Introduction

Top Abstract Introduction Methods Results Lack of choice in... Technology and litigation Hierarchy, power, and trust Discussion References

The organisation and provision of maternity care in the United Kingdom was challenged when the Changing Childbirth report recommended that it become more "woman centred."¹ The 10 research based leaflets (Informed Choice)² were developed by the Midwives Information and Resource Service to support consumer choice.³ The effectiveness of these leaflets has been studied in a randomised controlled trial which is reported separately.² To understand the social context in which the leaflets were used we undertook qualitative research alongside, but independently of, the randomised trial.

Attitudes of staff are thought to influence the choices available to childbearing women ^{4 5} and decision making in clinical practice.^6-8 Organisational culture affects the quality of health care.^9-11 "Socially complex interventions,"¹² such as the Informed Choice leaflets, should be evaluated within the context in which they are used and through a prudent combination of qualitative and quantitative methods. ^{13 14}

	Methods

Top Abstract Introduction Methods Results Lack of choice in... Technology and litigation Hierarchy, power, and trust Discussion References

In the randomised controlled trial, 13 maternity units formed 10 clusters, five of which received the intervention of the Informed Choice leaflets between May and December 1998. ^{3 15} Four female midwifery researchers, including two of the authors (HS and GT), undertook non-participant observation and in depth interviews with health professionals and women, in both intervention and control maternity units (table). All the researchers kept detailed field notes for analysis. We used a grounded theory approach to data collection and analysis¹⁶ and the software package QSR NUD*IST¹⁷ to organise and interrogate the datasets.

The combination of qualitative methods enabled us to examine the same issue from a range of different perspectives and to explore beyond "official" accounts of choice and decision making from health professionals and childbearing women.

We obtained approval for the study from the local ethics committee.

Observations
We used observations of antenatal consultations (table) to identify how the leaflets were used and how informed choice and decision making occurred in practice. We made detailed field notes concerning setting, actions, words, and non-verbal cues of all present.

Interviews
We undertook face to face interviews using a semistructured format. We developed interview guides that were specific to the different participant groups, but all participants were invited to discuss the availability and quality of information, including the Informed Choice leaflets, receiving and conveying information, the meaning of informed choice, and the role of childbearing women in decision making. We also discussed inferences made by the researchers about behaviours and interactions during consultations. More than half of the interviews followed on from observation sessions, and this enabled us to explore issues, especially those of a sensitive nature, within the context of a previously established relationship.

Sampling
Our initial observation sample was "opportunistic," being determined by the staff on duty and whether they and their clients were willing to accommodate the researchers. We identified commonly observed responses, such as pregnant women expressing satisfaction with their care and complying with the choices offered to them, staff expressing concern about time pressures, and midwives describing the leaflets as useful tools. As the research progressed, we sampled more selectively to ensure that all women of childbearing age, all social classes, and various current and previous obstetric experiences were represented, together with women from minority groups. We sampled many more midwives than other health professionals because they provided most antenatal care and disseminated most of the leaflets. In an effort to observe and understand good practice we sampled a small number of midwives in all maternity units who were described by their managers as excellent in facilitating informed choice.

Towards the end of the intervention period we selected interviewees to confirm or refute emerging theory. As most staff and women tended to "go with the flow" of routine clinical practices, such sampling thus included women who questioned or declined the choices offered to them and staff who offered choices (and leaflets) withheld by colleagues. For midwives this revealed a link between practice and work setting. Midwives in community or domicilary settings were generally more knowledgeable about women's individual needs and seemed more willing to advocate on their behalf. They also tended to make more openings for women to voice their concerns. Hence, we identified interplay between hierarchy, power, and trust and the impact on information sharing between women and different groups of midwives. We continued to explore themes with all relevant participant groups until repeated, rather than new, information was forthcoming and theoretical saturation was achieved.

We removed identifying information from selected transcripts and shared them with members of the research team and outside experts. This guided future data collection, guarded against any researcher dominating the analytical process, and helped to ensure validity and reliability. ^{18 19}

	Results

Top Abstract Introduction Methods Results Lack of choice in... Technology and litigation Hierarchy, power, and trust Discussion References

The "invisible" leaflets
Most health professionals initially expressed positive views about the principles underpinning the Informed Choice leaflets (box 1). Within practice settings, however, they were seldom used to maximum effect. Pragmatic usage resulted in many leaflets being withheld from women because staff disagreed with the contents of the leaflet or were concerned because some leaflets promoted choices that were unavailable locally. Some midwives also made assumptions about the ability and willingness of women to participate in decision making. These assumptions were sometimes incorrect.

The potential of the leaflets was further diluted because they were often given out "wrapped" within advertising materials or concealed within the maternity folder. During interviews, questions about the leaflets usually failed to elicit any response from most women. They often confused them with other information related to pregnancy or indeed denied having received them. It was often only after coaxing by the researcher or after her suggestion that women look within their maternity folder that leaflets were discovered and some comments were forthcoming.

Midwives generally distributed leaflets in routine ways and were rarely observed differentiating them from other information they offered women. Health professionals were seldom observed discussing the leaflets with women or asking them if they understood the information or found it useful. Women rarely initiated discussion about leaflet topics. A few women were complimentary about the leaflets and thought that they had influenced their intentions. Most women, however, did not find them helpful in decision making.

Health professionals under pressure
Most health professionals reported feeling pressured by time constraints (box 2). Midwives in particular were concerned about assuming the role of "information broker" without preparation or the allocation of additional time. Midwives on intervention sites sometimes viewed the leaflets as a pragmatic solution to time pressures. Women were often observed accommodating health professionals by limiting their questions, but some expressed dissatisfaction when written information was used as an alternative to discussion.

	Lack of choice in practice

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Health professionals noted that many leaflets suggested choices that were not available at a local level (box 3). Furthermore, some technological interventions, such as ultrasound scanning and monitoring in labour, have become so routine in maternity care that health professionals no longer perceive them as optional. Women sometimes made choices on the basis of their previous experiences of childbirth but were often met with resistance if their preferences contradicted established clinical norms. Staff sometimes expressed a strong dislike for an option covered by the leaflets to the extent that distribution of some leaflets was terminated on some sites. Women tended to comply with the suggestions of health professionals, and, unless openings were made, they rarely instigated discussion about their own preferences.

	Technology and litigation

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Researchers observed health professionals driving decision making towards technological intervention by conveying information which either minimised the risk of the intervention or emphasised the potential for harm without the intervention. This seemed to make it difficult for women to hear alternative messages, even from obstetricians. Fear of litigation promoted notions of "right" choices with which clinicians felt clinically secure and which they thought would afford them protection against litigation. Midwives occasionally expressed frustration when such imperatives, rather than evidence based information or client choice, determined the options available. Some women were aware of the influence of technological imperatives on the attitudes of health professionals, and they occasionally experienced this as bullying. Some views are shown in box 4.

	Hierarchy, power, and trust

Top Abstract Introduction Methods Results Lack of choice in... Technology and litigation Hierarchy, power, and trust Discussion References

We observed a strong hierarchy within the maternity services, with obstetricians at the top, midwives and health professionals other than doctors in the middle, and pregnant women at the bottom (box 5). This correlates with women's observations that midwives generally exercised little clinical influence compared with doctors. Midwives were concerned about the consequences of recommending options that contradicted obstetrically defined clinical norms. Most of the choices suggested in the leaflets required obstetric support, and hence the options offered tended to reflect the preferences of obstetricians rather than those of pregnant women or midwives. The practice of lower ranking doctors was similarly constrained by power differentials.

Women who experienced continuity of midwifery care were more likely to report trusting relationships in which they felt more able to ask questions. Such relationships, which were rarely encountered in this study, seemed to reduce imbalances in power and facilitate a partnership approach to maternity care.²⁰ Women who questioned practice norms in the absence of such support often reported feeling undermined and were sometimes mistrusted by health professionals.

	Discussion

Top Abstract Introduction Methods Results Lack of choice in... Technology and litigation Hierarchy, power, and trust Discussion References

This qualitative study of evidence based leaflets for pregnant women found that they did not promote informed choice. This was related to time pressures on staff working within a culture that supported existing normative patterns of care rather than informed choice. The hierarchical power structures within the maternity services, and the framing of information in favour of particular options, ensured compliance with the "right" choice.

Health professionals' initial views of the Informed Choice leaflets were generally positive but the ways in which leaflets were distributed or withheld, however, severely diluted their potential benefits. Health professionals, pressured by time and concerned about litigation, rarely discussed the content of the leaflets or promoted their difference from other literature. The resulting invisibility helps to explain why only 70% of women in the intervention sites reported receiving a minimum of one leaflet.¹⁵ Such findings are not unique to maternity care or to the use of evidence based decision aids.²¹

The way in which information is presented influences decision making²² and competing "hierarchies of evidence"¹⁴ are known to reduce the credibility of some healthcare choices. Passive dissemination of information is ineffective in changing the behaviour of health professionals.²³ Choices that are offered but not actively supported by staff are rarely taken up by pregnant women.²⁴ The absence of opportunities for discussion²⁵ that we observed is also likely to have hindered women in using the leaflets to make (informed) decisions.

The organisational and hierarchical structure of the maternity services worked against maximising the potential of the leaflets. The relative lack of continuity of care observed throughout the study made it difficult for women to follow up on issues raised in a previous consultation or to initiate discussion on leaflets and other topics related to pregnancy. Lack of continuity also precluded the formation of trusting relationships thought necessary to facilitate informed choice.²⁶ Societal and medical expectations tend to normalise technological interventions, and some choices promoted in the leaflets, such as whether to have ultrasound scanning or electronic monitoring in labour, were rarely available in practice because the technology had long been integrated into routine care. Health professionals generally felt responsible for anything that went wrong in maternity care, and a widespread fear of litigation caused many to promote technological interventions, even when they were contradicted by the evidence base of the Informed Choice leaflets.

Choice and decision making seemed to be heavily circumscribed by the pressures and norms of the local obstetric culture. The researchers observed little diversity in clinical practice between individual practitioners or maternity units. Inequalities in power and status were observed to be potent forces in maintaining the status quo, and this made it difficult to promote (informed) choice. As reported elsewhere ^{27 28} midwives were observed to "frame" information and "steer"²⁹ women towards making the "right" decisions to "protect" themselves and their clients from the consequences of inadvertently disrupting the status quo. Informed choice was therefore equated with making the locally defined "right" choice in accordance with the authoritative knowledge and experience of senior obstetricians. Unequal power relations resulted in bias towards the "objective" knowledge of health professionals and marginalised women's subjective knowledge.³⁰ Hence, power differentials served to reinforce informed compliance with the right choice rather than encourage informed choice. Hierarchical structures in the maternity services also made it difficult for lower ranking practitioners to support women in going against these right choices. There was little evidence to suggest that concepts such as partnership²⁰ or shared decision making³¹ were understood by staff who generally were observed to seek women's compliance with the professionally defined right choices.

Childbearing women generally complied with expected norms in their encounters with staff, who they perceived as busy people with many demands on their time. Our results show that cultural barriers within the maternity services encourage informed compliance, even though staff adopted the rhetoric of informed choice.

Conclusions and implications
The results of this study are not specific to maternity units in Wales as similar issues have been identified in units that independently purchased the leaflets.¹⁵ These leaflets are unlikely to promote informed choice in maternity care unless they are introduced as part of a coherent strategy addressing power imbalances and the ambiguities currently underpinning choice. The concept of informed choice carries great potential to resolve many of the issues faced by maternity services today, with informed choice and partnership in decision making lessening the burden of responsibility presently experienced by health professionals. From this and other research we can begin to understand the barriers facing the implementation of research based evidence and the use of decision aids for informed choice in various clinical settings. ^{14 21 26} The additional barriers we have identified are unlikely to be unique to maternity care. Their removal, however, will entail considerable cultural change at all levels of the maternity services.