Qualitative study of evidence based leaflets in maternity care

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Abstract
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. 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