Rates of induction in the United States have doubled since 1990 to 22.5% of births in 2006 while cesarean section rates are estimated to have increased 50% in the last decade to 31.8% of births in 2007. There is evidence that obstetrical interventions used for nonmedical indications carry the risk for uterine rupture, hemorrhage, and maternal or fetal morbidity or mortality. The purpose of this integrated review was to investigate what influenced women to make these choices, their perception of risk and their knowledge of potential complications of obstetrical interventions. This review of literature was conducted using the CINAHL and MEDLINE databases using various key terms including "induction", "augmentation" "awareness", "cesarean", and "decision making." Nine studies met the inclusion criteria and were included in this review. The literature suggests that women are not always included in decision making, are not fully educated on the risks, and have, over time, become more willing to accept obstetrical interventions. It has also been shown that women do not assess their own individual risk based on statistical odds, instead they judge the risk based on their understanding of complications associated with their pregnancy. The evidence supports that women need to be properly educated by caregivers and that positive natural birth experiences be portrayed to combat the influence of family/friends and social media on their decision making process. Nurses, midwifes and other healthcare professionals can use this information to assess a women's degree of knowledge and ensure they are making their decisions as informed as possible. More interventional research needs to be done regarding education and decreasing obstetrical intervention rates.

This thesis examines maternal decision-making regarding prenatal care and childbirth in the rural, north-central Andes in the province of Carhuaz. Semi-structured interviews (n=30) and participatory action research workshops (n=7) were conducted with local women to elucidate how they conceptualize, experience, and negotiate the shifting landscape of prenatal care and childbirth practices and providers. Semi-structured interviews with obstetricians, midwives, and social workers (n=9) were also conducted to compare perspectives and identify disconnects in knowledge and practices existing between these two groups in order to facilitate an open conversation on how to jointly improve the maternal experience and reduce maternal mortality and morbidity in rural Peru, where these risks are significantly higher than in urbanized, coastal areas. In the face of changing practices and the influx of biomedical ideologies, women are faced with competing and conflicting bodies of knowledge as well as varying concrete and symbolic values and consequences of their decisions, which they must navigate and evaluate in a dynamic environment. Issues of ethnic and gender discrimination and financial and social coercion arose as prominent forces structuring risks and constraining maternal agency. However, women also found ways to both resist and accommodate these challenges, demonstrating the intricate and on-going negotiations that occur throughout gestation and the maternal experience. The results of this investigation illustrate the various and nuanced ways in which macro-level maternal health policies are manifesting on the local level and impacting the lived realities of rural, Andean women.

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