"In an ideal world": A qualitative exploration of shared decision-making and weight stigma in antenatal care.

BACKGROUND: Shared decision-making supports women's autonomy in antenatal care, but several barriers to shared decision-making have been identified in practice. Women with high body mass index experience a higher rate of interventions, which could provide more opportunities for shared decision-making in antenatal care. However, weight stigma may exist as a barrier to shared decision-making, limiting access to collaborative care. AIM: To explore how shared decision-making is implemented and whether body mass index influences maternity clinicians' use of shared decision-making when providing antenatal care for women. METHODS: Maternity clinicians were recruited via purposive sampling from two sites in metropolitan Melbourne, Australia. Semi-structured interviews were audio recorded, transcribed, and analysed using reflexive thematic analysis. FINDINGS: Twelve maternity clinicians consented to participate. Three themes and ten sub-themes were identified. The themes were: 1) Whose choice is it anyway? 2) Pregnancy as risky 3) Excess weight as a diseased state. DISCUSSION: Maternity clinicians in this study view pregnancy through a risk management lens that complicates women's involvement in decision-making, demonstrating inherent beliefs that may further limit options for women with high body mass index. CONCLUSION: Shared decision-making is difficult to implement in the current antenatal clinic setting and requires significant structural consideration to become a reality for women. Clinicians may inadvertently limit meaningful opportunities to engage in shared decision-making with women with high body mass index due to preconceived perceptions of risk and stigmatising beliefs about women with high body mass index.

"Ask for my ideas first": Experiences of antenatal care and shared decision-making for women with high body mass index.

BACKGROUND: Shared decision-making supports women's choices in pregnancy. Women with high body mass index (≥35 kg/m2) experience a high rate of interventions in pregnancy, labour, and birth, providing an opportunity for clinicians to implement shared decision-making in practice. However, weight stigma may limit women's opportunities for shared decision-making. AIM: To understand how pregnant women with high body mass index perceive their involvement in antenatal decision-making, including whether weight stigma influences their experience. METHODS: Women with high body mass index were recruited via purposive sampling from two sites in Melbourne, Australia. Semi-structured interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis. FINDINGS: Ten pregnant women consented to participate. Three themes and six sub-themes were identified. These were: 1) Trusting the system, 2) Who takes the lead?, and 3) Defying disease. DISCUSSION: Shared decision-making is limited for women with high body mass index in antenatal care, and weight stigma is experienced by women. Clinical practice recommendations relating to excess weight have the potential to further limit women's involvement in decision-making if adequate support is not provided to ensure women's understanding and involvement in care. CONCLUSION: Women's involvement in care is a central component of shared decision-making and it is currently limited for women with high body mass index. Transparency regarding the rationale for recommendations is required, and further work must be done to address the influence and impact of weight stigma on the care of women with high body mass index.

Maternity clinician use of shared decision-making in antenatal care: A scoping review.

BACKGROUND: Implementation of shared decision-making in antenatal care has had limited exploration. OBJECTIVE: To assess what is known about shared decision-making in antenatal care. SEARCH STRATEGY: Five databases were searched (1997-2022) limited to English language studies from OECD countries. DATA COLLECTION AND ANALYSIS: A data collection table was constructed with findings from 32 papers. A narrative synthesis was conducted with subsequent thematic analysis of included papers. MAIN RESULTS: Four areas of decision-making were identified with six themes revealing enablers and barriers to shared decision-making in antenatal care. CONCLUSION: Implementation of shared decision-making requires continuity, time and personalisation of care.

Subversive acts and everyday midwifery: Feminism in content and context.

BACKGROUND: Midwives are often at the forefront of political campaigns for women's empowerment, overtly advocating for women's rights and reproductive justice. However, midwives can also be found engaging in inadvertent activism on a daily basis within routine care. When casting a feminist lens over both the content and context of midwifery practice in Australia, subversive acts and opportunities for feminist reform can be found. AIM: To interrogate the significance of feminism in midwifery practice, identifying feminist successes and further opportunities for implementation including: analysis of the Midwifery Standards for Practice; the primary tenets of woman-centred care; the content versus context of midwifery in Australia; and feminist opportunities for enhanced practice. This paper will discuss the importance of feminism in midwifery practice and its significance in informing optimal midwifery care. DISCUSSION: Incorporating women's voice and respecting women's bodies and agency in the delivery of care is a fundamental component of midwifery practice. However, while the content of midwifery practice is innately feminist in its emphasis on woman-centred care, it will be argued that the context of birthing in Australia is not. The resultant effect is the emergence of victim blaming in maternity care and the construction of an archetypal 'good birthing woman'. IMPLICATIONS AND RECOMMENDATIONS: Moving away from the myth of the 'good birthing woman' and the act of victim blaming, midwifery could instead direct its focus towards challenging the rigid systems and structures within which midwives implement care. By further embracing feminist principles midwives will ensure a truly woman-centred future.