When I received the ALCI 2019 Conference Programme, I was very excited to see Denise O’Brien’s presentation listed, recognising the deep impact the ability to exercise informed decision making around birth has on a woman with implications for her health and well-being into motherhood, and highlighting the importance of listening to women’s voices. The talk did not disappoint. It offered vital insights for all who work with women and families in pregnancy, birth and the postnatal period, and for informing healthcare policy and practice.

Dr Denise O’Brien is a lecturer and assistant professor in the School of Nursing, Midwifery and Health Systems at UCD. Since noticing as a midwifery student in the early 1990s that confident women were saying, “I can’t do it” or “I lost my confidence”, when it came to labour and birth, she has been interested in what happens to a woman’s sense of self when she enters the maternity care system. Dr O’Brien pointed out that until recently maternity service users have not been asked about their experiences, or invited to the table to help shape service provision. This year marks the Irish health services’ first ever national maternity care experience survey (Linda Drummond from HIQA presented to ALCI on this immediately after O’Brien’s talk).

To hear more from women, in particular how they themselves define informed choice, and building on previous Irish research revealing that women have long been asking for improvements in the provision of information to improve their overall birth experiences (O’Hare and Fallon, 2011), O’Brien and co-researchers, Professor Mary Casey and Professor Michelle M Butler designed a fascinating participatory action research study.

The objective of their research was to explore women’s understandings and definitions of informed choice as a concept, during pregnancy and childbirth. In other words, how do women define and internalise their experiences of exercising choice? They also wanted to investigate with women and midwives what supports were necessary to enable informed choice.

The setting for the study was a national referral hospital in Dublin with a normal birth rate of 57% and caesarean rate of 29%, lower than the national average, and a greater diversity of care options (obstetric-led, midwife-led, Domino midwifery services) compared to hospitals nationally. Women were recruited from postnatal wards, the postnatal baby clinic, the community midwives postnatal support group and the breastfeeding support clinics.

O’Brien outlined their study’s three distinct phases:

1. Interviews with 15 women (11 of whom, O’Brien noted, were breastfeeding) undertaken over a 6-month period.
2. A series of group meetings (n=7) with 5 women over a 13-month period, using a co-operative inquiry (CI) approach to explore the information and other supports needed to support the concept of choice.
3. Evaluating the information pack using a CI approach with midwives’ input, as requested by women during the inquiry process, to fully understand the supports and changes necessary to implement informed choice as a cultural norm for women during pregnancy and childbirth. Fathers were invited to be involved in this phase.

O’Brien’s presentation to ALCI honed in on the details of the first – interview – phase, the part of the study that has been published (O’Brien, Denise et al. 2017, Midwifery, Volume 46, 1 – 7). The interviews consisted of 12 open questions asking the women how they would describe informed decision making. Interviews were conducted between three and six months postpartum and lasted 33 minutes to 2 hours long each. The majority of women opted to have the interview in their own home.

In O’Brien’s illuminating analysis of the interviews, she focused on the first-person voice, how each woman spoke about herself. Pulling out the ‘I’ statements from each woman’s narrative, O’Brien created what American psychologist Carol Gilligan (1992) has termed an ‘I Poem’ for each interview.  O’Brien explained how the poems revealed what women said about ‘the self’ and demonstrated how relationships influenced the women’s expressed sense of self. She then pulled each occurrence of ‘they’ when the women spoke about their relationships with maternity care professionals, to form ‘they’ poems. The two poems together illustrate the interplay between women and maternity care professionals as each woman exercised (or tried to exercise) choice during and around her birth, as well as the influence of relationships on a woman’s sense of self.

In defining informed choice, the women held multiple meanings, but there were recurring themes:

• The provision of up-to-date information and coming to an understanding of that information through in-depth discussions with a maternity care provider of their choice was a prerequisite to making informed choices;
• The new sense of responsibility to their baby was hugely important;
• If they knew and trusted their midwife or doctor, the women were happier with their choices.

Other themes that emerged in the interviews included

1. A sense of uncertainty and a sense of regret: Women were certain when they described their desires and expectations of making informed choices and uncertain when they described their actual experiences of making informed choices. Uncertainties and regrets related to choice and access to pathways and models of care, and the inability to build relationships in the current maternity system. Monica’s ‘I poem’ serves as an illustration:

“I looked for”
“I don’t know”
“I wasn’t able”
“I wished”
“I missed”
“I needed more”

“I realised too late”

“I regretted”

2. A sense of anxiety and isolation in early pregnancy.
3. A sense of disappointment in care and support.
4. Positive and negative feelings of self: 5 women expressed positive feelings of self when they spoke about making informed choices during the birth of their baby, while 10 felt they could not make informed choices and expressed negative feelings of self when they spoke about their experiences.
5. A sense of conflict between what the doctors and midwives were saying and the women’s intuition.
6. A sense of empowerment among the 5 women who felt supported to make their own decisions during birth and who expressed positive feelings of self when describing their interactions with their caregivers (midwives). Jo’s ‘They’ and ‘I’ poems highlight this dynamic:

“They told me”           “I knew”

“They trust you”         “I wasn’t worried”
“They make sure”      “I was delighted”
“They are always”      “I was really relaxed”
“They are so”              “I was very in control”

Of all the take-homes from O’Brien’s presentation, the biggest for me was just how vital it is that healthcare professionals and maternity care systems prioritise the relational aspects of informed decision making and work to foster relationships of trust and mutual respect between women and their care providers. This study shows how detrimental this action is to a woman’s post-birth sense of self, her mental health and well-being.

I look forward to seeing the results and information pack that emerge from phases 2 and 3 of this exciting research study!

Tara Durkin November 2019.

Tara received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.