Objective To examine the use of evidence based leaflets on informed choice in maternity services. Design Non-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care. Setting Women's homes; antenatal and ultrasound clinics in 13 maternity units in Wales. Participants Childbearing women and health professionals who provide antenatal care. Intervention Provision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use. Main outcome measures Participants' views and commonly observed responses during consultations and interviews. Results Health professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of "right" and "wrong" choices rather than "informed" choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women's trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced. Conclusions The way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

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Objective To assess the effect of leaflets on promoting informed choice in women using maternity services. Design Cluster trial, with maternity units randomised to use leaflets (intervention units) or offer usual care (control units). Data collected through postal questionnaires. Setting 13 maternity units in Wales. Participants Four separate samples of women using maternity services. Antenatal samples: women reaching 28 weeks' gestation before (n=1386) and after (n=1778) the intervention. Postnatal samples: women at eight weeks after delivery before (n=1741) and after (n=1547) the intervention. Intervention Provision of 10 pairs of Informed Choice leaflets for service users and midwives and a training session for staff in their use. Main outcome measures Change in the proportion of women who reported exercising informed choice. Secondary outcomes: changes in women's knowledge; satisfaction with information, choice, and discussion; and possible consequences of informed choice. Results There was no change in the proportion of women who reported that they exercised informed choice in the intervention units compared with the control units for either antenatal or postnatal women. There was a small increase in satisfaction with information in the antenatal samples in the intervention units compared with the control units (odds ratio 1.40, 95% confidence interval 1.05 to 1.88). Only three quarters of women in the intervention units reported being given at least one of the leaflets, indicating problems with the implementation of the intervention. Conclusion In everyday practice, evidence based leaflets were not effective in promoting informed choice in women using maternity services.

The culture of midwifery in the National Health Service was examined in order to foster understanding of the context of midwifery practice. In-depth interviews were conducted with midwives in five, very different, sites across England. The culture which emerged was one of service and sacrifice where midwives lacked the rights as women which they were required to offer to their clients. There was a lack of mutual support and of positive role models of support with considerable pressure to conform. Guilt and self-blame were common as was learned helplessness and muting. The dilemmas of this culture are considered and the resistance which it offered to change in relationships. Change was either resisted, brought about by stealth or strategically planned to equip midwives to change their culture.

The bioethical principle of respect for a person’s bodily autonomy is central to biomedical and healthcare ethics. In this article, we argue that this concept of autonomy is often annulled in the maternity field, due to the maternal two-in-one body (and the obstetric focus on the foetus over the woman) and the history of medical paternalism in Western medicine and obstetrics. The principle of respect for autonomy has therefore become largely rhetorical, yet can hide all manner of unethical practice. We propose that large institutions that prioritize a midwife–institution relationship over a midwife–woman relationship are in themselves unethical and inimical to the midwifery philosophy of care. We suggest that a focus on care ethics has the potential to remedy these problems, by making power relationships visible and by prioritizing the relationship above abstract ethical principles.

This article, the first in a series of six, presents findings from the Why do Midwives Leave? study which explored leavers’ reasons for ceasing to practise. For many midwives, making the decision to leave had been a protracted and difficult process. Although there were five main reasons given for leaving, the largest single group of leavers comprised those midwives who had grown dissatisfied with the way they were required to practise within the contemporary NHS. Concern was evident in relation to the standard of care they felt able to provide and the relationships that they were able to establish with their clients. Organisational issues were also highlighted, including low staffing levels and unsupportive midwifery management.

Information about clinical processes (and outcomes) is essential if informed decisions are to be made. The women in this review had reportedly accepted the potential consequences of their high-risk situations. If reality is to match rhetoric about "patient" autonomy, such decision making in high-risk situations must be accepted.

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