Qualitative study of evidence based leaflets in maternity care.

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.