The RESILIENT Study of Post-Pandemic Maternity Care Planning: A Qualitative Research Protocol for In-Depth Interviews With Women, Partners, Healthcare Professionals, and Policy Makers

Abstract

Maternity care is a core service provision of any healthcare system, delivering care for women and birthing people, and their wider family units. During the SARS-CoV-2 pandemic, much of maternity care service provision was reconfigured with the aim of continuing care provision which could not otherwise be re-scheduled or delayed, but in-line with infection control measures instituted through social and physical distancing. The RESILIENT Study was designed to investigate the impact of the COVID-19 pandemic and pandemic-related reconfigurations to maternity care service delivery. It is particularly concerned with the experiences of minority ethnic groups and those with social or medical complexity. One of our specific objectives was to investigate the experiences of maternity care during the pandemic from the perspective of women and birthing people; fathers, partners, and non-gestational parents; healthcare professionals; and policy makers through the use of in-depth interviews. We will analyse data on virtual care, self-monitoring, and vaccination (each using thematic framework analysis); care-seeking and care experience (using template analysis); and on building an ethical future of maternity care (using grounded theory analysis). This is the focus of this protocol. Our findings about the experiences of care receipt, provision, and planning during the pandemic will complement existing literature and our impact will be broad, on: individual patients, NHS maternity providers, NHS policies, and wider society.

Full text

Method and Protocol
International Journal of Qualitative Methods
Volume 23: 1–12
© The Author(s) 2024
DOI: 10.1177/16094069241293290
journals.sagepub.com/home/ijq
The RESILIENT Study of Post-Pandemic
Maternity Care Planning: A Qualitative
Research Protocol for In-Depth Interviews
With Women, Partners, Healthcare
Professionals, and Policy Makers
Sergio A. Silverio
1,2
*, Tisha Dasgupta
1,
*, Abigail Easter
1
, Gillian Horgan
1
,
Hiten D. Mistry
1
, Harriet Boulding
3
, Aricca D. Van Citters
4
, Eugene C. Nelson
4
,
Joel R. King
4
, Peter von Dadelszen
1
, Laura A. Magee
1
, and on behalf of The RESILIENT Study
Group
Abstract
Maternity care is a core service provision of any healthcare system, delivering care for women and birthing people, and their
wider family units. During the SARS-CoV-2 pandemic, much of maternity care service provision was reconfigured with the aim
of continuing care provision which could not otherwise be re-scheduled or delayed, but in-line with infection control measures
instituted through social and physical distancing. The RESILIENT Study was designed to investigate the impact of the COVID-19
pandemic and pandemic-related reconfigurations to maternity care service delivery. It is particularly concerned with the
experiences of minority ethnic groups and those with social or medical complexity. One of our specific objectives was to
investigate the experiences of maternity care during the pandemic from the perspective of women and birthing people; fathers,
partners, and non-gestational parents; healthcare professionals; and policy makers through the use of in-depth interviews. We
will analyse data on virtual care, self-monitoring, and vaccination (each using thematic framework analysis); care-seeking and
care experience (using template analysis); and on building an ethical future of maternity care (using grounded theory analysis).
This is the focus of this protocol. Our findings about the experiences of care receipt, provision, and planning during the
pandemic will complement existing literature and our impact will be broad, on: individual patients, NHS maternity providers,
NHS policies, and wider society.
Keywords
maternity care, women, partners, healthcare professionals, policymakers, qualitative research, COVID-19, pandemic, health
services research
1
Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, UK
2
Department of Psychology, Institute of Population Health, University of Liverpool, UK
3
The Policy Institute, Faculty of Social Science & Public Policy, King’s College London, UK
4
The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College, USA
*SAS & TD share joint First Authorship.
Corresponding Author:
Sergio A. Silverio, Research Fellow in Social Science of Women’s Health, Department of Women and Children’s Health, School of Life Course and Population
Sciences, King’s College London, 6th Floor Addison House, Great Maze Pond, Southwark, London SE1 1UL, UK.
Email: Sergio.Silverio@kcl.ac.uk
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://
creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further
permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/
open-access-at-sage).

Introduction
Background to The RESILIENT Study
Maternity care is a core service of any healthcare system,
including the United Kingdom’s (UK’s) National Health
Service (NHS). Substantial reconfiguration of maternity care
service delivery was undertaken during the health system
shock of the COVID-19 pandemic, in response to local in-
fection rates, ‘lockdown’measures, and staff shortages
(Jardine et al., 2021;Silverio, De Backer, et al., 2021). These
service reconfigurations were implemented with the intention
of reducing the risk of SARS-CoV-2 infection for pregnant
and postpartum women (and their babies) who were initially
deemed particularly vulnerable to the infection (Peterson et al.,
2024;Silverio et al., 2023). Reconfiguration was rapid,
changeable, and prolonged, rendering a fatigued workforce
(De Backer et al., 2022) and a patient population which had to
process a lot of new and often conflicting information (Magee
et al., 2024).
To understand the effects of the pandemic on the experi-
ences of maternity care, how maternity services were deliv-
ered, and how we can build back a better maternity care
system coming out of the pandemic, across the UK’s four
nations, the UK’s National Institute for Health and Care
Research [NIHR] funded The RESILIENT Study (Magee
et al., 2021;The Resilient Study Group, 2021; see Figure 1).
The Pandemic and Maternity Care
Initially, there was uncertainty about the severity and impact of
COVID-19 for pregnant women and their unborn babies, as
well as for newborns. Data from the start of the pandemic
suggested the potential for more severe outcomes for pregnant
women with COVID-19 (Gurol-Urganci et al., 2021;Homer
et al., 2021;Khalil et al., 2020;Yang et al., 2020). Although
this was debated over the course of the pandemic, subsequent
evidence suggested whilst pregnant women (vs. those not
pregnant) were not more vulnerable to becoming infected with
COVID-19, those with (vs. without) co-morbidities were at
increased risks of complications from COVID-19, and those in
their third trimester of pregnancy were more likely to have a
more severe symptom profile, justifying being prioritised for
vaccination and future research (Gurol-Urganci et al., 2021;
Loughnan et al., 2022;Royal College of Obstetricians and
Gynaecologists & Royal College of Midwives, 2022;Salem
et al., 2021;Vousden et al., 2021).
When vaccination for COVID-19 became available, uptake
by pregnant women was slow. This may have suggested a
population-level reluctance, with women citing exclusion from
vaccine trials, and being risk-averse, even when those risks are
unlikely, but unknown (Galanis et al., 2022;Magee et al., 2024).
Moreover, acceptance of vaccination in the general community
was not uniform, and was particularly low among Black, Asian,
and Minority Ethnic populations who are at heightened risk of
severe infection (Skirrow et al., 2022). When investigating de-
mographic characteristics among women of reproductive age, it
was found that older age, White ethnicity, and being in the least-
deprived index of multiple deprivation [IMD] were each inde-
pendently associated with higher acceptance of the COVID-19
vaccine (for first and second doses), with ethnicity exerting the
strongest influence and IMD the weakest (Magee et al., 2023).
Guidance has changed rapidly, and the precautionary principle of
needing evidence of no harm before recommending COVID-19
vaccination in pregnancy has weighed heavily in some
recommendations.
Aside from the direct health implications, there were early
indications of the indirect effects the pandemic was having on
service utilisation within maternity care (Hinton et al., 2022;
Jardine et al., 2021;Silverio et al., 2021); neonatal and perinatal
bereavement care (Bradford et al., 2024;deMontigny et al., 2023;
George-Carey et al., 2024;Silverio, Easter, et al., 2021;Silverio,
George-Carey et al., 2024); family health practices (Landoni
et al., 2022;Mamrath et al., 2024;Mashayekh-Amiri et al., 2023;
Silverio et al., 2024); perinatal mental health care (Bridle et al.,
2022;Jackson, Greenfield et al., 2024); and the trajectory across
all these joined-up services (von Dadelszen et al., 2020). As the
pandemic has continued, evidence has mounted that despite best
intentions, reconfiguration of maternity services has been det-
rimental to the maternity experience (Coxon et al., 2020;
Dasgupta et al., 2024;Flaherty et al., 2022). Negative conse-
quences have included: reduced access to maternity care services
Figure 1. The RESILIENT Study logo.
2International Journal of Qualitative Methods

(Greenfield et al., 2021;Jackson et al., 2022;2024;Silverio et al.,
2024); separation of women from chosen birthing partners
(Keely et al., 2023;Thomson et al., 2022); precarity amongst
healthcare staff working in maternity services (De Backer et al.,
2022); care perceived as unsafe or sub-optimal (Neal et al., 2023)
by women (George-Carey et al., 2024;Montgomery et al., 2023)
and staff (Silverio et al., 2023); and increasingly prevalent
perinatal mental health problems (Dickerson et al., 2022;Fallon
et al., 2021;Silverio et al., 2021), marring pregnancy and the
puerperium by poor psychological health and support (Jackson
et al., 2021,2023;Peterson et al., 2024;Riley et al., 2021;
Sanders & Blaylock, 2021). Importantly, these issues have
highlighted specific problems and concerns facing these mi-
noritised groups, including minority ethnic women (Pilav et al.,
2022) and sexual minorities (Greenfield & Darwin, 2024;
Mamrath et al., 2024), as well as non-White healthcare pro-
fessionals (Silverio, De Backer, et al., 2022). Evidence has been
synthesised and new collaborative networks formed (e.g., The
PIVOT-AL National Collaborative for Maternal and Child
Health Research during the Pandemic (The PIVOT-AL National
Collaborative, 2023).
Research Design, Aims, and Objectives
The RESILIENT Study was designed to investigate the impact of
the COVID-19 pandemic and pandemic-related reconfigurations
to maternity care service delivery (i.e., virtual care, self-
monitoring, and vaccination) on women and babies. Of particu-
lar interest has been those from minority ethnic groups and those
with social or medical complexity (i.e. with a focus on care-
seeking, care experience, and building an ethical future for ma-
ternity care in the UK; see also Fernandez Turienzo et al., 2021).
Our specific objectives will be addressed by three work packages
(WPs). First, in our quantitative WP, we will study maternal and
offspring outcomes, including costs, using the Born in South
London eLIXIR (BiSL-eLIXIR) data linkage platform in South
London, UK. Second, in our social science WP, we will survey
women of reproductive age regarding their COVID-19 vaccina-
tion choices, through the COVID Symptom Study ZOE app, as
well as undertake in-depth interviews (the focus of this protocol, as
below). Third, in our policy WP across the four nations, we will
engage with relevant stakeholders to develop policy interventions
for local, regional, and national health systems.
Research Approach, Theoretical Perspective, and
Research Paradigm
The qualitative interview arm of The RESILIENT Study adopts
a lifecourse analysis approach (Wainrib, 1992), whereby within
the UK’s Western society, a woman’s normative lifecourse will
usually include pregnancy and childbirth, and these transitional
experiences offer sites of empirical inquiry as women transition
into parenthood or from expectant parent to bereaved parent in
the case of a perinatal bereavement (Silverio, 2022). Given the
participant-orientated nature of our research, we situated the
study within a research paradigm of pragmatism (Allemang
et al., 2022) and adopted pragmatic ontological and episte-
mological perspectives accordingly.
Philosophical Underpinning. The qualitative interview arm of
The RESILIENT Study was designed to be philosophically
pragmatic (Morgan, 2014). This meant our ontological ap-
proach to our acquired knowledge accepted the existence of
differing and, on occasion, competing interpretations of the
world and experiences, and that there is not a single viewpoint
which is sufficiently able to provide a complete picture of the
phenomenon of interest; rather, each viewpoint provides the
researcher with actionable knowledge from which they can
draw consensus and therefore empirical conclusion (Kelly &
Cordeiro, 2020). Further, our epistemological approach was
defined pragmatically in terms of our acceptance of the
principle that the knowledge held, and realities lived, by
people is measurable in the real world and discernible from
falsehoods, but that the acquisition of this knowledge must
account for time and cultural shift (Ruwhiu & Cone, 2010).
Positionality. We are a large cross-disciplinary group of re-
searchers with backgrounds in psychology [SAS, AE], public
health [TD, GH, JRK, ADVC, ECN], social policy [HB],
medicine [PvD, LAM], and biomedical science [HDM].
Therefore, we engaged an ordered reflexive judgement to the
data we collected (i.e., our judgment of the data was framed
within the social norms of our society (Whitaker & Akinson,
2021), and aimed to adopt an absent position within the data
with regard to our acquisition of knowledge. Nevertheless, we
recognised that as individuals who have provided care within
maternity settings [PvD, LAM] or had children themselves
[LAM, ADVC, ECN, HB, PvD], our experiences may in-
troduce inherent biases (Pillow, 2003). As such, we engaged
with bracketing of preconceived ideas whilst collecting and
analysing data (Gearing, 2004), and then drew upon them in
the interpretive and writing phases (Tufford & Newman,
2012). We did so in collaboration with The RESILIENT
Study Patient and Public Involvement and Engagement Ad-
visory Group (PPIE-AG) and Technical Advisory Group
(TAG), to see whether acquired knowledge matched the lived
experiences of the research team and those with recent ex-
periences of maternity care in the UK. All work was overseen
by an independent Study Steering Committee (SSC).
The RESILIENT Study: Work Package 2 –
Social Science (Qualitative: In-Depth
Interviews)
Inclusion, Exclusion, and Sampling Criteria
Inclusion criteria restricted recruitment to just those more
than 18 years of age across all four groups of participants:
Women, Partners, Healthcare Professionals (HCPs), and
Policymakers; and their experiences of the SARS-CoV-2
Silverio et al. 3

pandemic (30 January 2020 –5 May 2023). Women could be
recruited if they were currently pregnant at the time of the
interview or had given birth during the pandemic. Partners of
pregnant or postnatal women did not have to take part in the
birth to make the partner eligible for participation. HCPs
were recruited if they had provided any aspect of maternity
care during the pandemic. Policymakers who were respon-
sible for any aspect of maternity care policy development or
implementation (local, regional, national, or international)
during the pandemic, were the final group to be recruited.
Sampling criteria were used to achieve diversity in ethnicity,
geographic area, social and medical complexity, following a
maximum variation sampling frame approach (Higginbotton,
2004;Palinkas et al., 2015). For HCPs and policymakers,
sampling criteria comprised: ethnicity, geographic region, pro-
fession, current role, and years in role. For women and partners,
sampling criteria comprised: ethnicity, geographic region, IMD,
and social complexity, and for women only, self-monitoring for
medical complexity during pregnancy. Social complexity was
self-identified by participants and included: lack of social sup-
port, mental health problems, or belonging to a minority group
relating to sexual orientation or gender identity. Medical com-
plexity was defined as having had to perform self-monitoring of
symptoms during pregnancy for any complication, including:
hypertension, gestational diabetes, additional scans for predis-
position to genetic complications, or previous pregnancy loss.
Materials, Procedure, and Recruitment Strategy
The example recruitment materials (Appendixes 1-6)andin-
terview schedules (Appendixes 7-10) were developed by The
RESILIENT Study Group (who included those experienced in
qualitative research [SAS, AE] –before and during the COVID-
19 pandemic), in consultation with our PPIE-AG and TAG. The
materials were approved by The RESILIENT Study SSC.
Participants were made aware of the study by advertisement
of the study poster (May 2022 –January 2023) through: social
media (i.e., posts of study recruitment poster), relevant charities,
the National Institute for Health and Care Research [NIHR]
sponsored Clinical Research Network [CRN] in London, and
existing networks of the wider RESILIENT study members (e.g.,
NIHR Applied Research Collaboration –South London [NIHR
ARC-SL], and participants of other research studies at King’s
College London who have consented to be recontacted).
Participants were directed to contact the study team directly
by e-mail, upon which they were sent an on-line screening
questionnaire, participant information sheet, and consent form.
The screening questionnaire collected baseline demographic
(e.g., sex, gender, sexual orientation), health (e.g., COVID-19
vaccination status), and pregnancy information (e.g., date of
delivery and care model), and included the criteria required for
the sampling framework (as discussed above). We aimed to
recruit 40 women, 15 partners, 25 HCPs, and 25 policymakers.
Participants were selected based on the sampling frame criteria
andinvitedtointerviewaccordingly.Womenandpartners
received £25 as reimbursement for their time, in-line with UK
Standards for Public Involvement (formerly ‘NIHR INVOLVE’
guidance; National Institute for Health and Care Research, 2024).
Participant Characteristics
A total of 96 participants were recruited to the study between
May 2022 and February 2023, representing women (n= 40),
partners (n= 15), HCPs (n= 21), and policymakers (n= 20).
Ages ranged from 23-70 years (Median Age = 39 years).
Demographics are narratively described below (omitting any
‘Prefer not to say’) and full demographics tables will be
produced in each of the constituent qualitative manuscripts
based on these in-depth interview data.
Overall, most participants identified as White or White
British (n= 65, 68%); with fewer identifying as Asian or Asian
British (n= 7, 7%); Black or Black British (n= 12, 13%);
Mixed or Multiple Ethnicities (n= 7, 7%); or Any Other
Ethnicity (n= 4, 4%).
For women, partners, and HCPs (n=76),halfofinterview
participants utilised or delivered maternity services in London
(n= 38, 50%); with fewer in the rest of England (n= 27, 36%);
Wal e s ( n= 4, 5%); Scotland (n= 4, 5%); and Northern Ireland
(n= 3, 4%). For policymakers (n= 20), rather than their physical
location in the country, we collected whether they exercised
national (n= 14, 70%), regional (n= 5, 25%), or local (n=1,5%)
influence and reach in establishing maternity care policy.
Amongst women and their partners (n= 55), approximately a
quarter self-reported on one or more social complexity (n=14,
25%) or a medical complexity which required self-monitoring of
symptoms (n= 24, 44%). Additionally, we collected information
on deprivation level (lowest quintile: n= 7, 7%; highest quintile:
n= 15, 16%), vaccination status (vaccinated with full dose and
boosters: n= 84, 88%; vaccinated with full dose, but no boosters:
n= 3, 3%; no vaccinations: n=7,7%),gender(women:n=84,
88%; male: n= 11, 11%; non-binary: n= 1; 1%) and sexual
orientation (heterosexual: n= 80, 83%; bisexual n=9,9%;
lesbian n=2,2%;gayn= 1, 1%); personal or household
COVID-19 high risk status (Yes: n= 23, 24%; No: n= 71, 74%);
care team for women and partners (midwifery-led: n= 32, 33%;
consultant-led: n= 23, 27%); and profession and current role of
HCPs and policymakers (medical: n= 18, 19%; midwifery and/
or nursing: n= 18, 19%; non-clinical: n=5,5%),andyearsin
role (≤5years:n=25,26%;≥6years:n= 16, 17%).
Data Collection
We conducted in-depth, semi-structured interviews, discussing
the lived experiences of utilising, delivering, or developing
policy for maternity care (as applicable per participant group)
during the COVID-19 pandemic. Interviews were planned to be
conducted virtually (in-line with Government physical and social
distancing restrictions) for between 30 and 60 minutes.
All interviews were conducted by video-conference (Zoom) or
telephone, by female qualitative researchers [TD, n=95;HB,n=
4International Journal of Qualitative Methods

1] with experience of conducting in-depth interviews about
sensitive health-related issues (Silverio et al., 2022). Following
the interview schedule, interviewers asked participants about their
general experience of using (including care-seeking) or delivering
maternity care during the pandemic (as applicable), access to and
quality of information about the impact of the SARS-CoV-2 virus
on pregnancy, the transition to virtual maternity care visits and
self-monitoring of symptoms, the COVID-19 vaccination pro-
gramme for pregnant women, and their ideas for building an
ethical future in maternity care which could withstand a future
health system shock. By asking participants to reflect back, speak
about current circumstances, and look to the future whilst offering
advice for the pandemic recovery period, we leant into the notion
of lifecourse analysis whereby past events will and do effect
present and future experiences.
Interviews lasted 19–76 minutes (Median Time = 42 min-
utes), with all audio digitally recorded and transcribed by an
approved third-party service (Devon Transcription, 2024). Field
notes were taken throughout and were required to supplement a
partial transcript for one interview during which recording failed
midway through. All interviews were uploaded to QSR NVivo
14 for data management and analysis. Initial high-level codes
were created in-line with the interview schedule (i.e., any data
related to The RESILIENT Study’s concepts (Virtual Care; Self-
Monitoring; Vaccination; Care-Seeking and Care Experience;
and Ethical Future of Maternity Care Services) were identified
and extracted from all interview transcripts. Granular coding –in-
line with specific analytic methodologies –then followed.
The RESILIENT Study Core Concepts
Care-Seeking and Care Experience
The concept of care-seeking and experience encapsulates the
general experience of utilising routine maternity care during
the COVID-19 pandemic for women and partners, along with
the experience of delivering care and developing policy for
HCPs and policymakers respectively. For service-users, we
sought information on overall quality of care received, support
from partners and/or staff members, availability of informa-
tion, adapting to rapidly changing guidelines and restrictions,
and handling increased risk of developing severe symptoms of
COVID-19 during pregnancy, among others. Staff and poli-
cymakers were interrogated about changes to their role during
the pandemic, experiences of facilitating or developing service
reconfiguration guidelines, perceived advantages or draw-
backs, information seeking and sharing, both from a personal
and professional perspective, and their overall reflections of
what could have been done better.
Virtual Care
The shift to provision of routine maternity care virtually, by
video-conference or telephone, affected all women who were
planning pregnancy, pregnant, or postpartum during the
pandemic. The concept of virtual care dealt with, in particular,
the perceived benefits, impact on day-to-day life and other
responsibilities, concerns about quality or effectiveness of
virtual care delivery, problems with implementation such as
lack of digital technology and infrastructure, and potential for
exacerbating health inequalities attributed to digital poverty.
Self-Monitoring
Another key service configuration was the accelerated use of
digital applications and approved measurement devices for
remote, at-home management of pregnancy complications
such as hypertension or gestational diabetes. The concept of
self-monitoring captures women and partner’s experiences of
having to undertake self-monitoring as part of their usual
maternity care, as well as associated out-of-pocket expenses.
For HCPs, this concept included their perception of managing
self-monitoring, barriers and facilitators, handling patients
who had limited use of English or others who could not
understand instructions fully, and the impact of self-
monitoring on quality of care provided.
Vaccination
We explored how women, partners, HCPs, and policymakers
perceived the offer of the COVID-19 vaccine for pregnant women.
It included questions on information and safety evidence, risk
assessment, vaccine hesitancy, trust in healthcare providers and the
government, as well as financial costs associated with vaccination.
We also asked participants to reflect on a proposed mandatory
COVID-19 vaccination program for maternity healthcare staff,
and whether it should be implemented in the future.
Ethical Future of Maternity Care
All participants were asked to reflect on what could have been
done better and to imagine a brighter future. This concept
summarised suggestions for improvement of services,
guidelines and restrictions which were deemed unethical,
lessons to be learnt, and how maternity services should be re-
built for a more equitable health system.
Mapped Analytical Methodologies
Template Analysis
Data on care-seeking and care experience will be extracted and
analysed using a Template Analysis (King, 2012), which follows
a methodical process including: refamiliarization with the data;
preliminary coding; and organization of themes into a template,
defining the template, application of the final template to the full
dataset, and finalisation of template definitions (Brooks et al.,
2015). Template analysis relies on critical reflexivity throughout,
iterative coding from the organisation of themes onwards, and
Silverio et al. 5

accuracycheckingwhenapplyingthefinal template, finalizing
the template definitions, and selecting quotations (King &
Brooks, 2017). For coding, the initial template will be based
on the concepts of candidacy theory, as defined by Dixon-Woods
et al. (2006;p.7)as“the ways in which people’s eligibility for
medical attention and intervention is jointly negotiated between
individuals and health services”and comprising of the following
key concepts: Identification of candidacy; navigation; the per-
meability of services; appearances at health services; adjudica-
tions; offers and resistance; and operating conditions and the
local production of candidacy.
Thematic Framework Analysis
Data on virtual care, self-monitoring, and vaccination will be
extracted and analysed separately using a Thematic Framework
Analysis (Spencer et al., 2014) for each concept individually.
Thematic Framework Analysis follows a deductive process
including: data preparation (achieving a good written record of
the recorded audio data); re-familiarisation (checking the
transcripts for accuracy and making analytical notes); devel-
oping a framework (an initial framework and then checking and
testing the framework); coding (pre-defined codes, selective
coding, and coding of the dataset); adapting the analytical
framework (re-naming themes where required and re-ordering
the framework if required); charting the data into the framework
matrix (assigning characteristics to participant cases on NVivo
and then stratifying participants by desired qualities before
summarising the data for each stratification); and interpreting
the data (by sorting data and presenting percentage cover and/or
spread of themes for different participant groups) as per
guidance on the methodology (Gale et al., 2013). Thematic
Framework Analysis is designed to cope with large amounts of
qualitative data, usually when the aim is to understand different
perspectives from multiple participant groups, and to inform
healthcare policy and practice (Spencer et al., 2003). In terms of
data analysis, we aim to stratify data by the most salient de-
mographic characteristics where appropriate and logical to the
research question of each analysis and participant population,
including: participant type; ethnicity; region of the country;
IMD; vaccination status; whether they had ongoing medical
conditions which required self-monitoring; and whether or not
they were living with social complexity.
Grounded Theory Analysis
Data on the ethical future of maternity care will be extracted
and analysed using a Grounded Theory Analysis (Glaser &
Strauss, 1967), which follows a stepped process including:
preparing data (data collection and transcription); cleaning
data (checking transcripts and re-familiarisation), coding
(sentence-by-sentence, then focused); theme development
(first into super-categories, then into themes); theory gener-
ation (consulting with memo notes, generating a theory);
defence of the theory (within the team, interpreting the theory,
and then framing it within the literature-base); all before
writing the theory up (Silverio et al., 2019). Grounded Theory
Analysis relies on inductive and iterative coding, analysis, and
interpretation, and especially relies on a constant comparison
between transcripts (Glaser, 1992). The aim is to produce a
theory of the specific phenomenon (an ethical future), for the
specific population (pregnant/postpartum women in the UK),
in a specific context (post-pandemic health system shock).
Data Quality
Rigour and Effectiveness
We have focussed on populations who engage with maternity
care, encompassing partners, fathers, and non-gestational
parents; other professionals working within maternity care;
and policy makers who are responsible for decision-making at
local, regional, and national levels. We have mimicked this
complexity, by drawing upon our varied expertise as a cross-
disciplinary team of researchers, to understand the pandemic
health system shock crisis from clinical and human-factors
perspectives, whilst ensuring both the team and participants
were directed to be forward-thinking about the possibilities for
UK maternity care services post-pandemic.
Affecting Change
Our robust methods provide evidence to drive these post-
pandemic changes; interestingtothosewhogatekeepand
safeguard policy and practice changes; and impactful enough to
provide the evidence-base for positive change. We have achieved
quality by drawing on experts in our methodologies [SAS, AE],
and clinical maternity care [PvD, LAM], and policy [HB,
ADVC, ECN], whilst providing relevant training [TD, GH,
HDM, ADVC, JRK]. We have worked closely with our PPIE-
AG, TAG, and SSC, as well as with the Royal College of
Obstetricians & Gynaecologists, Royal College of Midwives,
NHS Race & Health Observatory, and other third sector orga-
nisations, to ensure research maintains relevance in the changing
pandemic, para-pandemic, and then post-pandemic landscape.
Appropriateness and Saliency
As the UK is a diverse nation of diverse geography and eth-
nicities, we have engaged with the four corners of the UK,
ensuring representation on our advisory groups (especially the
PPIE-AG and TAG), and recruited from all sections of society.
As a mainly South-East London-based team of researchers, we
also have an interest in driving positive change in our local
population. Therefore, we over-recruited from South London to
ensure we do not neglect the local population, which has one of
the highest levels in the UK of ethnic diversity and notable social
disparity, health inequalities, and multi-morbidities (National
Institute for Health and Care Research Applied Research
Collaboration –South London, 2019).
6International Journal of Qualitative Methods

Research Governance
Funding
The RESILIENT Study was funded by the National Institute for
Health and Care Research Health [NIHR] Health Services & Delivery
Research programme (ref:-NIHR134293).
Ethics
The qualitative work for The RESILIENT study was approved
by the King’s College London Health Faculties Research
Ethics Subcommittee (HR/DP-21/22-26740).
Patient and Public Involvement and Engagement –
Advisory Group
Our PPIE-AG has 15 members. Membership represents
multiple ethnic backgrounds, birth histories, and geographies
within the UK. The group has been involved throughout, from
conception of the project and research questions, through to
checking findings for relevance. Meetings were held three
times a year, were well attended (with at least eight of 15
members present), and had good representation of parents,
healthcare professionals, and members representing com-
munity organisations. Each meeting allowed for in-depth
discussion and reflection of the work by the PPIE-AG, with
suggested changes incorporated into the study protocol and
subsequent manuscripts.
Management Group
The day-to-day running of The RESILIENT Study has been
overseen by a Management Group, comprising 20 members
and composed of: the Chief Investigator, Project Manager, all
WP Leads; plus all co-applicants and collaborators; and when
required, the operational research staff. This group has en-
sured data collection, analysis, and write-up follows the
project timelines, for timely research delivery.
Technical Advisory Group
The TAG provides academic and strategic guidance, expertise,
advisement, and direction, in accordance with the objectives
and work plans laid out in the National Institute for Health and
Care Research application. The TAG comprises 19 inde-
pendent advisors from a range of relevant academic disci-
plines, to support the project aims. The TAG has an
independent Chair to oversee the agenda and discussions, and
ensure adherence to recommendations.
Independent Study Steering Committee
The SSC is composed of 5 independent advisors from a range
of academic disciplines and institutions of relevance to the
study objectives and programme of work. The SSC has an
independent Chair to facilitate meetings and discussions, and
monitor study progress on behalf of the study Sponsor (King’s
College London) and Funder (NIHR), and ensure it is con-
ducted to the standards set out in the Department of Health and
Social Care’s Research Governance Framework for Health
and Social Care and the Guidelines for Good Clinical Practice.
Discussion
Strengths and Limitations
The RESILIENT Study as a whole and the qualitative arm of
the study have many strengths. To date it is the only
nationally-funded study to undertake work on post-pandemic
maternity care and represent of all four UK nations. The
diversity and breadth of participants recruited for in-depth
interviews was achieved using a maximum variation sampling
frame; this ensures a more representative set of findings can be
derived, and deviates from the usual demographic often re-
cruited to maternity care studies (e.g. White, middle-class,
well-educated women; see Lovell et al., 2023;Silverio,
Varman, et al., 2023). Furthermore, the range of expertise
and experience on the team has ensured we could design and
carry out a high-quality study, with rigorous findings, which
can feed directly into policy and practice.
Conclusion
Our findings about the experiences of care receipt, provision,
and planning during the pandemic will complement existing
literature. Manuscripts will be submitted for publication to
relevant journals across medicine, public health, and the social
sciences relating to health and healthcare services. We will
disseminate our results through established networks of local,
regional, and national stakeholders, to feed directly into na-
tional policy and practice for maternity care services across the
UK. Our strategy includes engagement events across the four
nations, virtual engagement via webinars and social media,
and publication of a bespoke plain-language and scientific
website and report. Our impact will be broad, on: individual
patients (to improve care quality, effectiveness, safety, and
experience), NHS maternity providers (to strengthen evidence
to inform service reconfiguration and support vaccination);
NHS Long Term Plan (to address maternal and fetal/newborn
death and morbidity and support implementation of digitally-
enabled care); and wider society (through innovation to
commercialise and decrease direct and indirect societal costs).
Acknowledgements
We would like to acknowledge The RESILIENT Study Group, which
consists of: Chief Investigator: Prof. Laura A. Magee (King’s College
London); and Co-Investigators: Prof. Debra E. Bick (The University
of Warwick), Dr. Harriet Boulding (King’s College London), Dr.
Kathryn Dalrymple (King’s College London), Ms. Tisha Dasgupta
Silverio et al. 7

(King’s College London), Prof. Emma L. Duncan (King’s College
London), Dr. Abigail Easter (King’s College London), Prof. Julia
Fox-Rushby (King’s College London), Miss. Gillian Horgan (King’s
College London), Prof. Asma Khalil (St George’s University Hos-
pitals NHS Foundation Trust & Liverpool Women’s NHS Foundation
Trust), Ms. Alice McGreevy (King’s College London), Dr. Hiten D.
Mistry (King’s College London), Prof. Eugene C. Nelson (Dartmouth
College), Prof. Lucilla Poston (King’s College London), Mr. Paul
Seed (King’s College London), Sergio A. Silverio (King’s College
London & University of Liverpool), Dr. Marina Soley-Bori (King’s
College London), Dr. Florence Tydeman (King’s College London),
Ms. Aricca D. Van Citters (Dartmouth College), Dr. Sara L. White
(King’s College London), Prof. Ingrid Wolfe (King’s College Lon-
don), Prof. Yanzhong Wang (King’s College London), & Prof. Peter
von Dadelszen (King’s College London). We would like to extend out
thanks to all members of The RESILIENT Study Patient & Public
Involvement & Engagement Advisory Group, The RESILIENT
STUDY Technical Advisory Group, and The RESILIENT Study
Steering Committee for their ongoing support of The RESILIENT
Study.
Author Contributions
Conceptualisation: S.A.S. Funding acquisition: L.A.M., S.A.S., A.E.,
H.B., A.D.V.C. Investigation: T.D., G.H., S.A.S., L.A.M. Method-
ology: S.A.S., A.E. Project administration: H.D.M., G.H., T.D.,
S.A.S., L.A.M. Resources: S.A.S., L.A.M., H.D.M. Software: T.D.,
G.H. Supervision: L.A.M., S.A.S., A.E. Validation: S.A.S., L.A.M.
Visualization: S.A.S. Writing –original draft: S.A.S., T.D. Writing –
review & editing: L.A.M., G.H., H.D.M., A.E., H.B., A.D.V.C.,
E.C.N.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: The RESILIENT Study has been adopted by and is
supported by the National Institute for Health and Care Research
Applied Research Collaboration South London [NIHR ARC
South London] at King’s College Hospital NHS Foundation
Trust. The views expressed are those of the authors and not
necessarily those of the NIHR or the Department of Health and
Social Care.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
RESILIENT Study was funded by the National Institute for Health
and Care Research Health Services & Delivery Research pro-
gramme (ref:- NIHR134293) awarded to Laura A. Magee, Sergio A.
Silverio, Harriet Boulding, Abigail Easter, Peter von Dadelszen &
Members of The RESILIENT Study Group. Sergio A. Silverio is in
receipt of a Personal Doctoral Fellowship awarded by the National
Institute for Health and Care Research Applied Research
Collaboration –South London [NIHR ARC-SL] Capacity Building
Theme (ref:- NIHR-INF-2170). Tisha Dasgupta is in receipt of a
Health Practices, Innovation & Implementation [HPII] Doctoral
Fellowship (ref:- ES/P00703/1), funded by the Economic & Social
Research Council [ESRC] as part of the London Interdisciplinary
Social Science Doctoral Training Partnership [LISS DTP]. Abigail
Easter is supported by the National Institute for Health and Care
Research Applied Research Collaboration South London [NIHR
ARC-SL] at King’s College Hospital NHS Foundation Trust. The
views expressed are those of the author and not necessarily those of
the NIHR or the Department of Health and Social Care. The funders
had no role in the work or write-up associated with this manuscript
and the views expressed are those of the authors and not necessarily
those of the funders.
Ethical Statement
Ethical Approval
The qualitative work for The RESILIENT study was approved by the
King’s College London Health Faculties Research Ethics Subcom-
mittee (HR/DP-21/22-26740).
Preprint Listing
Sergio A. Silverio, Tisha Dasgupta, Abigail Easter et al. The RE-
SILIENT Study of post-pandemic maternity care planning: A
qualitative research protocol for in-depth interview with women,
partners, healthcare professionals, and policy makers, 29 July 2024,
PREPRINT (Version 1) available at Research Square [https://doi.org/
10.21203/rs.3.rs-4803660/v1].
ORCID iDs
Sergio A. Silverio https://orcid.org/0000-0001-7177-3471
Hiten D. Mistry https://orcid.org/0000-0003-2564-7348
Supplemental Material
Supplemental material for this article is available online.
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