Between "a lot of room for it" and "it doesn't exist"-Advancing and limiting factors of autonomy in birth as perceived by perinatal care practitioners: An interview study in Switzerland.

BACKGROUND: Numerous studies show that negative birth experiences are often related to birthing people's loss of autonomy. We argue that a fetal-focused decision-making framework and a maternal-fetal conflict lens are often applied, creating a false dichotomy between autonomy and fetal beneficence. Given the high prevalence of autonomy-depriving decision-making, it is important to understand how autonomy can be enhanced. METHODS: We interviewed 15 Swiss perinatal care practitioners (eight midwives, five physicians, and two doulas) and employed reflexive thematic analysis. We offer a reflection on underlying assumptions and researcher positionality. RESULTS: We generated two descriptive themes: advancing and limiting factors of autonomy. Numerous subthemes, grouped at the levels of companion, birthing person, practitioners, birthing person-practitioner relationship, and structural determinants are also defined. The most salient advancing factors were practitioners' approaches to decision-making, antenatal contacts, and structural determinants. The most salient limiting factors were various barriers within birthing people (e.g., expertise, decisional capacity, and awareness of own rights), practitioners' attitudes and behavior, and structural determinants. DISCUSSION: The actualization of autonomy is multifactorially determined and must be understood against the background of power structures both underlying and inherent to decision-making in birth. Practitioners attributed a significant proportion of limited autonomy to birthing people themselves. This reinforces a "mother-blame" narrative that absolves obstetrics of primary responsibility. Practitioners' recognition of their contributions to upholding limits on autonomy should be leveraged to implement training towards rights-based practice standards. Most importantly, autonomy can only fully materialize if the underlying sociocultural, political, and medical contexts undergo a fundamental change.

A true choice of place of birth? Swiss women's access to birth hospitals and birth centers.

While the place of birth plays a crucial role for women's birth experiences, the interest in out-of-hospital births has increased during the Covid-19 pandemic. Related to this, various international policies recommend enabling women to choose where to give birth. We aimed to analyze Swiss women's choice between birth hospitals and birth centers. Employing spatial accessibility analysis, we incorporated four data types: highly disaggregated population data, administrative data, street network data, addresses of birth hospitals and birth centers. 99.8% of Swiss women of childbearing age were included in the analysis (N = 1.896.669). We modelled car travel times from a woman's residence to the nearest birth hospital and birth center. If both birth settings were available within 30 minutes, a woman was considered to have a true choice. Only 58.2% of women had a true choice. This proportion varied considerably across Swiss federal states. The main barrier to a true choice was limited accessibility of birth centers. Median travel time to birth hospitals was 9.8 (M = 12.5), to birth centers 23.9 minutes (M = 28.5). Swiss women are insufficiently empowered to exercise their reproductive autonomy as their choice of place of birth is significantly limited by geographical constraints. It is an ethical and medical imperative to provide women with a true choice. We provide high-resolution insights into the accessibility of birth settings and strong arguments to (re-)examine the need for further birth centers (and birth hospitals) in specific geographical areas. Policy-makers are obligated to improve the accessibility of birth centers to advance women's autonomy and enhance maternal health outcomes after childbirth. The Covid-19 pandemic offers an opportunity to shift policy.