Qualitative study of evidence based leaflets in maternity care

doi:10.1136/bmj.324.7338.639

BMJ 2002;324:639 ( 16 March )

Papers

Qualitative study of evidence based leaflets in maternity care

Helen Stapleton, research midwife, ^a Mavis Kirkham, professor of midwifery, ^a Gwenan Thomas, midwife. ^b

^a Women's Informed Childbearing and Health Research Group, School of Nursing and Midwifery, University of Sheffield, Sheffield S3 7ND, ^b Carmarthenshire NHS Trust, West Wales General Hospital, Carmarthen SA31 2AF

Correspondence to: H Stapleton h.stapleton{at}sheffield.ac.uk

Objective: To examine the use of evidence based leafletson informed choice in maternityservices.
Design: Non-participant observation of 886 antenatalconsultations. 383 in depth interviews with women using maternityservices and health professionals providing antenatalcare.
Setting: Women's homes; antenatal and ultrasound clinicsin 13 maternity units inWales.
Participants: Childbearing women and health professionalswho provide antenatalcare.
Intervention: Provision of 10 pairs of Informed Choice leafletsfor service users and staff and a training session in theiruse.
Main outcome measures: Participants' views and commonly observedresponses during consultations andinterviews.
Results: Health professionals were positive about theleaflets and their potential to assist women in making informedchoices, but competing demands within the clinical environmentundermined their effective use. Time pressures limited discussion,and choice was often not available in practice. A widespread beliefthat technological intervention would be viewed positively inthe event of litigation reinforced notions of "right" and "wrong"choices rather than "informed" choices. Hierarchical power structuresresulted in obstetricians defining the norms of clinical practiceand hence which choices were possible. Women's trust in healthprofessionals ensured their compliance with professionally definedchoices, and only rarely were they observed asking questions ormaking alternative requests. Midwives rarely discussed the contentsof the leaflets or distinguished them from other literature relatedto pregnancy. The visibility and potential of the leaflets asevidence based decision aids was thus greatlyreduced.
Conclusions: The way in which the leaflets were disseminatedaffected promotion of informed choice in maternity care. The cultureinto which the leaflets were introduced supported existing normativepatterns of care and this ensured informed compliance rather thaninformedchoice.

What is already known on this topic
Informed Choice leaflets are widely used in maternity care but little is known about their ability to influence informed choice and decision making

High quality information is essential for promoting informed choice but is insufficient by itself

What this study adds
Time constraints and other pressures on health professionals resulted in a lack of discussion of the content of the leaflets

Fear of litigation, power hierarchies, and the technological imperative in maternity care limited the choices available

Health professionals promoted normative practices rather than choice, and as women valued their opinions this led to the promotion of informed compliance rather than informed choice

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Rapid Responses:

Read all Rapid Responses

Information provision is only one component of informed choice: Diane Reeves
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A primary care approach to supporting choice in midwifery: Anna E Livingstone, et al.
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Health professionals and the terminology of maternity care: Helen M Stapleton, et al.
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Compliant behaviour in the antenatal setting: James B. Robins
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Compliance, Coersion and Power: Dr Barbara Vernon, et al.
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Informed Consent for Cord Clamping: Ask Erasmus Darwin!: George M. Morley, MB ChB FACOG, et al.
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Evidence based leaflets in maternity care: their design matters: Andrew Herxheimer
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Informed Choice or Informed Compliance?: Victoria A Carne, et al.
bmj.com, 7 Apr 2002 [Full text]
Apologies for factual inaccuracy: Victoria A Carne
bmj.com, 8 Apr 2002 [Full text]
evidence based leaflets in maternity care: design certainly does matter: Helen Stapleton
bmj.com, 10 Apr 2002 [Full text]