Subtheme 1.1: social influences

The experiences and opinions of friends and family shaped the decisions women made for labour and birth. Most women felt that friends and family offered valuable and trusted information to assist them with decision-making. Women said that advice from others who had positive birth experiences provided comfort when facing decisions about intrapartum interventions. However, it was other women’s stories of negative experiences that influenced actual decisions made, ‘I have heard people who have been induced (…) found it really tough, so that’s why I think I would probably want an epidural’ (016AN). Additionally, women recognised how reliance on friends’ and family’s opinions and experiences can narrow options for labour and birth, ‘(…) negativities I guess around caesarean option, I almost discounted it without really thinking about it’ (002PN). In antenatal interviews, women reported that other women often described difficult births, ‘a lot of my friends have had babies and said it’s almost like a competition who had the worst birth’ (008AN). Postnatally, women compared what they had heard about difficult birth experiences from friends and family with their own experiences, suggesting that their experiences were not so bad, ‘If anything it was like friends and family putting me off it [stretch and sweep] saying (…) it would be uncomfortable (…) but actually it was fine’ (009PN).

Societal norms influenced how women interpreted available information. During antenatal and postnatal interviews, women reported stigma associated with caesarean section, induction of labour, assisted vaginal birth and pain relief options, and how culture influenced their thoughts about the decisions to be made. As encapsulated in the following quote, some women held the belief that, ‘(…) in society there is almost this sense of you can do it as a woman’ (005AN). Alongside this, particularly postnatally, women highlighted that societal stigmas are unrealistic and unhelpful to women’s birth experience, ‘There’s a bit of a stigmatism[sic] around having an epidural, you feel like you’re cheating or whatever, but actually it was the nicest thing in the entire world’(008PN).

Subtheme 1.2: patient responsibility for information seeking

Women felt that they had to take responsibility for obtaining information about labour and birth. One participant described this particularly when asked about information they wish to receive about birth interventions before labour, ‘I think sometimes you have got to take a bit of responsibility yourself. If you want to understand it, you need to go and read it’ (008AN). Other women described taking responsibility to seek out information for labour and birth, either due to insufficient antenatal information provided or because they wanted more details on specific options, ‘I haven’t been given any information, it’s only what I have researched myself’ (003AN). Some women were proactive in sourcing information from websites, books, apps and private antenatal classes, including the National Childbirth Trust (NCT), ‘I got information because I went to and paid for NCT (…) I wouldn’t have had any information unless I sought it out from community midwives’ (002 PN). Other women felt more information should be provided by the NHS and lacked knowledge in preparation for labour and birth. One participant expressed the responsibility not only to seek their own antenatal information, but to also initiate SDM during labour and delivery, attributing this to a lack of communication around specific choices, ‘I felt some of the decisions were more needed to be initiated more by myself as opposed to being raised by the midwives’ (016PN).

Subtheme 1.3: National Health Service (NHS) versus non-NHS resources

During antenatal and postnatal interviews, women described how they sought information from a variety of NHS and non-NHS resources with mixed views on which were best and why. Many women found NHS information interfaces lacked personal relevance, which at times deterred them from engaging with it, ‘The information in the NHS website I find is very generic (…)’ (001AN) and ‘a lot of the NHS resources and website and everything just looks super corporate (…)’ (004PN). Nevertheless, most women perceived that NHS information was the most reliable source of information available and therefore used it despite these issues, ‘I do tend to follow NHS to be honest because that’s…I think it’s still the best source of information (…)’ (011AN) and ‘I personally try not to read things online unless they are on the NHS website (…) only use the NHS as a source of truth’ (008AN).

Women also sought information from non-NHS sources such as private antenatal classes or non-NHS apps. However, these resources were perceived as more restrictive and in support of specific birth choices, ‘I felt like the [private] antenatal class was a bit too biased towards hypnobirthing, and the promotion of natural birth’ (013AN), a different private antenatal class provider, ‘was really quite negative about caesarean, (…) and six out of seven of our group ended up having caesareans’ (002 PN). Some women therefore preferred to seek NHS information over these classes. One participant also expressed concern over contradictions in information provided by NHS vs non-NHS resources, ‘(…) the information from [private class] and NHS was not quite marrying up’ (004PN). NHS and non-NHS were both valued, but inconsistencies caused concern.

Subtheme 2.1: patient and professional roles in decision-making

Almost all participants understood SDM as the process of making choices together: ‘a balance with the woman deciding with the professional’ (013AN). Antenatally, women wanted involvement in most decisions with their HCPs, ‘For me, yeah, I generally want to participate in everything, that’s my assumption’ (004AN). A few women thought decision-making authority should lie with the birthing person, ‘I think the midwife and the doctor would tell you the information that you need to know (…) but then ultimately the decision is yours’ (007AN). Postnatally, women’s views and experiences encapsulated how the balance of SDM is contextual and dependent on the nature of the decision.

During labour, the pressures of the busy hospital environment limited HCP capacity to support DM as reported by this woman: ‘the four midwives who were all wonderful but just too overwhelmed to ever have a discussion that could constitute shared decision-making’ (002PN). Some women did feel they were supported, particularly in decision-making about episiotomy and instrumental birth, despite the fact that decisions were too quick to be considered shared: ‘I remember her asking me if it was okay that’s what they were going to do, is it okay, and I said yes (…) so it was shared in a sense, but it was also quite a quick decision’. (016PN). Even when there was a time to reflect on a decision and decisions were being made under less time pressure (induction, epidurals), not all participants felt they had autonomy around/had participated in shared decision-making, ‘A lot of the decisions were taken from me…I handed my body over’ (005PN) and ‘I don’t believe that bit was as much of a shared decision as it could have been’ (008PN). This left one participant ‘angry’ (013PN) as her birth choices did not occur as planned.

Despite this, five women detailed positive birth experiences, and three women discussed experiences that were neither positive nor negative, but they felt supported by the HCPs in making decisions, ‘It was shared, but the decisions weren’t anything different from what I wanted (009PN). Some women in some circumstances actually preferred to not be the ultimate decision maker, ‘It made me feel safer to not make that decision in a way’ (012PN).

Subtheme 2.2: conflicting advice and preferences

Some women perceived how HCPs provide information reflecting the HCPs preferences, ‘I worry that the information that I am being given is presented from a perspective of what actually makes healthcare professionals more comfortable’ (001AN). One woman discussed how antenatal advice provided by HCPs was ‘a little pushy around natural birth, very dismissive of any other pain relief options, or discussion around that, which was a little tricky’ (002AN). Postnatally, women reflected on how this sometimes made decisions difficult as they sometimes felt the need to advocate for certain choices in the intrapartum period, ‘I felt like I was already having to almost persuade them that this is a change of plan’ (002PN). Both antenatally and postnatally, women therefore discussed how the preferences of the HCP caused them to feel a lack of control and autonomy, leading to some outcomes that did not meet their expectations, ‘I felt really pushed and I ended up agreeing to an induction in the end’ (012 AN) and ‘So then they said that they wanted me to have the drip, which was not really what I wanted’ (013PN).

Some participants also highlighted that different HCPs occasionally offered differing advice and opinions on choices for labour and birth, which subsequently made decision-making challenging, ‘So I guess there was conflict, not conflict, but there’s definitely different opinions depending on who you spoke to, I felt like through the journey’ (016 PN). This was often attributed to their role, seniority and experience grade, ‘different doctors are different grades as well…Then you speak to your midwives who…have a very different perspective altogether’ (001AN). Inconsistency was a common reflection among participants antenatally and postnatally, suggesting the need for better standardisation, ‘It felt like the information from the two sources didn’t exactly marry up, like they hadn’t come from the same perspective’ (004PN).

Subtheme 2.3: taking authority in emergency decision-making

Women were asked if there were any scenarios in which SDM with HCP would not apply. Antenatally, there was consensus that: ‘…if there was a situation where I was unable to make the best decision for me at that time, then I would want [the HCP] to take that decision out of my hands’ (003AN). Between women, while there were different definitions of an emergency, the HCP always held the key to communicating information and decision-making. Emergencies were variously described as a threat to their life, compromised health of the baby, or when time-sensitive decisions were necessary, ‘I was expectant that the decision about the labour or the birth was going to be dictated to me by the consultant when he said, ‘Okay so the placenta now is not functioning, we need to get the baby out’ (005PN). Women acknowledged how the pain of labour made communicating their preferences and their role in DM a challenge. Although most women were happy for a HCP to take over decision-making in an emergency, both antenatally and postnatally women articulated concerns over their lack of control. Most women deliberated about how decisions should be communicated to them or their birthing partner during emergencies, ‘They should tell me or my partner what they are doing and say why they are doing it, but I don’t think it should be a conversation as such’ (011AN). Two participants wanted potential decisions to be made during an emergency to be discussed with them in advance to retain their role in the decision-making process, ‘I would expect that I had been asked to make the decision beforehand and that they may remind me of that.’ (012AN).

Subtheme 3.3: when: ‘it’s definitely information and time’

In both antenatal and postnatal interviews, the timepoint that information was given and how long women had to process it before being involved in DM was important. ‘It’s definitely information and time, so giving you as much information as possible, and then giving you the time to process it and make a decision’ (008AN). Women who received limited antenatal information expressed hope that more information would become accessible over time, ‘ I thought, oh well, I will potentially have an appointment later down the line where I can talk about this’ (002AN). Another woman assumed information would be provided at the right time, ‘So no, I haven’t got the information yet and I am not worried about that at all’ (005AN). Postnatally, some women felt that having all the information prior to labour positively affected their birth experience; hence, all information should be provided before the intrapartum period, ‘…what I found most helpful for me was having all of that information beforehand’ (009PN). In both antenatal and postnatal interviews, many women referred to a lack of time to process and consider options for labour and birth, ‘they don’t have a lot of time with you and I needed to take that fact on board’ (001AN) and ‘I was rushing to get all my questions out really quickly, and not really taking in the answers’’ (002 PN). Postnatally, women reflected on how they were also left unable to ask questions during labour and birth due to time constraints within the NHS, ‘obviously they’re busy, they were so busy, there was no one actually available to speak to us directly (…)’ (013PN). Over half of the participants stated that they still had a positive birth experience despite the effects of a lack of time, ‘I feel like I sound like I have been quite negative and actually it was overall a very positive experience (…)’ (002 PN). Only one participant felt they had adequate time to consider options in labour which contributed to their positive birth experience, ‘We had loads of time and space to make the decision, people weren’t rushing us at all’ (012PN).

Subtheme 3.2: how—presentation of information

Throughout the antenatal and postnatal interviews, women discussed how the presentation of information can influence decision-making. First, women explored the differences between verbal vs written information. Some women preferred access to information verbally over written information to aid further discussions and questions, ‘I think generally having someone there to talk to is really good (…) I think I wouldn’t want to be given a piece of paper’ (013AN) and ‘written information it’s quite static information, you almost need to have the opportunity to ask questions if you don’t understand something that’s written’ (009PN). Some women preferred exclusively written information so that they could have time to review and process it, ‘I felt like if I could read something and process it in my own time, that would have helped. But it was just spoken to me about’ (007PN). Some women described how having verbal information first, and then written information to supplement this would be of benefit, ‘Definitely a conversation to begin with (…) and then almost have a really high level sheet, a piece of paper or a leaflet or something afterwards that you can refer back to’ (008AN). The majority of women, however, expressed the view that a hybrid of written and verbal methods is the most effective approach for presenting antenatal information. Antenatally, women also proposed a visual decision-making tool as a simple visual way of providing information to assist them in decision-making for labour and birth, ‘For me personally, I would imagine things like information sheets coupled with a decision-making tool could be useful’ (005AN). The usefulness of further information tools such as apps, websites and books was also considered, and many women discussed the helpfulness of online forums discussing other women’s birthing experiences to aid decision-making.

Both antenatally and postnatally, there was also emphasis on the significance of tailoring and personalising the presentation of information depending on the preference of the individual, ‘I think pain relief should be something on a handout, because that’s choice’ (011AN) and ‘I think for some women that’s quite a major surgery (caesarean section) and so I think it’s about tailoring the advice I guess to what people are expecting’ (009PN). Hence, it was discussed that information should be presented considering both the importance of the decision medically and the relevance of the decision to the individual, ‘I suppose it all depends on how big the decision is, and what the decision is about’ (013AN).

Subtheme 3.3: what—information required

It was apparent that women who felt that they had adequate information, whether from a HCP or other information source, still lacked knowledge in some key areas surrounding labour and birth. Women were often knowledgeable about specific singular interventions, yet discussed other specific antenatal information that they felt they required to assist them with decision-making. Women wanted more information about induction of labour, instrumental birth, pain relief, pelvic examination, foetal monitoring, anti-sickness injections and the immediate postnatal experience. During antenatal interviews, women also reported that they wanted additional information about caesarean section, ‘Because I feel like opting for a C-section, if I can manage a vaginal delivery is a big con, just because I feel like the recovery will be harder, and I do wonder whether I have no evidence on this (…)’ (001AN) and ‘I certainly had more information about a stretch and sweep than I did about a caesarean’ (002 PN). Four women had an emergency caesarean birth but had received no information about what to expect. Some women felt that they required every available detail of information to assist them with decision-making, for example, details of the pros and cons of specific options, ‘they probably haven’t really done much of the pros and cons on C-sections or vaginal delivery with me’ (001AN). One participant felt that information concerning the pros and cons of every option may not facilitate decision-making for some individuals, ‘Only talking about risks without talking about benefits makes me feel threatened (…) that’s harder then to make decisions’ (012AN). Therefore, there was concern that providing extensive information could complicate decision-making; hence, some women suggested the need to tailor information to the individual, ‘It can almost give too much information, and so it’s better to have face-to-face discussion so that the responses that you want can be obviously more tailored to the questions that you’re asking’ (009PN).