Choice in maternity: rhetoric, reality and resistance.

OBJECTIVE: to inform the organisation of the maternity services in Scotland, a phenomenological study was planned to examine maternity decision making in two similarly small countries. The aim was to examine the experience of contributing to decisions at clinical, organisational and policy-making levels. When examples were needed the informants were asked to use their experience of place of birth decisions.

DESIGN: a hermeneutic phenomenological approach was employed. In-depth, semi-structured conversations were used. The fieldwork extended over a 4-month period in 2005. The data were analysed using Colaizzi's method.

SETTING: Finland and New Zealand were chosen because the parallels in their health care and maternity care systems would limit disparities. In one of the Finnish centres, the findings were particularly homogeneous and exemplified many of the issues arising in other settings. The findings of the fieldwork in this Finnish centre are the focus of this paper.

PARTICIPANTS: the informants were mothers, midwife managers/policy makers, midwives and other maternity care providers. The findings of 12 conversations, including mothers and all groups of staff, are reported here.

FINDINGS: the background theme which emerged was 'trusting the system'. The informants were aware of the extent to which change is happening. One of the sub-themes contrasted the informants' perceptions of their lack of strength and courage with Finnish stereotypes. Being safe proved to be another crucial issue. The final sub-theme was 'playing the system'.

KEY CONCLUSIONS: trust in a well-respected health-care system was necessary for the informants to be able to subvert or resist that system. While such resistance has been documented in other disciplines, such as nursing, reference has not been found in relation to maternity. The resistance to the system was, at the time of the fieldwork, neither co-ordinated nor collaborative.

IMPLICATIONS FOR PRACTICE: the findings of this study carry important implications for women's and midwives' input into maternity care.