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Abstract

Decisions about health and care are rarely uncomplicated, and in maternity, they are no less so. In England, choice is at the forefront of maternal health policy, which maintains that women with straightforward pregnancies should have a choice of place of birth. A growing body of evidence shows that midwifery-led settings, such as midwifery units and home birth, are as safe as obstetric units (OUs), and that women planning their births in these settings have better outcomes with reduced chances of medical interventions and caesarean sections. However, a majority of those eligible for midwifery-led care are still giving birth in OUs. Policymakers, clinicians and stakeholders are now focused on augmenting ‘informed’ choice about place of birth among parents as a means for improving services and uptake, zeroing in on decision-making as the crucial point in which it is initiated and formed. What delineates an informed choice, and how does decision-making during pregnancy engender such a choice? Creating decisions aids or rolling out models of ‘shared decision-making’ are popular solutions for augmenting informed choice, with the intention of easing the burden of decision-making for parents. Researchers commonly approach each from a disembodied standpoint, assuming rationality in complex, lived phenomena that are in actuality neither linear nor uniform.

This thesis, instead, explores decision-making and choice as a process, building an ethnographic account of parents’ place of birth decision-making experiences in East London and investigating the feasibility of research related to decision aids and informed choice. To achieve this, I conducted two studies over nearly two years: a community based study situated in the boroughs of Newham, Tower Hamlets and Waltham Forest; and a feasibility study based in Barts Health NHS Trust, which offers all four birthplace options for women with straightforward pregnancies. I argue, contrary to long-held decision theory, that decision-making about place of birth is an embodied practice, one that has corporeal, temporal and affective modalities and involves enskilment built up before, during and after pregnancy. Modern English maternity continues to be a nexus of biomedical and obstetric dominance, uncertainty in terms of risk and safety and notions of good motherhood, all of which are layered through women’s decision-making and reified by the frameworks that shape it. My analysis illuminated that informed choice, in the context of place of birth decision-making, is a culmination of skilled practice, a phenomenological and embodied event. Its establishment, in maternity policy and care, is marked by silences concerning knowledge and services. Current conceptions of choice in English maternity are built on a market ideology, which places the onus of improvements to services on women and their families; however, in seeing parental decisionmaking and informed choice as embodied, we can begin to envision future policy and practice based on a platform of human rights.

Publication Type:	Thesis (Doctoral)
Subjects:	R Medicine > RT Nursing
Departments:	Doctoral Theses School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses School of Health & Psychological Sciences > Nursing

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