Towards a relational model of decision-making in midwifery care

Objective: current individualistic ideas of autonomy and decision making do not fit within the context of decision-making in the midwife-woman relationship. This article critically explores current issues around decision-making and proposes a relational decision-making model for midwifery care. Design: qualitative prenatal and postnatal interviews around decision-making within childbirth in general, and the third stage of labour in particular. Participants: eight midwife-woman pairs in urban settings in New Zealand. Findings: a range of relational, social and political factors that are not present within existing decision-making models were highlighted. The themes included ontological and philosophical influences on decision-making; uncertainty, vulnerability and relational trust; and socio-political and cultural influences. Inconsistencies in knowledge arising from social, cultural and familial considerations as well as identities, beliefs, values, conversations, and practices were found to produce uncertainties around potential courses of action, expected consequences and outcomes. Unplanned' birth experiences decreased client autonomy and increased vulnerability thereby intensifying relational trust within decision-making. The political context may also open up or close down possibilities for decision-making at both national and local levels. Conclusion: decision-making for women and midwives is influenced by complex human, contextual and political factors. This study supports a relational model of decision-making that is embedded in understandings of choice as 'entangled'. A relational model enables consideration of how factors such as identity projects, individual practices, the organisation of maternity care, local hospital cultures, medicalised childbirth, workforce shortages, funding cuts and poverty shape the way in which care decisions are made. (C) 2012 Elsevier Ltd. All rights reserved.