specifically: “try to feel that the image is finding you, not that you are trying to fit your ideas into a particular image.” The interviewees were subsequently asked to draw a picture of the image, part of the image or a synthesis of several images, using crayons. Conversation about the images and the drawing ensued. Visual materials have shown to be effective in generating valuable information that other methods fail to do [47, 48]. Among other advantages, using images and talking about them can; I) level the field between interviewee and interviewer [49], II) “make the familiar unfamiliar” again for the insider [50], III) disclose the unperceived in an experience-taken-for-granted and IV) benefit the co-creative aspect of interviewing [51]. Here, images and drawings were used to evoke new ways of thinking and talking freed from ideas and concepts overly repeated within the profession [38, 48]. The interviews were generally unstructured and free flowing. The interviewer embraced a non-confronting attitude towards the interviewee and actively listened to each one [42, 52]. Questions were asked during the interview in order to clarify or to further develop the interviewees’ ideas [42, 52]. Additionally, the interviewer occasionally shared his own thoughts in order to further explore a train of thoughts, however always empathizing with the participant [42, 52]. An interview guide was only used in the rare cases of a stalled conversation [42, 52]. The interviews were audiotaped and lasted from 35 to 97 min. (mean = 63 min.).

Data analysis

All interviews were initially transcribed verbatim (including pauses, onomatopoeias, sighs, laughs, and other sounds). The text was condensed and unorganized spoken language transformed into a more readable form [34, 53]. Preservation of the internal coherence and meaning of what was said was sought for [54]. The polished version of the transcripts were sent to each interviewee to check for validity [34, 53]. An inductive approach of thematic narrative analysis was used for interpreting the data [34, 53]. The interpretation already occurring as part of the conversation, and now embedded in the transcript, was further systematized [34, 53]. By focusing on “what” was said in the text, a search for patterns, differences and similarities within and between the interviews was performed through a process of reading and re-reading [34, 53]. Intact narrative segments, defined as a bounded section of text about decision-making, were identified [34, 53] and labeled according to what ideas were expressed. Ideas from across interviews were clustered into recurrent themes. Each transcript was also treated as an independent whole, with the assumption that physicians had something meaningful to say about themselves in how they made decisions. Ideas within each transcript were therefore also clustered independently into an overarching meaningful perspective on decision-making. Furthermore, a tentative interpretation of each interview was also presented to the respective participants for comments [34, 53]. The process of interpretation as an oscillating movement, back and forth between the whole and its parts [42] was also developed in collaboration with the other authors [34, 53].

Results and analysis

The purpose of this study was to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies. Through a process of narrative analysis [40, 55] and by using the transcribed data as a whole, eight recurring themes across the interviews were constructed: (a) feeling lonely, (b) awareness of time, (c) sense of responsibility, (d) keeping calm, (e) work experience, (f) the attending midwife, (g) mind-set (thoughts, moods and expectations) and setting (time, place and circumstances) and (h) hedging. Additionally, three decision-making perspectives were constructed: (I) individual-centered strategy, (II) dialogue-distributed process, and (III) chaotic flow-orientation. The decision-making perspectives were the expression of physicians’ identities transformed into practice, influenced by the different themes. The themes pertain to the environment common to all interviewees and are therefore presented before the decision-making perspectives.

Themes

a. Feeling lonely

You are very lonely. When making a decision. You are often very, very lonely. (Physician 9)

The physicians felt lonely most of the time during obstetric emergencies. This was somewhat of a confession as current work-culture puts an almost compulsory emphasis on the team, teamwork, and cooperation. Nevertheless, feeling lonely was a reality with qualitative differences, ranging from factuality (being alone) to existential anxiety (loneliness) to empowering realization (aloneness). The physicians felt lonely with their decisions, the responsibility, and potential consequences from making the “wrong” decision. For some, the associated malaise of loneliness felt in early years would diminish with work experience. This was not a conscious choice but something that happened naturally over time. Maturation through personal, often distressing experiences helped in this process.

b. Awareness of time

The most important thing in the situation is to be aware of time andKnow that you have to, sometimes act quickly. Time, in some way, is always in the background. (Physician 14)

The awareness of time would most often become more acute as a situation became more pressing. Ultimately, time was a limiting factor that could put tremendous pressure on physicians with a demand for immediate action in the most extreme situations. As they gained work experience, they would develop their capacity for assessing the urgency of a situation and to modulate their responses. With lesser time pressure the physicians were also more likely to invite other team members to suggest ideas. In contrast, when time pressure was higher, the physicians felt a stronger need to regain control, and make decisions by themselves. A few of the physicians had the peculiarity of being able to move more fluidly between reclaiming control and openness, even to a point of letting go of control altogether, irrespective of the urgency.

c. Sense of responsibility

I have always felt a big responsibility, butAfter I was involved in a situation in which the child got affected, I became much more aware of the responsibility. It became clearer somehowAnd a little scary. (Physician 14)

The physicians were well aware of that childbirth is a natural process but considered it as a potentially high-risk situation. They all expressed a strong sense of responsibility, but the quality of the feeling could differ. Most of the physicians described responsibility as a burden, a source of stress accompanied by an underlying fear of not being able to manage. However, for some there was less interest in being the one that needed to solve “the problem”. Medical responsibility was a given and focus had moved from fear to care, from concerns with oneself to concerns for the woman/couple giving birth, including for her/them to reclaim the experience. The physicians wanted their interventions to be remembered as less severe or exceptional than they were.

I think a lot about the couple. It’s a very sensitive and important moment for them. It’s great fun to be involved… But sometimes you get involved when things go awry… So you don’t want to contribute to any terrible experience… I try to think a little long-term. (Physician 5)

Finally, some physicians felt the responsibility as empowering rather than crippling. By being engaged and integrated in the unfolding situation, they now had the capacity to respond. There was also awareness of how inter-dependent everyone involved were, seeing equal value in contribution from each one in the team.

When you’ve been in some emergency situations you become much humbler and understand the importance of cooperating. You learn about all the components of the process. You notice if there’s a spanner in the works and you also know you were not alone when things go well. (Physician 17)

d. Keeping calm

Back then I was only an observer. I couldn’t help in any way and… I saw the reactions from the others in the room… How they became more and more stressed, after my colleague had said: ‘I can’t get the baby out, I can’t get the baby out…’ Especially after he lost it and started shouting: ‘I can’t get the baby out! I can’t get the baby out!’ And then I saw… You know the mother also heard. (Physician 13)

Keeping calm was a quality the physicians held in high regard and continued to want to develop throughout their career. As trainees, some had even experienced situations in which the colleague in charge lost their cool, leaving a traumatic impression as a numbing panic spread to other team members. For most, keeping calm was a purposeful commitment. It was about keeping the stressful thoughts and emotions in control or simply to pretend that everything was in order not to aggravate the situation. Projecting a sense of assurance or being perceived as cool enabled others to give to their fullest ability and for the woman/couple giving birth to feel safe enough regardless of circumstances. Others’ apparent sense of calm and safety would give positive feedback to the physicians who would in turn start feeling calmer.

I try to radiateThat I control the situation even if it doesn’t feel that way. It’s important to try to convey that, so as not to create anxiety, especially for the parents. Anxiety is contagious. But if you’re calm instead, that can also spread. (Physician 14)

A couple of the physicians expressed less conscious struggle with keeping calm. One physician felt innately calm and had always done so. The other one expressed calm to be a by-product of being fully immersed in the moment.

e. Work experience

In many situationsI just follow a routine. I’ve been exposed to the same situations so many times. And just act without further reflectionIt works wellFor sure. Then it’s not about decisions. Well, yesYou still make a decision. But it comes so fast ‘cause you just recognize the situation. (Physician 16)

Having gained work experience, the physicians had invariably developed both routines and know-how. A resulting ease heightened the threshold for what was critical and enabled a greater range of maneuvering within each situation. The more experienced physicians also expressed a better appreciation for nuances and subtleties. They were more interested in getting more information. Seemingly insignificant or even cumbersome bits of information for a beginner could be determinative for a more experienced person. Eventually some of the most experienced physicians had developed an intuitive capacity that they used in decision-making during obstetric emergencies.

Finding different patterns. What information you want and from whom and boil it down to a decision. But it’s difficult to know what causes it sometimes, even though external factors are often quite similar, you do a little, little different… It eventually happens when you’ve worked for a long time, that sometimes you can’t really sayWhy you did this or that. (Physician 12)

Notably this was also more than know-how and pattern recognition. Intuition included the whole person projecting her conscious awareness (encompassing memories and experience) into the unfolding situation. Thus, participating in the construction of new possibilities for decision-making.

We fill the gaps with what we bring with us. With the knowledge and experience we have. And if you’ve worked for a long time, you can handle more bits of the puzzle. (Physician 12)

f. The attending midwife

Midwives, it’s part of itJust like fetal heart monitoring or clinical examination and stuff… Sometimes when we’re thrown into a situation, we might not even have timeTo read the patient’s recordSo then you have to rely on what the midwife tells you in those twenty seconds… So I think it’s an importantPart of our jobTo have a good relationship with them. (Physician 10)

In Sweden, midwives are the primary caregivers during uncomplicated pregnancies, labor, and childbirth. It is only when complications arise that a physician gets involved, either through temporary consultation or by taking over the responsibility altogether. In an emergency this could result in a particular intervention such as,VE/forceps or a CS. Because midwives both have authority over the uncomplicated, sometimes also labeled normal, births and spend the most time with patients, the physicians felt awkwardly dependent on them for their decisions. Indeed, even if guidelines helped determine normality it was up to the midwife to involve the physician on call. Once the physician got involved, the midwife also decided how much information she wanted to share. The physicians had to negotiate their role and identity in relationship to midwives; first as an implied part of their training and then later as new staff got hired or if they changed workplace.

The relationship with the midwife is perhaps most problematicAnd really, both if we think alike or and if we think differently. If we think the same, it affects me in my process because it makes it easier for me to make decisions. But if we think differently, it might make it harder. Because then I get a little worried that there will be a conflict. (Physician 2)

In practice, the physicians experienced midwives as gatekeepers, overtly or covertly preventing them from intervening because of a fear that it would disrupt the natural process of giving birth. At times, formal transfer of the medical responsibility could also be ambiguous, and physicians felt mislead instead of empowered. Ambiguity arose when physicians experienced that it was unclear if the midwife wanted them to be involved or if she only followed guidelines, but actually did not want to involve them. Ambiguity also emerged when transfer was not about medical responsibility, but rather about emotions such as uncertainty and fear, in the guise of medical responsibility.

It’s a special dynamicYou have to weight her reactions somehow, because she still has control over the patient. And been thereAnd everything. At the same time, you still have to be a little immune to that emotional game. So both and. Because I’m the one deciding. So I have to relate to the things she conveys that can be valuable information. It can be both factual and emotional, but alsoHer opinions and will in this, and her thoughts on how the process should move forward. You can’t let yourself be dragged along either. What you feel when you work with the midwife… If you have a lot of past history together. And if you have a collaboration with someone you don’t really trust. It’s a whole different story than if you work with someone you know‘No! ButHer assessments usually make sense.’” (Physician 9)

g. Mind-set and setting

It can be how I feel that dayWhat mindset I bring with me or what I’ve done earlier. There are lots of things that can affect. How tired you are. The impressions you get in the situation. (Physician 9)

The mind-set and setting were inner and outer circumstances affecting decision-making. The inner circumstances were about moods, levels of energy and stress amongst others. The outer circumstances could be workload, time of day, conflicts at the workplace or disorder in the delivery room, etc. An obstetric emergency was seldom a bounded event. The time-horizon extended both backwards and forward through memories and expectations, respectively. An earlier personal conflict that had generated anxiety lowered the capacity for bearing uncertainty, or the prospect of having to confront an interrogation from senior colleagues the next morning had led to a safer decision. The physicians coped with circumstances during decision-making in various ways. Many simply endured most of them. Treating every obstetric emergency as a specific problem to be solved was also helpful.

It’s this woman lying there that I have to focus on, now… First, I have to identify where I need to make a decision. And temporarily shield off the rest. (Physician 16)

Some of the physicians were more susceptible to be affected by the circumstances than others. This was based on their sensitivity alone. In general, increasing the awareness around their sensitivity through self-reflection and conversations with colleagues and midwives outside of an emergency was usually helpful enough for coping. A few of the physicians had come to accept circumstances as a range of uncontrollable parameters integral to any emergency situation.

h. Hedging

Much of the decision-making process is about being one step ahead. It’s about anticipating or preparing, sometimes only in thought, for potential problems. (Physician 6)

Hedging was about having alternatives and imagining possible scenarios on how a situation could develop. This was a mental event, mainly based on the guidelines’ algorithms and/or knowledge from past experiences.

I had my inner checklist. And it made me feel pretty safe. I felt I was little step ahead in my mind andFelt that even though I hadn’t done this many times, I had thought about it. (Physician 7)

But hedging was also about empowering the team through “thinking out loud” (i.e., the overtly sharing of thoughts). Beyond simply verbalizing the guidelines’ algorithms it was an invitation for other team members to participate and share their perspectives and thoughts.

It’s not that everyone is silent and waits for me to say something but rather like… Everyone helps with what they can bring to the table. (Physician 17)

Consequently, relationships between team members and trust within the team got strengthened. The patient/couple could sometimes be included in the discussion, even in the midst of an emergency. This was mainly for informative and pedagogical purposes but could also be as a preventive/therapeutic measure. Informing a patient of an upcoming intervention such as a VE could for example motivate her to push and give birth, consequently avoiding the intervention altogether. Finally hedging could be more of an attitude integrated in decision-making itself, less as different scenarios and alternatives and more as leaning into the next moment.

What’s the best thing we can do based on the prevailing conditionsAnd in the next moment, and the moment after that. And then you have to be at it again, all the time: ‘what’s advisable now? How do I relate to that?’” (Physician 3)

Perspectives

I. Individual-centered strategy

I’m the one in charge… I’m the one that needs to make that decision. (Physician 13)

The individual-centered strategy as a decision-making perspective was preferred among 7 physicians. From this perspective, physicians took for granted that they were the focal point. All information, mostly external–visual or verbal–was perceived as input and processed in the black box of their mind eventually resulting in directives to others, who were mostly seen as instrumental. Teams and teamwork were perceived as ideological concepts rather than a way of working that reflected reality.

There’s a lot of input and some mess… And then you want to try and get a little bit of order and structure and… Try to form it to something manageable. There’s a process in the brain. (Physician 11)

Physicians having this perspective would rather function according to rules, and had a strong sense of right and wrong as well as a particular respect for authority. For them there was a good decision and a bad decision, and the closer to guidelines the better.

So, according to the guidelines I did right. And nobody can say I didn’t. (Physician 15)

This was particularly significant when they had to deal with unfamiliar situations or make a decision when there was great uncertainty regarding the resulting outcome. For physicians with this perspective the best direction would always involve as little unknowns as possible, thus minimizing the risk of a detrimental outcome and/or personal discomfort. Physicians felt they needed to regain control, even if it was immediately detrimental for the woman in labor. Performing a CS, which is a routine procedure in a controlled environment, rather than attempting a breech delivery, a vaginal birth considered to be a higher risk, was for example preferred.

If everything goes well, that’s good. But if it doesn’t, I want to feel that I have that much to back it up… That it was the right decision. And, if something goes wrong… It should have been the right decision anyway. (Physician 11)

In summary, a profound sense of personal responsibility, loneliness, and a need to be in control were essential to physicians having this type of decision-making perspective. The parturient was often described as someone suffering and/or a helpless person in need of assistance. Physicians felt they got involved to help a victim in distress and that their actions would restore order from chaos.

Patients are like angels. They can’t do anything by themselves. Rather, it’s us taking care of it. I mean the patients. Innocent… Right!? They are victim of the situation. (Physician 13)

II. Dialogue-distributed process

In earlier years I thought I needed to know everything, what to do, and what would happen. Nowadays, we make decisions together. We have a conversation. You don’t need to be the one with all the answers and have a solution to every problem. (Physician 2)

The dialogue-distributed process as a decision-making perspective was preferred among 7 of the physicians. From this perspective physicians saw themselves as part of a team and were looking for dialogue with others involved, sometimes even including the patient and at times the partner/relative present in the room. In lesser emergencies, a senior colleague’s advice could also be sought for. Furthermore, communication, mostly verbal but sometimes also through gazes and/or even body language was central in getting information or making headway with the situation.

You communicate with touch and how you move. The body gives out signals. And you know what to do. It’s rehearsed. It’s not only verbal or visual. You can do your work with physical contact, that sort of communication… And there’s an energy in working together that carries things forward. There’s communion. And everybody’s fully concentrated on what to do, but at the same time there’s this sensitivity and wakefulness to each other. (Physician 2)

Generally speaking, decisions would rather be distributed or delegated. A commonly used tool was again “thinking out loud”. Other team members would suggest actions and measures to take, and the physician would only need to give an approval, rather than solving the situation himself. Knowing each other on a personal level or simply having worked together previously was facilitating this type of decision-making. Notably, when physicians who used this type of communicative perspective were in a tense or conflict-laden situation they would still prefer to discuss, in order to solve the issue at hand, rather than reclaiming their medical authority or a need for control. In summary, the main characteristic of this perspective was a shift of attention from individual concerns to group-work, including the patient. And because of the feeling of meaning created in this communitarian micro-cosmos, engagement as a team was also stress reducing and at times even enjoyable.

It’s also about getting relief from stress. I don’t need to be busy with the thought of having to control everything, while having to make all the decisions… I know I can trust that others are doing what they should. It’s like choreography. (Physician 2)

III. Chaotic flow-orientation

The chaotic flow-orientation as a decision-making perspective was preferred among 3 of the physicians. What particularly characterized this perspective was dynamism and letting go. For these physicians this type of decision-making had emerged over time, through maturation, self-reflection, and a more personal development and not just from sheer work experience. Physicians who preferred this perspective also felt that they could modulate their responses and revert back to either one of the two perspectives previously described. They also expressed an understanding that fundamentally, obstetric emergencies are full of uncertainty and accepted it to be so.

We don’t know when we make decisions. We don’t have all the information. When everything is over, then you know. But, when you stand there, then that’s just the way it is! Most of it is still unknown. (Physician 12)

In combination with that, physicians also expressed an appreciation for their finitude as human beings, on the limitations of how much one can possibly know and do.

It’s not always we have firm ground to stand on. Sometimes we’re just treading water, even if we think we know what we’re doing. We don’t really have control over things. (Physician 12)

From this perspective physicians’ focus and perceived role in emergency situations had changed. Focus was no longer on oneself, the team, or the birthing woman anymore, as in the two other perspectives. Focus was rather on “something greater than oneself”. The physicians’ role was to make oneself and one’s skills and knowledge available in an unfolding situation.

Believing in yourself when you are in front of the unsolvable is grounded in a trust that there’s something higher, that you can’t explain. You go into it with humility at the same time. You feel that you have a guaranty that it’s going to be all right in the end. It’s not dependent on you that much, it’s rather: ‘so be it!’” (Physician 17)

Concomitantly, emergency situations were perceived as inclusive (i.e., physicians felt immersed in the experience, not standing apart from it). Physicians were part of both the solution and the problem. Emergency situations were also perceived as dynamic and participatory, (i.e., the physicians expressed an acceptance over the ever-changing nature of situations and that every participation from any team member mattered). No one could avoid participating.

I have to be there and see and say what I think. Because then others can also say what they think. And then it’s easier to find the direction you need to take right there and then. (Physician 3)

There was also an active and particular attention to detail, as if everything mattered, because solutions could come when most unexpected.

It’s like a lightning bolt, suddenly you know what you must try. You get an insight: ‘this I have to try! It moves things forward.’” (Physician 17)

Ultimately, this perspective was grounded in a synergy between trust in the unfolding situation, as process and a responsibility for participating in that process. Physicians preferring this perspective had a belief that things would develop “as they should”, with an understatement that the outcome would be favorable. At the same time, they knew fully well that it wouldn’t necessarily be the case. Here physicians did not feel a need for control as in the first perspective. Instead, physicians expressed an appreciation for creativity and improvisation. Both were considered as necessary assets and what felt as a natural consequence of this decision-making perspective.

It’s a creative process that’s helping you, getting to an unconventional solution. You go through, unhinged, all possible alternatives. Your fantasy runs wild. There’s no inhibition, no barrier. (Physician 17)

Discussion

In maternity care, there is an assumption that everyone will act according to the same rules and norms in each situation [1719, 32]. A plausible explanation for this comes from a historical perspective. In 1979 Archie Cochrane anecdotally awarded obstetrics the wooden spoon award for being the poorest of all medical specialties in evaluating its practices. As a result, the interest in evidence-based medicine and standardization of effective practice has grown stronger and stronger ever since [13]. Many of today’s better outcomes of pregnancy and childbirth, for both woman and child, are often attributed to this development [1, 13, 15, 16]. Simultaneously, evidence that guidelines significantly improve health outcomes in obstetrics and gynecology is relatively scarce [56]. Researchers have also expressed reservation regarding the value of best practice for healthcare situations that show a great deal of variability, uncertainty and risk [57], such as emergency obstetrics. Our results of reconstructed narratives, expressed through themes and perspectives, indicate that physicians were, to a great extent, driven by individual motivations and rationales during their decision-making. This goes somewhat against the current trend of standardization. But most importantly, those motivations and rationales seemed to exist unnoticed, unless brought to the interviewee’s awareness, with the help of retelling an event and discussing images. This raises a couple of questions. How do these unconscious themes and perspectives impact the dynamics of teamwork, the functioning of a ward or a clinic, and per extension influence outcomes during childbirth? Would there be any value or even tangible effects from making themes and perspectives more conscious?

Recurrent themes as emergent discretionary space

The eight recurring themes were the most common elements physicians directly or indirectly related to during obstetric emergencies. Themes show how physicians both are continually constructed within-, and continuously constructing, a discretionary space for their decision-making [58, 59]. Constraints and possibilities are not simply determined by the preset limit-conditions of work but are also emergent properties of the physicians’ own (inter)actions, relations and involvement with their immediate surrounding [60, 61]. To keep one’s calm was volitionally self-imposed and yet often understood as a necessity, for different reasons such as keeping one’s thoughts in check or not distressing the woman giving birth. The relationship with ‘the attending midwife’ both existed as a negotiable power-dynamic and as a factual condition. In other words, interactions between midwives and physicians were part of the way work was organized and how that interaction was enacted depended on both the midwife and the physician. A similar discussion regarding the balance between structure and agency aspects in each of the other themes could be developed. In general, our findings confirm previous research showing that decision-making in critical situations is more complex than adherence to routines, regulations and procedures [27, 62]. Indeed, similar intricacies of work processes in the delivery room have been highlighted and problematized by other ethnographic studies pointing towards often unexamined and more complex dimensions of decision-making in obstetrics [6365]. As shown in this study, environmental conditions–including human interactions, norms, and cultures–and the physicians’ motivation and rationale engaged in a co-creative process with one another [66, 67]. Nevertheless, in the quest for quality, safety and accountability in healthcare, the tendency has been to split reality of practice into agent and environment, practitioner and working conditions [17, 68]. We suggest that organizational attempts taking into account the deep entanglement of the two [6870] are worthwhile exploring.

Decision-making perspectives, identity creation and variation

The three preferred decision-making perspectives expressed by physicians were contingent upon how different themes weighted and were valued in any given situation. More precisely, perspectives were the unification of the physicians’ disparate stories of professional identity and practice. Paradoxically, these stories of identity were often undisclosed to the self [71, 72]. The underlying perspectives appeared to be of importance in defining the physicians’ actions in emergency situations in general and more specifically towards the other members of the team, and the woman/couple giving birthing. Several aspects of the three different decision-making perspectives have also been the target of previous research. Our findings, characterized as ‘individual-centered strategy’ parallel those of an agent centered research on cognitive and affective aspects of decision-making [2023], those of ‘dialogue-distributed process’ parallel research on teams and teamwork [24, 26, 30, 73, 74], and those of ‘chaotic flow-orientation’ parallel research on effortless attention [75] and intuition [7678]. As a whole, the findings resemble three of four decision-making styles described in a 1995 study by Scott and Bruce [79]. Four decision-making styles were identified through the literature and further tested into an assessment tool. The four styles were: (a) a rational decision-making style characterized by a thorough search for and logical evaluation of alternatives, (b) an intuitive decision-making style characterized by reliance and hunches and feelings, (c) a dependent decision-making style characterized by a search for advice and direction from others and (d) an avoidant decision-making style characterized by attempts to avoid decision making [79]. Moreover, seen as a unified model the three perspectives are also akin to Dreyfus and Dreyfus’ model of skill acquisition [80, 81] describing how professionals develop from novice to expert through different stages, how each stage gives rise to a certain understanding of the world and how individuals express their stage specific skills. Indeed, interviewees hinted at a developmental aspect of decision-making suggesting that their perspective evolved from ‘individual’ to ‘dialogue’ to ‘chaos’ along with their professional and personal experience. Putting decision-making, as strategy, style, or perspective at the level of individuals into a structural framework of the development of expertise through experience would have implications, at least for trainee education. In fact, this has been highlighted in nursing research [81]. For example, novices showing a strict technical application of knowledge do not have the skills required for discerning the nature of a situation and its possibilities and constraints. Experts on the other hand, remain open to experiential learning and read changes in transitions in fast-paced, open-ended environments [81]. And most importantly, experts have shown to be able to act under time pressure, either after their quick recognition of a problem or by applying a strategy that has proven successful in similar situations [82]. Another theory worth mentioning here is Hammond’s cognitive continuum theory that models clinical decision making on a spectrum between intuitive and analytic modes [8386]. Location on the spectrum is dependent on various factors such as type of task at hand (action versus planning), time available (short amount versus greater amount), type of knowledge available (unstructured versus structured), and the kind of health problem needing to be dealt with (acute/unstable versus long-term/stable). The cognitive continuum theory parallels some of the physicians’ narratives about their capacity to modulate their responses during emergencies (i.e., the more urgent the demand for an action was, the more intuitive their decision would be). Finally, even though three perspectives were characterized, most physicians rarely embraced one style exclusively. Individuals embodied, to a varying degree, a plurality of perspectives. Eventually, one perspective would dominate over the others, seemingly depending on personal characteristics and situational circumstances as exemplified through the themes. In terms of personal characteristics, physicians were more or less sensitive, and some possibly resistant to the impact of different themes. Examples from interviews, such as the statement of “being born naturally calm” or that some interviewees experienced difficulty in relating to images, suggest that individual-specific, non-contingent factors are at play during their decision-making. It has been suggested that personality, the unchangeable characteristics of an individual, could be such a factor [21, 87, 88]. In fact, studies have shown that individual propensity for anxiety, type of coping and adaptive traits are associated with perinatal outcomes [21, 87, 88]. Furthermore, it has also been suggested that other traits facilitating collaboration, coordination, cooperation, and participation impact team effectiveness, team member satisfaction and achievement of better patient outcomes [73]. There is a considerable amount of research on the subject of individual differences (e.g., risk behavior tendency, sensitivity to situational factors, personality, etc.) in relation to decision-making [89]. However, this work has generally been confined to psychology and more specifically to the research field of judgment and decision-making. With a focus on patient safety and optimizing care, the interest in decision-making applied to healthcare has rather been on trying to minimize the impact of individual differences and, to some extent, understand the impact of situational factors. Further research on the relationship between decision-making perspectives, themes as exemplified in this study, personality and the impact of individual traits in obstetric care is warranted.

Methodological considerations

Self-reflexivity

The fact that he first author (GMR) was an experienced obstetrician provided certain advantages for the interviews. Acknowledging each other’s expertise within the domain of interest established an atmosphere of trust during the interview situation. Shared contextual understanding was reinforced by the first author further acknowledging participants’ responses, often from having had similar experiences to the ones described and having reflected upon them over the years. This contributed to an ease and flow during the interviews. Participants were enabled to open up more. Knowing the jargon provided a unique opportunity for reaching deeper faster with each interview and by-passing polite, superficial or expectable answers [90, 91]. Being an experienced obstetrician and being inherently embedded within the research context also conferred some difficulties both during the interview and analysis. Indeed, one will always be unable to fully appreciate one’s own assumptions within the domain of interest. In this regard, our understanding and use of both the insider researcher approach and the narrative approach in this paper is grounded in the views of hermeneutic phenomenology [92, 93]. Accordingly, our preconceptions (i.e., knowledge, insights, and experience) of the world come from being inextricably involved within it and “stepping outside” or leaving our biases aside is understood as impossible [92, 94, 95]. However, through a dialogical process of interpretation, preconceptions and the creation of new meanings and an understanding of the world can simultaneously be disclosed [95]. The general approach of the inquiry was co-creative [41]. The emerging data was constructed through unfolding conversations-cum-interpretation [53], with just enough involvement in facilitating the interviewees’ responses [42]. Neither the interviewee nor the interviewer were neutral observers of a phenomenon to be ultimately revealed [90, 91], and no one was considered to have the true answers. It was rather two colleagues reflecting on each other’s way of handling an emergency. In this context, meaning and reality were constructed through language [35, 53, 96, 97].

On the use of visual materials

Overall, the use of images helped most interviewees in developing their responses, sometimes even generating new ideas. Yet, a few interviewees had difficulties choosing and talking about images, suggesting that this method is either not suitable for all or that special guidance or sensitivity on the part of the interviewer might be necessary. Notably, most physicians felt the drawing part to be initially distressing. However, as curiosity for the method and a desire to share their stories quickly evolved, they became more at ease and playful with the concept. The combination of retelling an event and using images was thought to provide particular richness to the interviews [98]. Eventually, analysis was derived from a bulk of data consisting of text.

Truth and validity

The narrative approach is interpretive in its nature. We acknowledge that our original material is context-dependent and can be analyzed in different ways [99]. Furthermore, the results and analysis are influenced by the authors’ respective background, and the first author’s deep involvement in the process, as described above. Nevertheless, several methodological steps were taken in an attempt to create a trustworthy and valid reconstructed narrative in accordance with the participants responses [47]. Firstly, a narrative approach will have validity in its contribution to making sense of the world and ourselves [53]. Here, we subscribe to a pragmatist view [55, 100]. We believe the study has value for both clinical practitioners and researchers alike. Whether this research ultimately contributed anything of value is for the readers to judge [34, 40]. Secondly, coherence of interpretation for each interview and between interviews was sought for [54, 101]. We believe that both themes and perspectives form coherent wholes that make sense to practitioners. Thirdly, sending the interview and the written interpretation back to respective interviewee insured further validity [34, 36, 42]. Interpretation was found to be in accordance with participants’ answers. Fourthly, the use of visual materials functioned as a neutral ground for inquiry, effective in generating valuable information to some degree freed from preconceptions [38, 4751]. Finally, having an ongoing discussion about different findings amongst the four co-authors was a way to keep the interpretation alive [53, 102]. The authors’ different backgrounds and perspectives fueled new reflections.

Conclusions

The purpose of this study was to explore physicians’ sense-making of their decision-making during obstetric emergencies. A co-creative narrative approach was used. The analysis interpreted themes of how physicians were both situated within-, and creators of, conditions in an ongoing dynamically adaptive process. Furthermore, the analysis indicated how physicians gave meaning to their decision-making through individual motivations and rationales, interpreted in the form of three perspectives: an individual-centered strategy, a dialogue-distributed process, and a chaotic flow-orientation. Finally, the analysis also suggested that an individual’s perspective evolve with experience, and over time. Physicians’ narratives confirm previous findings about the multilayered complexity of decision-making in intrapartum care. Various aspects of the reconstructed perspectives are reminiscent of previous findings on individual and team decision-making in emergency medical settings. However, we believe that perspectives understood as identity, during decision-making in obstetric emergencies, has previously been insufficiently explored. Overall, the findings have relevance for continuous efforts to improve clinical practice and contribute to our understanding of the variability of strategies and decision-making processes in intrapartum care. The narrative approach used, including visual materials, proved rewarding and might be well suited for similar research on social complexity in other healthcare areas.

Supporting information

S1 Appendix. Interview guide.

Interview guide used in the rare cases of a stalled conversation.

(PDF)

S2 Appendix. Interview guide in Swedish.

Intervjuguide, används i de fallen samtalet stannar upp.

(DOCX)

S3 Appendix. List of visual materials.

List of visual materials chosen by respondents.

(DOCX)

Acknowledgments

The authors would like to thank the 17 obstetricians and gynecologists for their time, commitment, and interest in the study. The authors would also like to thank Dr. Karin Sjöström for providing psychotherapeutic counseling support during the study. The authors would also like to thank Dr. Lena Erlandsson for her thoughtful suggestions to the final version of the manuscript.

Data Availability

Data relevant to this study are available on the Swedish National Data Service at https://snd.gu.se/en/catalogue/study/2021-315 (https://doi.org/10.5878/ejjg-8477).

Funding Statement

- Initials of the author who received the award: SRH - Grant number: 20190142 - Full name of the funder: The Kamprad Family Foundation for Entrepreneurship, Research and Charity - URL: https://familjenkampradsstiftelse.se - The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Bernadette Watson

Transfer Alert

This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present.

28 Jun 2021

PONE-D-21-12199

Decision-making during obstetric emergencies: A narrative approach

PLOS ONE

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I have now received feedback from the two reviewers. They both see the value in the paper but make very important points. While one reviewer suggest minor revisions, there is an important question posed about making sure your research question is clear. I think both reviewers' comments merit a major revise and resubmit, which I hope you will do. Please address their comments carefully. I look forward to your revisions.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #2: No

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5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review the paper "decision-making during obstetric emergencies: A narrative approach". Overall, I thought the paper was interesting and the methodology in particular was interesting and conducted with rigour. I do however feel that further work is required before the manuscript is published.

In particular, I feel that more needs to be done to justify why the study was needed. Why is there a need to understand how physicians make sense of and give meaning to their decision-making? And how will will understanding their sense making and meaning making processes help us to address a problem/issue. The problem/issue with our current understanding of decision making in emergencies was alluded to but not well defined. It seems like a gap that was trying to be filled was considering team-based decision making (which has evidently been used in anaesthesiology), but if that was the case, why were only Physician’s included? Given the plethora of literature on medical decision making, I felt that the introduction was too short and lacking critical analysis of the existing evidence base and thus lacking the justification for the current study.

Typically, qualitative research is used to answer a research question. I wasn’t clear what the research question was that was being answered in the study.

I thought the method and description of the approach was good, though I wasn't clear why median years experience was chosen rather than the traditional mean and standard deviation, which gives more indication of spread, was chosen. Age is also commonly reported though is perhaps less relevant for some reason in this study.

Given the study was a 3 different units, I was interested in whether the unit they worked in influenced the themes and style used. Perhaps this was considered and was not of interest as experience drove most of the effect, but I would be interested to know.

The use of the images was fascinating and I can see how it may have lead to richer data by breaking down the typical interview process - particularly for those with who likely have strong associations of the norms associated with the format. I think this is a particular strength of the study.

I think the results could be strengthen by restating with the research question/aim to situation the themes. I was a little confused about how the two different sets of themes were related, though this was somewhat cleared up later in the paper.

In terms of discussion, and partly related to the issue outlined with the introduction, but I struggled to understand what is novel and new about the findings. Experience as a variable affecting decision making is widely researched and understood. The authors also themselves state that their findings mirror some of the common models on decision making. I think more needs to be done to explicitly highlight what this paper adds in terms of a) practical implications (which is somewhat done in the conclusion) and b) theoretical implications.

I would also recommend that the restating of the method is removed from the conclusions section and that this section is strengthened so that the contribution is more specific and explicit and less vague.

While I enjoyed and was thankful for the self-reflexivity section, I do think the author (as an insider researcher) needs to say more on how they bracketed their own preconceptions during the data collection and analysis and/or if, as it seems, they leant into their own background, I would appreciate a deeper analysis of the impact this may have had on findings.

A final note, a read through the reference list shows a distinct lack of referencing of most of the decision making models in medicine. Dual process theory is briefly mentioned but cognitive continuum theory (as an example), which is arguably relevant is not. I recommend that the authors dialogue with the existing models more directly to position their studies and findings. There has also been considerable work on individual differences in decision making that goes above and beyond the novice/expert and personality perspectives.

I wish the authors the best in publishing this interesting methodological paper.

Reviewer #2: This manuscript reports on findings from an interesting narrative analyses of interview data from obstetricians and gynecologists in Sweden on their perspectives and experiences of decision making during obstetric emergencies. It is an important area of research, with implications not only for quality of healthcare in obstetric emergencies but potential to add to our understanding of professional decision making processes across a range of healthcare settings. Unfortunately, the research is reported too superficially to realise its potential for understanding decision making even in this specific context, nor the implications for improving decision making processes and outcomes.

The authors set a context for their work as being about understanding variations in intervention rates and outcomes, including potentially harmful over-use of medical intervention. However, this premise is not adequately considered in the subsequent analyses and interpretation. What do the findings offer for uncovering possible explanations? How do they fit (or not) with other research on the possible explanations for these variations and/or overtreatment in terms of obstetric/gynecological decision making?

There are very interesting nuances in the data presented that are missing from the analysis and discussion altogether. For example, the authors indicate at various times that they observed an apparent lack of easy self-awareness and professional reflection when engaging with research participants on this topic (e.g., “motivations and rationales seemed to exist unnoticed”). Is critical self-reflection and debriefing part of routine professional practice (and/or training)? Further, there is an embedded lack of consideration of the patient’s right to autonomy in decision making processes in the participants’ responses and the author’s interpretations. The invisibility of the birthing woman and indicators that her autonomy is largely unacknowledged in the narratives and interpretations (‘could sometimes be included in the discussion’ etc. etc.) may be an integral finding here that goes unmentioned. These findings are of direct relevance to understanding why there may be unwarranted variations in practice and are key to advancing quality decision making in obstetric emergencies. A much deeper and more critical analyses is needed of what is, and perhaps just as importantly what is NOT, embedded in the narratives reported here. Indicators of control and agency, in particular, require deeper analyses and critical reflection.

Related to this, there is insufficient acknowledgement of the role, assumptions and beliefs of the authors and how they may have influenced the research process. The first author/interviewer is noted to be an obstetric and gynecology specialist and senior consultant in perinatology, but much more is needed to understand the researcher bias inherent here. Was the interviewer previously known to participants, and how? What was the power dynamic between researchers and participants? What are the authors’ own fundamental philosophical positions on decision making in obstetrics (including other authors, who are reported to have been involved in ongoing discussions about the findings)? Much stronger reflexivity is needed in both reporting these factors up-front and in consciously acknowledging their influence on analyses and interpretations of the data. The sections of the Discussion on methodological considerations only heighten concerns of bias with a lack of insightful critique on the range inherent assumptions of the research processes.

Interesting that at least one quote about midwifery colleagues was so gendered (see lengthy quote starting page 13 with “It’s a special dynamic”). What was the gender of Physician 9? Are there both cross-professional and cross-gendered power dynamics at play here? Social complexity in this context is mentioned as warranting further research, but could be discussed much more within this work as well.

The context of maternity care organisation in Sweden and the specific role of obstetricians and gynecologists within it would be helpful to a broad readership.

More careful, humanised language is recommended to describe the people being cared for in emergency situations (consider replacing ‘parturient’ with ‘birthing woman’ or ’birthing patient’ if a non-gendered description is preferred). Also consider replacing ‘delivery care’ with ‘intrapartum care’ or ‘care during labour and birth’.

Overall, the implications of these findings could be discussed with much more useful degree of specificity, with some reference to key theories or other research that would be useful in their realisation/implementation.

There are also some typographical/grammatical errors that should be addressed in any subsequent revisions.

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Reviewer #1: No

Reviewer #2: Yes: Associate Professor Yvette D Miller

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PLoS One. 2022 Jan 26;17(1):e0260277. doi: 10.1371/journal.pone.0260277.r002

Author response to Decision Letter 0


15 Sep 2021

Reviewer #1:

General response to reviewer #1’s comments:

We welcome reviewer #1’s valuable and thoughtful comments. The reviewer acknowledges the method(s) and the manuscript for being interesting and conducted with rigor. However, the reviewer underlines that the manuscript needs more work before publication. We have attempted to remedy the concerns in the revised version of the manuscript, especially with regards to contextualizing and justifying the study. We have also expanded on the section regarding self-reflexivity.

Comments and responses

Thank you for the opportunity to review the paper "decision-making during obstetric emergencies: A narrative approach". Overall, I thought the paper was interesting and the methodology in particular was interesting and conducted with rigor. I do however feel that further work is required before the manuscript is published.

In particular, I feel that more needs to be done to justify why the study was needed. Why is there a need to understand how physicians make sense of and give meaning to their decision-making? And how will understanding their sense making and meaning making processes help us to address a problem/issue. The problem/issue with our current understanding of decision making in emergencies was alluded to but not well defined.

- The introduction has been expanded and the problem/issue somewhat redefined. Because the changes were many, we kindly refer to the manuscript (Line 51 to 92), instead of reproducing the ‘introduction’ text in full.

- A central assumption in the paper was that the disclosure of lived experience through the telling and re-telling of stories would highlight differences in practices (i.e., how physicians make sense out of the complexity of their experience). The narrative approach we used bridges a gap between the individual, understood as agent, and the complexity of human interactions.

It seems like a gap that was trying to be filled was considering team-based decision making (which has evidently been used in anaesthesiology), but if that was the case, why were only Physician’s included?

- Only physicians (i.e., obstetricians and gynecologists) were included in the study because they:

• “[…] hold a central role in the obstetric team as they are assumed to make key decisions before and during childbirth, especially during emergency situations”. (Line 86 – 88)

Given the plethora of literature on medical decision-making, I felt that the introduction was too short and lacking critical analysis of the existing evidence base and thus lacking the justification for the current study.

- There is indeed a rich literature on medical decision-making. However, it is oftentimes from a nursing context or a non-emergency context or a non-obstetric context or a non-naturalistic context. With the authors having backgrounds in obstetrics and gynecology, narrative science, social science, complexity and systems theory as well as safety science, references were primarily drawn from those domains. In our initial literature review, the causal explanation for the shift between safety and accident, error and correct action, intervention or no-intervention is usually found at one of two opposite poles of a spectrum between individual(s) and system(s). Even groups/teams are either considered as individuals interacting or as a complex system of its own. As referenced in the original article, only a few papers actually manage to keep a complexity perspective on groups/teams in obstetrics without reverting back to a reductionist view. Generally speaking, when considering the individuals, either in isolation or in groups, it is the de-contextualized cognitive (and affective) aspects of their actions/decisions that are in focus.

Typically, qualitative research is used to answer a research question. I wasn’t clear what the research question was that was being answered in the study.

- The research question was expressed affirmatively as the study’s purpose/aim. The terms ‘exploration’ and ‘how’ refer to a qualitative approach. The bits of sentences ‘make sense of’ and ‘give meaning to’ refer to a narrative approach.

I thought the method and description of the approach was good, though I wasn't clear why median years experience was chosen rather than the traditional mean and standard deviation, which gives more indication of spread, was chosen. Age is also commonly reported though is perhaps less relevant for some reason in this study.

- The median was chosen in the original paper as there were two “outliers” among the participants, one was a trainee with only 3 years of experience and the other was a senior with 31 years of experience. We also intuitively thought that reporting age was less relevant. Nevertheless, age as well as the mean and standard deviation for both age and experience have replaced the median in the revised manuscript:

• “Mean age: 45 years ± 8.7 years, mean years of experience: 15 ± 9.4 years”. (Line 144 – 145)

Given the study was at 3 different units, I was interested in whether the unit they worked in influenced the themes and style used. Perhaps this was considered and was not of interest as experience drove most of the effect, but I would be interested to know.

- It was mistakenly noted in the original manuscript that participants were from 3 different maternity units. They were in fact from 4 different units. We have corrected this mistake (Line 137). We have also added that:

• “The maternity units used similar guidelines, routines and practices”. (Line 138)

- It is possible that there exist different work cultures influencing the themes and styles. However, this particular question wasn’t the focus of our inquiry. It would be a stretch to speculate on the matter based on the available data. Another complicating factor was the fact that some of the participants had worked at several of the units over the years.

The use of the images was fascinating, and I can see how it may have led to richer data by breaking down the typical interview process - particularly for those with who likely have strong associations of the norms associated with the format. I think this is a particular strength of the study.

- Thank you! We are glad that the method of inquiry triggered your interest.

- Indeed, using art images opened up for a common exploratory space between the interviewer and participants, away from preconceptions about working practices and interview situations.

I think the results could be strengthened by restating the research question/aim to situate the themes. I was a little confused about how the two different sets of themes were related, though this was somewhat cleared up later in the paper.

- The research aim has been restated at the beginning of the result and analysis section:

• “The purpose of this study was to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies”. (Line 203 – 204)

- A sentence has also been added to highlight the relationship between themes and decision-making perspectives at an earlier stage:

• “The decision-making perspectives were the expression of physicians’ identities transformed into practice, influenced by the different themes”. (Line 210 – 211)

In terms of discussion, and partly related to the issue outlined with the introduction, but I struggled to understand what is novel and new about the findings. Experience as a variable affecting decision-making is widely researched and understood. The authors also themselves state that their findings mirror some of the common models on decision-making.

- We believe that the novelty of our findings is essentially three-fold: (1) previously observed findings were disclosed through a radically new approach (at least for such a context as the one described in this study), (2) the physicians were both situated within-, and creators of, conditions – for decision-making during obstetric emergencies – in an ongoing dynamically adaptive process, and (3) that this adaptive process was given meaning through an identity expressed as a decision-making perspective. We kindly refer to the revised manuscript (Line 740 to 763), instead of reproducing the ‘conclusions’ section in full.

I think more needs to be done to explicitly highlight what this paper adds in terms of a) practical implications (which is somewhat done in the conclusion) and b) theoretical implications.

- The practical implications of the findings are mainly twofold. They are important for: (1) the training of individuals and teams, (2) patient-safety and the improvement of care. Indeed, the insights into the physicians’ thinking can be used to better understand why certain decisions were made, possibly guide/mentor in doing things differently, and eventually reorganize work:

• “Overall, the findings have relevance for continuous efforts to improve clinical practice and contribute to our understanding of the variability of strategies and decision-making processes in intrapartum care”. (Line 756 – 758)

- Regarding the theoretical implications, some of the findings confirm previous research:

• “Physicians’ narratives confirm previous findings of multilayered complexity of decision-making in intrapartum care. Various aspects of the reconstructed perspectives are reminiscent of previous findings on individual and team decision-making in emergency medical settings”. (Line 750 – 753)

- There are also implicit, method related findings. Those were mentioned in the original version of the manuscript and have been un-altered in the new version.

I would also recommend that the restating of the method is removed from the conclusions section and that this section is strengthened so that the contribution is more specific and explicit and less vague.

- The restating of the method has been removed from the ‘conclusions’ in the revised version of the manuscript.

- The description of the contribution has been made more explicit. We kindly refer to the previous response on the implication of the findings.

While I enjoyed and was thankful for the self-reflexivity section, I do think the author (as an insider researcher) needs to say more on how they bracketed their own preconceptions during the data collection and analysis and/or if, as it seems, they leant into their own background, I would appreciate a deeper analysis of the impact this may have had on findings.

- The self-reflexivity section has been expanded in the revised manuscript in order to acknowledge for the interviewer/first author’s (GMR) preconceptions and how they might have impacted data collection and analysis:

• “The fact that he first author (GMR) being was an experienced obstetrician provided certain advantages for the interviews. Acknowledging each other’s expertise within the domain of interest established an atmosphere of trust during the interview situation. Shared contextual understanding was reinforced by the first author further acknowledging participants’ responses, often from having had similar experiences to the ones described and having reflected upon them over the years. This contributed to an ease and flow during the interviews. Participants were enabled to open up more”. (Line 683 – 689), and

• “Being an experienced obstetrician and being inherently embedded within the research context also conferred some difficulties both during the interview and analysis. Indeed, one will always be unable to fully appreciate one’s own assumptions within the domain of interest. In this regard, our understanding and use of both the insider researcher approach and the narrative approach in this paper is grounded in the views of hermeneutic phenomenology [1, 2]. Accordingly, our preconceptions (i.e., knowledge, insights, and experience) of the world come from being inextricably involved within it and “stepping outside” or leaving our biases aside is understood as impossible [1, 3, 4]. However, through a dialogical process of interpretation, preconceptions and the creation of new meanings and an understanding of the world can simultaneously be disclosed [4]”. (Line 692 – 701)

A final note, a read through the reference list shows a distinct lack of referencing of most of the decision-making models in medicine. Dual process theory is briefly mentioned but cognitive continuum theory (as an example), which is arguably relevant is not. I recommend that the authors dialogue with the existing models more directly to position their studies and findings. There has also been considerable work on individual differences in decision making that goes above and beyond the novice/expert and personality perspectives.

- Kenneth Hammond’s cognitive continuum theory has now been mentioned:

• “Another theory worth mentioning here is Hammond’s cognitive continuum theory that models clinical decision making on a spectrum between intuitive and analytic modes [5-8]. Location on the spectrum is dependent on various factors such as type of task at hand (action versus planning), time available (short amount versus greater amount), type of knowledge available (unstructured versus structured), and the kind of health problem needing to be dealt with (acute/unstable versus long-term/stable). The cognitive continuum theory parallels some of the physicians’ narratives about their capacity to modulate their responses during emergencies (i.e., the more urgent the demand for an action was the more intuitive their decision would be)”. (Line 647 – 655)

- However, we have failed to find literature on more decision-making models applicable in a medical emergency setting – including ones taking individual differences into account –other than the ones already mentioned, or else alluded to in the references. Some changes have been made to the manuscript:

• “As a whole, the findings resemble three of four decision-making styles described in a 1995 study by Scott and Bruce [9]. Four decision-making styles were identified through the literature and further tested into an assessment tool. The four styles were: (a) a rational decision-making style characterized by a thorough search for and logical evaluation of alternatives, (b) an intuitive decision-making style characterized by reliance and hunches and feelings, (c) a dependent decision-making style characterized by a search for advice and direction from others and (d) an avoidant decision-making style characterized by attempts to avoid decision making [9]”. (Line 626 – 633), and

• “There is a considerable amount of research on the subject of individual differences (e.g., risk behavior tendency, sensitivity to situational factors, personality, etc.) in relation to decision-making [10]. However, this work has generally been confined to psychology and more specifically to the research field of judgment and decision-making. With a focus on patient safety and optimizing care, the interest in decision-making applied to healthcare has rather been on trying to minimize the impact of individual differences and, to some extent, understand the impact of situational factors”. (Line 668 – 674)

I wish the authors the best in publishing this interesting methodological paper.

- We thank the reviewer for his/her time, comments and encouragement!

Reviewer #2:

General response to reviewer #2’s comments:

We welcome reviewer #2’s valuable and thoughtful comments. The reviewer acknowledges the method(s) and data for being interesting and that the area of research is important, with the findings having potentially significant implications. However, the reviewer criticizes the analysis and discussion for being too superficial. Eventually, the paper does not help to understand decision-making (in obstetric emergencies), or how it could help improve decision-making processes and outcomes. We have attempted to remedy the concerns in the revised version of the manuscript, especially with regards to the disclosure of preconceptions as well as the philosophical underpinnings of the method(s) and our research approach.

Comments and responses

This manuscript reports on findings from an interesting narrative analyses of interview data from obstetricians and gynecologists in Sweden on their perspectives and experiences of decision making during obstetric emergencies. It is an important area of research, with implications not only for quality of healthcare in obstetric emergencies but potential to add to our understanding of professional decision making processes across a range of healthcare settings. Unfortunately, the research is reported too superficially to realise its potential for understanding decision making even in this specific context, nor the implications for improving decision making processes and outcomes.

The authors set a context for their work as being about understanding variations in intervention rates and outcomes, including potentially harmful over-use of medical intervention. However, this premise is not adequately considered in the subsequent analyses and interpretation. What do the findings offer for uncovering possible explanations? How do they fit (or not) with other research on the possible explanations for these variations and/or overtreatment in terms of obstetric/gynecological decision making?

- The context has been expanded upon in the revised manuscript. The significance of the findings has been highlighted as well. We kindly refer to the manuscript for the ‘introduction’ (Line 51 to 92) and the ‘conclusions’ (Line 740 to 763) sections.

- Please see the comments to reviewer #1 for more details concerning implications of the findings.

There are very interesting nuances in the data presented that are missing from the analysis and discussion altogether.

- The study was essentially descriptive. A thematic narrative analysis outlined by Riessman was used. Narrative analysis interpreted by Czarniawska was also used especially regarding the co-creative and pragmatist approaches of the study. A critical analysis of attitudinal differences in relationship to variations and overtreatment in particular was not the study’s focus. Our intent with the narrative method was to render disparate stories into a coherent whole. This was expanded upon in the ‘study design’ section and the ‘truth and validity’ section of the revised manuscript:

• “Using a thematic narrative analysis outlined by Riessman, and further influenced by Czarniawska’s interpretation, the intent was to eventually render disparate stories into a coherent whole through a dialogical process [11-13]”. (Line 103 – 105), and

• “Here, we subscribe to a pragmatist view [14, 15]. We believe the study has value for both clinical practitioners and researchers alike. Whether this research ultimately contributed anything of value is for the readers to judge [12, 13]”. (Line 726 – 728), and

• “We believe that both themes and perspectives form coherent wholes that make sense for practitioners”. (Line 730 – 731)

For example, the authors indicate at various times that they observed an apparent lack of easy self-awareness and professional reflection when engaging with research participants on this topic (e.g., “motivations and rationales seemed to exist unnoticed”). Is critical self-reflection and debriefing part of routine professional practice (and/or training)?

- Swedish obstetricians and gynecologists are invited and encouraged to self-reflect both as trainees and proficient physicians. This is naturally done during clinical rounds and instances of tutoring or when work does not go as planned. Many of the participants’ answers witness of self-awareness and professional reflection to various degrees. However, our interpretation was that the unification of disparate stories into a professional identity driving the physicians’ actions and practice was rather unconscious. Herein lies a paradox.

- A possible explanation for this paradox could be that, after the training period is over and physicians have integrated practices into a way/style that works for them they often work alone (i.e. not with another physician). Peers no longer mirror each other and self-reflection becomes more difficult.

Further, there is an embedded lack of consideration of the patient’s right to autonomy in decision-making processes in the participants’ responses and the author’s interpretations.

- Although we subscribe to the reviewer’s concern regarding “consideration of the patient’s right to autonomy” in general, we believe this to be less relevant in this particular study, for two reasons:

o (1) It was conducted in a Swedish healthcare setting. Sweden is a country in which trust in governmental institutions, including the healthcare system has traditionally been high. “The patient’s right to autonomy” has been given less outspoken focus in the collective narrative. It is integrated in medical practice through law. The Swedish law on patients’ rights stipulates that: (a) the patient should be treated according to the best available care according to science and clinical experience, (b) the patient has the right to healthcare but do not have the right to choose the care she wants (unless two treatments are equal), (c) the patient can refuse treatment or intervention (except for particular cases when she is suffering of a psychiatric condition, but always after the assessment from a psychiatrist), and (d) treatment should be provided in consultation with the patient and with her consent.

o (2) It was about the particular context of obstetric emergencies. Even if there are variations in the types of emergencies physicians (and midwives) are confronted with, they all happen under a certain time constraint, as was also reported in the participants’ narratives. There is also an assumption of care built into an obstetric emergency, namely that the woman giving birth wants to be a mother (i.e., she want to stay in health to care for her healthy newborn child) and that both physicians and midwives will act in the patient’s best interest. There is certainly a paternalistic bias in this assumption. However, it does not mean that it is wrong. We develop this further in the comment on “the invisibility of the birthing woman”.

o As a side note, we would like to add that malpractice cases are for the great majority handled by a governmental regulatory board, not the courts. Litigations are a rare exception.

The invisibility of the birthing woman and indicators that her autonomy is largely unacknowledged in the narratives and interpretations (‘could sometimes be included in the discussion’ etc. etc.) may be an integral finding here that goes unmentioned.

- An assumed goal driving obstetric care is “a healthy child and mother”. In that sense neither of them are invisible. If by “the invisibility of the birthing woman” the reviewer meant that the woman giving birth was referred to as an object, then the authors agree with the reviewer. This can in fact be the case and was also alluded to in the paper. From a developmental perspective it is only natural that when a practitioner feels less stressed during an emergency, he or she would have more room to empathically connect with the woman/couple, thus considering her/them more as subjects. However, there are at least two problems with this oftentimes-pragmatic approach to obstetric care and particularly to intrapartum care. The first is when the capacity for empathetic connection, or lack thereof is tied to the person (physician or midwife) and/or unexamined practices. The second, related to the first, is when the horizon of care (or even caring) does not reach further than the delivery suite; when the whole life of the woman/couple/family isn’t taken into consideration (e.g., including potential traumatic memories).

- We acknowledge here the lack of feminist critique in the manuscript. However, this wasn’t the focus of our paper. We welcome others to use our rich and original transcriptions in doing so.

These findings are of direct relevance to understanding why there may be unwarranted variations in practice and are key to advancing quality decision making in obstetric emergencies. A much deeper and more critical analyses is needed of what is, and perhaps just as importantly what is NOT, embedded in the narratives reported here. Indicators of control and agency, in particular, require deeper analyses and critical reflection.

- There are indeed two significant weaknesses in the research approach outlined in the study: (1) it is descriptive rather than critical, and (2) it fails to connect narratives and obstetrical outcomes.

Related to this, there is insufficient acknowledgement of the role, assumptions and beliefs of the authors and how they may have influenced the research process. The first author/interviewer is noted to be an obstetric and gynecology specialist and senior consultant in perinatology, but much more is needed to understand the researcher bias inherent here.

- The section on ‘self-reflexivity’ has been expanded upon in the revised manuscript. We kindly refer to a previous response to reviewer #1.

Was the interviewer previously known to participants, and how? What was the power dynamic between researchers and participants? What are the authors’ own fundamental philosophical positions on decision making in obstetrics (including other authors, who are reported to have been involved in ongoing discussions about the findings)? Much stronger reflexivity is needed in both reporting these factors up-front and in consciously acknowledging their influence on analyses and interpretations of the data.

- The relationship of the interviewer to the participants has been added to the manuscript:

• “The interviewer and participants were known to each other on a professional level after having worked together to various degrees over the years”. (Line 147 – 149)

The sections of the Discussion on methodological considerations only heighten concerns of bias with a lack of insightful critique on the range inherent assumptions of the research processes.

- We kindly refer to our response on self-reflexivity to reviewer #1 concerning bias and assumptions. The research process has also been brought up in an earlier response to reviewer #2. In summary, the approach outlined in this paper follows a descriptive, co-creative tradition within narrative analysis. Biases drive an interpretive dialogical process during which the line between the researcher’s and the participants’ ideas tend to get blurred. The goal being the reconstruction of new coherent and sensible narrative. The value of this new narrative is deemed to be ascribed by its readers. This approach differs from other forms of narrative analysis [16] such as ‘Critical Discourse Analysis’ (CDA) and the tradition of Jürgen Habermas for example, which is concerned with analyzing structural relationships of dominance, discrimination, power and control [17]. In contrast to the approach in this study, in CDA the researcher needs to consider the data from at a distance.

Interesting that at least one quote about midwifery colleagues was so gendered (see lengthy quote starting page 13 with “It’s a special dynamic”). What was the gender of Physician 9?

- Physician 9 is a middle-aged woman with substantial experience in obstetrics. She was particularly reflective on her experience and sensitive to the use of pictures.

- Gendering the quotes does not provide more nuances, more depth or more coherence to the narrative as a whole in this study.

Are there both cross-professional and cross-gendered power dynamics at play here?

- A critical assessment of both cross-professional and cross-gendered power dynamics was not the focus of this study. However, the new section on childbirth in Sweden includes the following section:

• “Historically, a non-interventionist ideal, i.e., wait and see rather than intervene, has guided practice for both midwives and obstetricians in Sweden [18]. The relationship between physicians and midwives in Sweden has also been characterized by considerably more teamwork rather than conflicts [18]”. Line (131 – 134)

- However, cross-professional power dynamics have been alluded to in previous research as well [19] and cross-gender power dynamics most certainly exist within the world of Swedish obstetrics. Some these aspects embedded in practice are formally discussed in the midwifery education or during physicians’ training in obstetrics.

Social complexity in this context is mentioned as warranting further research, but could be discussed much more within this work as well.

- The sentence: “Further research on social complexity in this domain is also warranted” (Line 612) has been removed.

The context of maternity care organisation in Sweden and the specific role of obstetricians and gynecologists within it would be helpful to a broad readership.

- A specific section about maternity care organization in Sweden has been added to the revised version of the manuscript:

• “Intrapartum care in Sweden is institutionalized and publicly funded. There are 40 maternity units, and about 115.000 to 120.000 births per year serving a population of 10,2 million (2019) [20]. Pregnancy, labor, and childbirth are first and foremost considered natural processes. In 2020, 88% of births were so called normal births. Normal births are births without greater intervention: no Caesarean sections or no VE/forceps, postpartum bleeding below 1500 mL or no need for blood transfusion, no sphincter rupture, no Apgar score below 7 at 5 minutes [20]. The care is standardized by national and local guidelines. Trained and autonomous midwives follow most of patients during pregnancy and assist during labor and childbirth. Midwifery is a university degree constructed around the medical sciences and modern medicine, and a previous degree in nursing is required. Physicians, trainees or specialists in obstetrics and gynecology are primarily involved in the care of patients with complicated pregnancies or when complications occur during labor and childbirth. Physicians take over the medical responsibility from the midwife when getting involved during pregnancy, labor, or childbirth.” (Line 119 – 131)

More careful, humanised language is recommended to describe the people being cared for in emergency situations (consider replacing ‘parturient’ with ‘birthing woman’ or ’birthing patient’ if a non-gendered description is preferred). Also consider replacing ‘delivery care’ with ‘intrapartum care’ or ‘care during labour and birth’.

- The necessary changes have been made to the revised manuscript.

Overall, the implications of these findings could be discussed with much more useful degree of specificity, with some reference to key theories or other research that would be useful in their realisation/implementation.

- We kindly refer to one of the previous responses to reviewer #1 concerning the implications of the findings.

There are also some typographical/grammatical errors that should be addressed in any subsequent revisions.

- The necessary changes have been made to the revised manuscript.

- We thank the reviewer for her time, comments and encouragement!

References

1. Laverty SM. Hermeneutic phenomenology and phenomenology: A Comparison of historical and methodological considerations. Int J Qual Methods. 2003;2(3):21-35.

2. Salvador JT. Revisiting the philosophical underpinnings of qualitative research. Int educ res. 2016;2(6):4-6.

3. Tufford L, Newman P. Bracketing in Qualitative Research. Qual Soc Work. 2010;11(1):80-96.

4. Alvesson M, Sandberg J. Pre-understanding: An interpretation-enhancer and horizon-expander in research. Organ Stud. 2021;10.1177/0170840621994507.

5. Hamm RM. Clinical intuition and clinical analysis: Expertise and the cognitive continuum. In: Dowie JA, Elstein AS, editors. Professional judgment: A reader in clinical decision making. New York, NY: Cambridge University Press; 1988. p. 78-105.

6. Standing M. Clinical judgement and decision-making in nursing - nine modes of practice in a revised cognitive continuum. J Adv Nurs. 2008;62(1):124-34.

7. Standing M. Clinical judgement and decision-making in Nursing and interprofessional healthcare. 1st ed. Berkshire (UK): Open University Press, McGraw-Hill; 2010.

8. Parker-Tomlin M, Boschen M, Morrissey S, Glendon I. Cognitive continuum theory in interprofessional healthcare: A critical analysis. J Interprof Care. 2017;31(4):446-54.

9. Scott SG, Bruce RA. Decision-Making Style: The Development and Assessment of a New Measure. Educ Psychol Meas. 1995;55(5):818-31.

10. Appelt KC, Milch KF, Handgraaf MJJ, Weber EU. The Decision Making Individual Differences Inventory and guidelines for the study of individual differences in judgment and decision-making research. Judgm Decis Mak. 2011;6(3):252-62.

11. Riessman CK. Narrative analysis. In: Lewis-Beck MSB, Alan; Futing Liao, Tim editor. The Sage Encyclopedia of Social Science Research Methods. 3. Thousand Oaks, CA: SAGE Publications, Inc.; 2003.

12. Riessman CK. Narrative methods for the human sciences. Thousand Oaks (CA): SAGE Publications, Inc; 2008.

13. Czarniawska B. Narratives in social science research. London (UK): SAGE Publications Ltd; 2004.

14. Rorty R. The pragmatist’s progress. In: Collini S, editor. Interpretation and overinterpretation - Umberto Eco. Cambridge (UK): Cambridge University Press; 1992. p. 89-108.

15. Topper K. In defence of disunity: Pragmatism, hermenustics and the social sciences. Polit Theory. 2000;28(4):509-39.

16. Landman T. Phronesis and narrative analysis. In: Flyvbjerg B, Landman T, Schram S, editors. Real social science: Applied phronesis. Cambridge, UK: Cambridge university press; 2012. p. 308.

17. Wodak R, Meyer M. Methods of critical discourse analysis. 4th ed. London (UK): SAGE Publications, Inc; 2005.

18. Milton L. Midwives in the Folkhem: Professionalisation of Swedish midwifery during the interwar and postwar period [Dissertation]. Uppsala: Uppsala University; 2001.

19. Bergström J, Dekker S, Nyce JM, Amer-Wåhlin I. The social process of escalation: a promising focus for crisis management research. BMC Health Serv Res. 2012;12:161.

20. Graviditetsregistret 2021 [The Swedish Pregnancy Register is a Certified National Quality Register initiated by the Swedish Healthcare. It collects and processes information all the way from early pregnancy to a few months after birth]. Available from: https://www.medscinet.com/gr/default.aspx.

Attachment

Submitted filename: Response to Reviewers.docx

Decision Letter 1

Bernadette Watson

8 Nov 2021

Decision-making during obstetric emergencies: A narrative approach

PONE-D-21-12199R1

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Acceptance letter

Bernadette Watson

17 Jan 2022

PONE-D-21-12199R1

Decision-making during obstetric emergencies: A narrative approach

Dear Dr. Raoust:

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Appendix. Interview guide.

    Interview guide used in the rare cases of a stalled conversation.

    (PDF)

    S2 Appendix. Interview guide in Swedish.

    Intervjuguide, används i de fallen samtalet stannar upp.

    (DOCX)

    S3 Appendix. List of visual materials.

    List of visual materials chosen by respondents.

    (DOCX)

    Attachment

    Submitted filename: Response to Reviewers.docx

    Data Availability Statement

    Data relevant to this study are available on the Swedish National Data Service at https://snd.gu.se/en/catalogue/study/2021-315 (https://doi.org/10.5878/ejjg-8477).


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