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Evidence based patient information leaflets in maternity care had limited visibility and did not promote informed choice of childbearing women
  1. Linda O’Mara, RN, PhD
  1. Assistant Professor, School of Nursing
    McMaster University
    Hamilton, Ontario, Canada

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QUESTION: From the perspectives of childbearing women and health professionals who provide maternity care, do 10 pairs of research based leaflets on informed choice in maternity services (Informed Choice leaflets) influence choice and decision making?


Grounded theory study done in conjunction with a randomised controlled trial.


Women’s homes and antenatal and ultrasound clinics in 13 maternity units in England and Wales, UK.


Childbearing women using maternity services and health professionals who provide maternity care.


10 pairs of research based Informed Choice leaflets were provided for service users and staff in the control sites. Non-participant observation of 886 antenatal consultations (of 886 childbearing women, 653 midwives, 167 obstetricians, and 66 obstetric ultrasonographers) and 383 indepth interviews (with 163 childbearing women, 177 midwives, 28 obstetricians, 12 obstetric ultrasonographers, and 3 obstetric anaesthetists) were done by women midwifery researchers. These face to face, semistructured interviews focused on the availability and quality of information in the Informed Choice leaflets, the meaning of informed choice, and the role of pregnant women in decision making. Convenience sampling was used, but became purposive as the research progressed. Detailed field notes were kept, and data were collected until theoretical saturation was achieved.

Main findings

Most health professionals were positive about the leaflets and their potential for influencing the decisions of childbearing women. However, within practice settings, the leaflets were often “invisible” and were concealed among other literature related to pregnancy, and this limited their use. The time constraints on health professionals limited discussion of the contents of the leaflets with women. The availability of technological interventions influenced the attitudes of some health professionals, and fear of litigation promoted notions of “right” and “wrong” choice rather than “informed” choice. Obstetricians were placed higher in the hierarchy of maternity service providers, and consequently they defined the norms of clinical practice and influenced the choices available to pregnant women, midwives and other healthcare professionals. Women’s trust in health professionals often led to their agreeing with choices that were professionally, rather than jointly, defined.


Evidence based leaflets promoting informed choice in maternity care had limited visibility and did not promote informed choice in childbearing women. The environment into which the leaflets were introduced supported existing normative patterns of care. Because pregnant women trusted the professionals involved in their care, they usually complied with professionally defined choices instead of making informed choices.


The study by Stapleton et al adds to our understanding of the processes involved when promoting informed choice and decision making in maternity care. Researchers used observations and interviews with both patients and healthcare professionals, thereby examining what professionals said they did as well as what they actually did. This study is an exemplar for showing how qualitative findings can add depth and descriptive power to our understanding of health care.

The authors attribute the lack of impact of the information leaflets to several factors. Time constraints left little time for discussion with patients. This lack of discussion may be critical. Jones et al examined the uptake of antenatal HIV testing.1 They found that pretest discussions lasting >5 minutes doubled the uptake of HIV testing. In the study by Stapleton et al, power imbalances between physicians, midwives, and patients created professionally driven decisions, rather than informed choices. Little evidence existed that concepts of partnership and shared decision making were understood by staff. However, feelings of trust between patients and professionals led to increased ease when asking questions. These findings are supported by Falk-Rafael, who found that a nurturing patient-provider relationship enhanced partnerships in healthcare decisions by providing information and helping patients develop skills.2

The study by Stapleton et al shows how using evidence based decision aids in practice is not straightforward. The relative lack of visibility of leaflets and promotion of normative patterns of care show how “top down” services will not work unless all personnel are involved in the implementation process. Healthcare professionals with a genuine desire to increase patients’ informed choice need to develop coherent strategies to address power imbalances and ambiguities currently underpinning choices.


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  • For correspondence: Ms H Stapleton, Women’s Informed Childbearing and Health Research Group, School of Nursing and Midwifery, University of Sheffield, Sheffield, UK. h.stapleton{at}

  • Source of funding: Department of Health.

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