Rost Michael, Stuerner Zelda, Niles Paulomi, Arnold Louisa
Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.
Rory Meyers College of Nursing, New York University, New York, USA.
Birth. 2023 Dec;50(4):1068-1080. doi: 10.1111/birt.12757. Epub 2023 Aug 18.
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.
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.
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.
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.
大量研究表明，负面的分娩经历往往与分娩者自主权的丧失有关。我们认为，以胎儿为中心的决策框架和母婴冲突视角经常被应用，在自主权和胎儿利益之间制造了一种错误的二分法。鉴于剥夺自主权的决策普遍存在，了解如何增强自主权很重要。
我们采访了15名瑞士围产期护理从业者（8名助产士、5名医生和2名分娩陪伴者），并采用了反思性主题分析。我们对潜在假设和研究者立场进行了反思。
我们生成了两个描述性主题：自主权的促进因素和限制因素。还定义了许多子主题，这些子主题按陪伴者、分娩者、从业者、分娩者与从业者关系以及结构决定因素等层面进行了分组。最显著的促进因素是从业者的决策方式、产前接触和结构决定因素。最显著的限制因素是分娩者自身存在的各种障碍（如专业知识、决策能力和对自身权利的认知）、从业者的态度和行为以及结构决定因素。
自主权的实现是由多因素决定的，必须在分娩决策中潜在的和固有的权力结构背景下加以理解。从业者将很大一部分自主权受限归因于分娩者自身。这强化了一种“责怪母亲”的叙事，免除了产科的主要责任。应利用从业者对其在维护自主权限制方面所做贡献的认识，开展基于权利的实践标准培训。最重要的是，只有在潜在的社会文化、政治和医疗背景发生根本性变化的情况下，自主权才能完全实现。
