This thesis focuses on the concept of informed choice in family planning and how numerical and systematic targeting aimed at raising the numbers of contraceptive acceptors fundamentally undermines this concept in highland Chiapas. The Government of Mexico’s policy aims within its Reproductive Health Programme (1995-2000) are to reduce the total fertility rate whilst promoting reproductive health services and family planning choices. Though Mexico has seen a decline in its total fertility rate attributed to increased contraceptive use in urban areas, in rural parts the rate remains high. Consequently, the rural poor, and in Chiapas overwhelmingly indigenous populations, have become a major target of the Reproductive Health Programme. Monthly targets are set for clinics and family planning services are offered systematically every time a woman attends a clinic for whatever reason. Amongst the factors which must be accounted for in assessing family planning provision in highland Chiapas are cultural differences between mestizo providers and the indigenous target groups as well as local economic and political conditions. Presently, the state of Chiapas is highly militarised and under the cloud of a low intensity war precipitated by the Zapatista uprising in 1994. The provision of any kind of health services is difficult under these situations, but more so what one considers the distrust sown between some indigenous communities and the government Who provide the health services. This thesis examines the practicalities of implementing a global policy at a local level and the constraints faced by both providers and intended recipients in the social context of Los Altos. Mindful of the care required in identification most people in this thesis (with the exception of a few well-known academics) appear under pseudonyms.

Medical decision making is complicated and requires a full understanding of the options being presented. It is easy as a practitioner to assume that a patient has capacity, when in fact they might not. Evidence indicates that frequently with the best intentions, health care practitioners allow people to make medical decisions when they do not understand the implications of that choice. I believe that this happens when practitioners feel that the patient is autonomously making a choice that promotes beneficence. This too creates an ethical dilemma, as it does not fully promote autonomy if the patient does not have capacity to make the decision. I believe that further reflection can help physicians understand what motivates their patient’s, and their own, decision making. / Urban Bioethics

United Kingdom (UK) health policy over the past thirty years has been predicated on a partnership model focusing on empowering service users to be fully involved in their care. Within maternity care partnership relationships have been conceptualised as empowering women to have continuity, choice and control (Department of Health (DoH), 1993), within a relationship of personal autonomy between the woman and her carers. In this study I sought to identify the extent to which the Government agenda for partnership working and choice is realised or desired by women during pregnancy and childbirth. In addition, I wanted to examine the level of alignment between the views of midwives with that of women accessing the maternity services. This study took a qualitative approach, drawing on the principles of grounded theory. In the first phase of the study a purposive sample of sixteen pregnant women were recruited and invited to complete a diary and to take part in two interviews. Women maintained diary entries following appointments with the midwife during pregnancy and childbirth. Semi–structured interviews were undertaken at 36 weeks of pregnancy and four weeks after the birth, based on the diary entries. In the second phase, four focus groups were undertaken with two groups of community midwives and birth centre midwives from two National Health Service (NHS) Trusts. Quotes from the diary-interviews from phase one were utilised to develop three vignettes which acted as a prompt during the focus group interviews. Following a thematic analysis of the data, I analysed women’s views on partnership working and choice. Most women in this study did not feel that they developed a partnership relationship with the midwife. This was associated with a lack of continuity of care and insufficient time to engage in meaningful discussion in an environment which was not conducive to shared decision making. Women described wide variations on the midwives role in supporting decision making. This ranged from decisions being dictated to midwives guiding choices and for some women, being facilitated to make informed choices. Many women described input of family and friends and widespread use of the internet as an information source. Women depicted their antenatal midwifery care as medicalised and felt that whilst their bio-medical needs were met their psycho-social and emotional needs were not. Women described the visits frequently as ‘in and out’ or ‘ticking the boxes’ to describe this approach to care. A small number of women (n=5) did experience a partnership relationship. Three of these women knew the midwife from a previous pregnancy; the remaining two women attended a midwifery led unit for all of their care. In relation to the choice agenda, most of the women who participated in this study were not aware that they had a choice about who provided their care or where they would have their care. The midwife focus groups concurred with the women’s findings and suggested that a lack of time was a significant factor hindering the formation of a partnership relationship. Midwives felt that this was exacerbated by the paperwork they were required to complete in order to audit care and meet the ‘payment by results’ agenda (DoH, 2003b). During the focus groups midwives identified strategies which could be implemented to enhance midwifery led care, including offering antenatal care to small groups of women and undertaking an antenatal home visit towards the end of pregnancy, to provide women with the time to discuss any issues that they wanted to explore in more depth. The findings from this study contribute to the current body of knowledge on midwifery led care particularly in providing the women’s perspective on partnership working. Women want to experience midwifery care that meets their psycho-social needs as well as bio-medical needs through a model of care that provides continuity. In contrast to previous research findings, the women in this study described community based care as mechanistic, clinically focused and time bound, more in line with an obstetric model of care than a midwifery model. However, midwifery led care offered within a birth centre was perceived by women as providing a more holistic, social model of care. Whilst continuity of care is not a new concept, what this study contributes is that despite successive administrations supporting partnership working and informed choice over the past twenty years, most of the women in this study did not experience this level of care. The findings from this study resulted in the development of a midwifery partnership model as a theoretical framework that could be utilised in future research studies to evaluate the extent to which a partnership relationship exists within a range of midwifery care settings.

This study was designed to complement local audit data by examining the lived experience of women who elected to attempt a vaginal birth following a previous caesarean delivery. The study sought to determine whether or not women were able to exercise informed choice and to explore how they made decisions about the method of delivery and how they interpreted their experiences following the birth. Background.¿ The rising operative birth rate in the UK concerns both obstetricians and midwives. Although the popular press has characterized birth by caesarean section as the socialites' choice, in reality, maternal choice is only one factor in determining the method of birth. However, in considering the next delivery following a caesarean section, maternal choice may be a significant indicator. While accepted current UK practice favours vaginal birth after caesarean (VBAC) in line with the research evidence indicating reduced maternal morbidity, lower costs and satisfactory neonatal outcomes, Lavender et al. point out that partnership in choice has emerged as a key factor in the decision-making process over the past few decades. Chaung and Jenders explored the issue of choice in an earlier study and concluded that the best method of subsequent delivery, following a caesarean birth, is dependent on a woman's preference. Design and methodology.¿ Using a phenomenological approach enabled a holistic exploration of women's lived experiences of vaginal birth after the caesarean section. Results.¿ This was a qualitative study and, as such, the findings are not transferable to women in general. However, the results confirmed the importance of informed choice and raised some interesting issues meriting the further exploration. Conclusions.¿ Informed choice is the key to effective women-centred care. Women must have access to non-biased evidence-based information in order to engage in a collaborative partnership of equals with midwives and obstetricians. Relevance to clinical practice.¿ This study is relevant to clinical practice as it highlights the importance of informed choice and reminds practitioners that, for women, psycho-social implications may supersede their physical concerns about birth.

The Birth Centre is a midwife-led, out-of-hospital facility for normal births in Winnipeg, Manitoba. Exploring women’s experiences of choosing the Birth Centre was the primary objective for this thesis. Through a feminist perspective and using interpretative phenomenological analysis (IPA), each participant’s idiographic description of the decision-making experience was analysed. A sample of seventeen women participated in in-depth interviews. Six themes emerged through the qualitative analysis: Exercising personal agency; Making the decision in the context of relationships; An expression of one’s ideology; Really thinking it through; Fitting into the eligibility criteria; and The psychology of the space. The findings suggest that a woman’s sense of safety is related to these themes. The women had a normal birth influence in their lives from personal relationships, past experiences, or personal values and beliefs. The study highlighted the importance of access to midwifery services in order to increase awareness and access to the Birth Centre.

The overwhelming social norm for pregnant women in the U.S. is to receive prenatal care from an obstetrician and to give birth in a hospital setting. However, the incidence of midwifery care and out-of-hospital birth is increasing, particularly among White, non-Hispanic women. Florida has been considered a "model" state for home birth midwifery given legislative support that mandates coverage of all types of midwifery (e.g., Certified Professional Midwives and Certified Nurse-Midwives) care in all birth settings (e.g., hospital, home, birth center) and by all forms of insurance (e.g., commercial and Medicaid). Medicaid is the payer source for nearly half of the births in the United States and in Florida. However, Florida is one of only ten states where Certified Professional Midwives, who attend the vast majority of planned home births, are actively able to receive Medicaid reimbursement for home birth care. A key question then becomes, how is the system for Medicaid-funded home birth in Florida functioning? The central aim of this research was to better understand how Medicaid impacts the practice of and access to planned home birth in Florida. This was examined through quantitative analysis of Florida birth certificates as well as through qualitative data collection and analysis that sought to describe the experiences of women who had planned home birth while on Medicaid as well as the experiences of midwives that cared for these women. Findings are presented through the lens of Critical Medical Anthropology, which helps to interpret how and why home birth is systematically supported or threatened by legislation, policy, and practice at the level of the State of Florida, the federal-state Medicaid program, and the professional organizations in the United States involved in maternity care. Key findings demonstrate that the vast majority (87%) of planned home birth in Florida is attended by Certified Professional Midwives, and that while Florida Medicaid paid for 45% of all births between 2005 and 2010, only 31% of planned home births were paid for by Medicaid. However, after controlling for multiple factors (e.g., race/ethnicity, age, parity), in fact women who completed home (vs. hospital) birth were much more likely to be self-pay (AOR 10.1) or on Medicaid (AOR 4.6) compared to private, commercial insurance. Women interviewed for this study who received Medicaid for their home births overwhelmingly appreciated the "safety net" that Medicaid provided to them and the "relief" of knowing that if a hospital transfer was necessary it would be covered. However, they nearly universally stated that they would have found a way to pay for a home birth if they had not received Medicaid. Women felt that home birth with midwives provided them the greatest chance of having a "natural" birth in the environment most likely to maintain autonomy over decisions related to their pregnancy and birth. Several women experienced significant delays in enrolling in Medicaid, and found that the only providers who would provide care during "presumptive eligibility" were Licensed, Certified Professional Midwives. Midwives appreciated the steady, reliable payments Medicaid provided, despite that these were at about 30 to 40% of their rates charged to privately insured or self-pay clients. They felt that providing care to Medicaid funded women served as a form of social justice. They strongly disliked interfacing with Medicaid HMOs. Some midwives felt that the Florida legislation supported their practice, while others felt that it constrained their practice. Medicaid coverage of planned home birth in Florida now stands at a crossroads, given that Florida Medicaid has recently transitioned to a 100% managed care program (i.e., HMOs). These HMOs act as intermediaries between Medicaid providers and their reimbursements, as well as between Medicaid providers and recipients. The new relationships between providers, patients and the HMOs have shifted from that with a state agency to that with a private, for-profit industry. It remains to be seen whether home birth providers will enroll with Medicaid HMOs in order to continue providing care to pregnant women receiving Medicaid. Key policy recommendations therefore are to monitor women's access to pregnancy Medicaid, and specifically access to services mandated under Florida statute, including home birth and midwifery care. Furthermore, the creation of an integrated maternity care system that better supports transfers of care from the home to hospital setting is needed.

Recent changes in legislation and access to information, through sources such as the media, may have influenced peoples' expectations for information about their prescribed medication. As a result, health care professionals may perceive an increased pressure to provide information. A case study approach was employed to examine the sources and scope of information patients draw upon when they are prescribed oral steroids for asthma. The aim was to examine the extent to which patients can be said to exercise an `informed choice' when they take prescribed medication. The role and importance of GPs (general practitioners) in informing the choices patients make was also examined. Both qualitative and quantitative methods were employed. Interviews conducted with both patients and GPs indicated `gaps' in understanding. Although the GP was the preferred source of information, patients reported that the choices they made were based on information from a range of sources. General practitioners justified not providing information to patients so as to `protect' patients from knowledge of side effects. However, there was some awareness of the range of sources of information used by patients. A vignette technique was employed to further investigate GPs' recognition and understanding of the range of sources of information patients' use to inform the choices they make. Approximately half of the GPs who responded to the vignette recognised the influences presented. General practitioners who had been practising for a shorter period of time were significantly more likely to recognise these influences. The conclusions draw on the literature of the sociology of the professions. In spite of the way in which the Government has sought to encourage patients to act as consumers, the state has also continued to endorse GPs right to make decisions concerning the level of information to provide. If GPs do not believe it is in the interests of patients to be provided with information to make choices about their medications then the information available to patients may be limited. This will have an impact on the ease with which patients may make `medically' informed choices about their prescribed medication. Only when the communication between patients and GPs improves, will it be possible for a relationship to develop where patients may be assured of gaining information from their GP at the level they feel is appropriate to enable them to make informed choices about their medication.

Yes / Aims and objectives.  This study was designed to complement local audit data by examining the lived experience of women who elected to attempt a vaginal birth following a previous caesarean delivery. The study sought to determine whether or not women were able to exercise informed choice and to explore how they made decisions about the method of delivery and how they interpreted their experiences following the birth. .  The rising operative birth rate in the UK concerns both obstetricians and midwives. Although the popular press has characterized birth by caesarean section as the socialites’ choice, in reality, maternal choice is only one factor in determining the method of birth. However, in considering the next delivery following a caesarean section, maternal choice may be a significant indicator. While accepted current UK practice favours vaginal birth after caesarean (VBAC) in line with the research evidence indicating reduced maternal morbidity, lower costs and satisfactory neonatal outcomes, Lavender et al. point out that partnership in choice has emerged as a key factor in the decision-making process over the past few decades. Chaung and Jenders explored the issue of choice in an earlier study and concluded that the best method of subsequent delivery, following a caesarean birth, is dependent on a woman's preference. Design and methodology.  Using a phenomenological approach enabled a holistic exploration of women's lived experiences of vaginal birth after the caesarean section. Results.  This was a qualitative study and, as such, the findings are not transferable to women in general. However, the results confirmed the importance of informed choice and raised some interesting issues meriting the further exploration. Conclusions.  Informed choice is the key to effective women-centred care. Women must have access to non-biased evidence-based information in order to engage in a collaborative partnership of equals with midwives and obstetricians. Relevance to clinical practice.  This study is relevant to clinical practice as it highlights the importance of informed choice and reminds practitioners that, for women, psycho-social implications may supersede their physical concerns about birth.

The literature concerning what medical students learn from midwives during specialist obstetric rotations is scarce. In the UK, despite a long tradition of providing midwifery attachments for medical students, it is almost non-existent. Working with midwives is arguably the only opportunity medical students have to experience holistic or social models of maternity care, focusing on normality rather than on the medical concept of risk. This study sought to discover how medical students constructed their knowledge about childbirth during a six week specialist rotation in obstetrics in a Northern English teaching hospital (NETH), with particular emphasis on whether participants assimilated any concepts from midwifery knowledge (MK). A Delphi Study, done as the first phase of the research, focused on MK, utilizing an international sample of experienced midwives. Resulting themes were used to develop the data collection tool for the second phase of the research. The research employed a qualitative case study method with students from a single year cohort comprising the case. Data were collected using a tool consisting of three problem based learning (PBL) scenarios. These were presented to the students in consecutive interviews at the beginning, the middle and the end of their obstetric rotation. Following analysis, five main themes were identified which illuminated the medical students' construction of knowledge about maternity care. These were explored and discussed. The thesis concludes with recommendations for increasing opportunities for IPE in the medical and midwifery curricula.

Introdução O direito à escolha informada das mulheres sobre suas vivências na gravidez e no parto é fruto do percurso histórico dos direitos sexuais e reprodutivos, respaldados em bases éticas da autonomia, integridade corporal, igualdade e diversidade. No Brasil, sua história política e social vem sendo construída por meio da interlocução com o movimento de mulheres e os aparelhos governamentais, propulsionando políticas públicas que os garantam. Entretanto, as desigualdades de gênero no âmbito do conhecimento médico-científico levaram a uma leitura pessimista acerca do corpo feminino, que trata a experiência do parto como um evento patológico, dependente da tecnologia e de intervenções desnecessárias na assistência. Objetivo Descrever e analisar a perspectiva das mulheres sobre a dinâmica da disponibilização, acesso e qualidade das informações no pré-natal para as negociações do tipo de parto e os procedimentos da assistência focados na episiotomia, ocitocina e acompanhante, nas redes de saúde pública e suplementar. Metodologia Estudo qualitativo, alicerçado nas perspectivas teóricas de gênero e dos direitos reprodutivos, realizado por meio de entrevistas semiestruturadas de três tipos (por email, Skype e presencial), com 26 mulheres assistidas nos dois setores de saúde, em diversas regiões do país. Resultados Embora garantido pela política pública, ainda é difícil o acesso das mulheres às informações de qualidade que favoreçam suas escolhas e decisões de parto e intervenções na assistência. Essa dificuldade está imbricada em fatores sociais, econômicos, culturais e de gênero que transferem o poder de decisão sobre o tipo de parto e de intervenções no parto normal para os profissionais médicos e suas instituições. Conclusões Frequentemente, a disponibilização das informações no pré-natal foi insuficiente nos dois setores de saúde, revelando o silêncio em torno do parto. No pré-natal, as mulheres não são incentivadas à busca ativa por informações; e, quando elas existem, são imprecisas e desconsideram os seus direitos reprodutivos. Mesmo quando existe o acesso às informações da rota específica da humanização não há total garantia da possibilidade de negociação. Além disso, nem todas as mulheres conseguem acessá-la. De modo geral, a informação, isoladamente, não representou a possibilidade de êxito para as decisões no parto, dadas às diversas dificuldades que os mecanismos profissionais e institucionais impõem às mulheres / Introduction The right of women to informed choice about their experiences of pregnancy and childbirth is the result of the historical journey of sexual and reproductive rights, supported on ethical foundations of autonomy, bodily integrity, equality and diversity. In Brazil, its political and social history is being constructed through dialogue with the women\'s movement and the government apparatus, propelling public policies that guarantee these rights. However, gender inequalities within the medical and scientific knowledge led to a pessimistic approach to the female body, resulting in an a experience of childbirth as a pathological event, dependent on technology and unnecessary interventions in care. Objective To describe and analyze the women\'s perspective on the dynamics of availability, access and quality of information on prenatal care for the negotiations of the type of delivery and the procedures of care, focused on episiotomy, oxytocin and companion in public and insurance- managed health services. Methodology A qualitative study, based on the theoretical perspectives of gender and reproductive rights, conducted through semi-structured interviews of three types (email, Skype and face), with 26 women who attended the two health sectors in various regions of the country. Results Although guaranteed by public policy, it is still difficult for women to access quality information that support their choices and decisions about interventions in childbirth care. This difficulty is embedded in social, economic, cultural and gender aspects that transfer the power to decide on the type of delivery and interventions in childbirth to medical professionals and their institutions. Conclusions Often, the availability of information on prenatal care was insufficient in both health sectors, revealing the \"silence\" around childbirth. In prenatal care, women are not encouraged to actively search for information, and when information is available it is often inaccurate and ignoring of women`s reproductive rights. Even when there is access to information coming from specific route of humanizade care is no complete assurance about the possibility of negotiation. Also, not all women are able to access it. In general, information alone does not represent the possibility of success for decisions in labor, given the various difficulties that professional and institutional mechanisms impose on women