López-Toribio et al.

BMC Pregnancy and Childbirth (2021) 21:631

https://doi.org/10.1186/s12884-021-04070-3

RESEARCH Open Access

Exploring women’s experiences of

participation in shared decision-making
during childbirth: a qualitative study at a
reference hospital in Spain
María López-Toribio1,2, Paulina Bravo3,4* and Anna Llupià1,2,5

Abstract
Background: Women’s engagement in healthcare decision-making during childbirth has been increasingly
emphasised as a priority in maternity care, since it increases satisfaction with the childbirth experience and provides
health benefits for women and newborns. The birth plan was developed as a tool to facilitate communication
between health professionals and women in Spain, but their value in routine practice has been questioned. Besides,
little is known about women’s experiences of participation in decision-making in the Spanish context. Thus, this
study aimed to explore women’s experiences of participation in shared decision-making during hospital childbirth.
Methods: An exploratory qualitative study using focus groups was carried out in one maternity unit of a large
reference hospital in Barcelona, Spain. Participants were first-time mothers aged 18 years or older who had had a
live birth at the same hospital in the previous 12 months. Data collected were transcribed verbatim and analysed
using a six-phase inductive thematic analysis process.
Results: Twenty-three women participated in three focus groups. Three major themes emerged from the data:
“Women’s low participation in shared decision-making”, “Lack of information provision for shared decision-making”,
and “Suggestions to improve women’s participation in shared decision-making”. The women who were willing to
take an active role in decision-making encountered barriers to achieving this and some women did not feel
prepared to do so. The birth plan was experienced as a deficient method to promote women’s participation, as
health professionals did not use them. Participants described the information given as insufficient and not offered
at a timely or useful point where it could aid their decision-making. Potential improvements identified that could
promote women’s participation were having a mutually respectful relationship with their providers, the support of
partners and other members of the family and receiving continuity of a coordinated and personalised perinatal
care.

* Correspondence: pbbravo@uc.cl
3
School of Nursing, Pontificia Universidad Católica de Chile, Santiago, Chile
4
Centro Núcleo Milenio Autoridad y Asimetrías de Poder / Millennium
Nucleus Center Authority and Power Asymmetries Santiago, Chile
Full list of author information is available at the end of the article

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López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 2 of 12

Conclusion: Enhancing women’s involvement in shared decision-making requires the acquisition of skills by health
professionals and women. The development and implementation of interventions that encompass a training
programme for health professionals and women, accompanied by an effective tool to promote women’s
participation in shared decision-making during childbirth, is highly recommended.
Keywords: Shared decision-making, Patient participation, Birth plan, During childbirth, Delivery rooms, Parturition

Background hospitals stated that the plans were out-of-date and that
Shared decision-making (SDM) has been identified as some could perpetuate unrecommended practices, such
the ideal approach to promote patients’ involvement in as optional enemas or perineal shaving, rather than giv-
health decisions [1, 2]. SDM is a process in which clini- ing voice to women’s preferences and needs [20]. As an
cians and patients consider available information about alternative, some authors have advocated for a ‘birth
the medical problem and work together to make a deci- partnership’ between care providers and women that
sion taking into account the patient’s preferences and goes beyond the checklist of limited choices presented
values [3]. SDM has proven to increase satisfaction and on birth plans [13, 21]. According to this shift towards a
reduce decisional conflict, as well as to improve health ‘birth partnership’, the creation of a trustworthy and
outcomes [4, 5]. Particularly in maternity care, SDM has supporting relationship through effective communica-
been associated with higher satisfaction of childbirth ex- tion between women and care providers is the corner-
perience among women and increased involvement in stone that ensures respect for women’s values and
decision-making [6–8]. Additionally, the health benefits preferences and promotes their participation in SDM
of women’s participation in decision-making during during childbirth. This approach is also desirable in
childbirth have been associated with reductions in peri- high-risk pregnancies, where safety concerns could be
natal depressive symptoms, preterm birth, and low birth- associated with more uncertainty and anxiety among
weight rates [9]. In the context of a growing number of pregnant women [22].
facility-based childbirths, where over-medicalisation and In Catalonia, at the time of the study, women with
inappropriate use of interventions may occur [10], low- and medium-risk pregnancies receive antenatal care
women’s engagement in SDM has been increasingly by midwives at community health centres. In the third
emphasised as a priority in maternity care [11]. trimester of pregnancy, all women have an appointment
Birth plans were developed as a tool to facilitate com- with a hospital midwife at the hospital where they will
munication and promote women’s participation in give birth. On the other hand, women with high- or very
decision-making during childbirth [12]. However, their high-risk pregnancies receive antenatal care at hospitals,
value has been widely questioned, since birth plans can mainly by obstetricians. During antenatal care, women
irritate professionals and create unmet expectations in are more frequently attended by the same midwife or
women if the plan is not accomplished. Indeed, a birth obstetrician, which facilitates continuity of care. How-
plan could serve to hinder communication rather than ever, constant shifts of personnel at the hospital delivery
promote it among care providers and women [13–16]. room hinder continuity of care during the attendance of
Moreover, it has been reported that women who used a childbirth and immediate postpartum.
birth plan were less satisfied and felt less in control dur- Although some studies have evaluated women’s expe-
ing childbirth in comparison with women without a riences of choice during childbirth [23], most of them
birth plan [17]. The Spanish Ministry of Health officially have focused on the election of the place of birth [24].
introduced the birth plan as a recommendation in 2008 In addition, to the best of our knowledge, there have
[18] and a birth plan sample template was published in been no studies in Spain which have comprehensively
2012 [19]. It has the format of a checklist where women explored women’s experiences of participation in SDM
can select their preferences regarding support, physical throughout the continuum that comprises prepartum,
space, and medical interventions during childbirth and birth, and immediate postpartum [25]. This study aimed
immediate postpartum. Additionally, each hospital can to explore women’s experiences of participation in
offer their own birth plan template with its own adapted shared decision-making during hospital childbirth.
options. Frequently, birth plans are offered to women
during antenatal care and women should hand it in at Methods
the Hospital when they are admitted for childbirth, as An exploratory qualitative study using focus groups was
the birth plan is a paper-based document, and it is not carried out in one maternity unit of a large reference
currently digitalised in the National Health System. A hospital in Barcelona, Spain. Ethical approval was
review of the birth plans offered by Catalonian public granted by the Clinical Research Ethics Committee of
López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 3 of 12

the Hospital Clinic of Barcelona (Reference number: Participants who expressed an interest in the research
HCB/2017/1069). This study complied with the basic received a participant information sheet and a consent
ethical principles contained in the 2013 Helsinki Declar- form to take home and read before deciding if they
ation [26]. wished to participate. Later, all participants were con-
tacted by telephone and invited to take part in scheduled
Aim and research questions focus groups. Participation was voluntary and no finan-
This study aimed to explore women’s experiences of cial incentive was offered. All women signed and
participation in SDM during hospital childbirth. Specif- returned an informed consent form prior to their par-
ically, two research questions were stated: 1) What were ticipation in a focus group and had the opportunity to
the barriers and facilitators to women’s involvement in ask the researchers any questions they had.
SDM during hospital childbirth? 2) What were the op-
portunities for improvement regarding participation in Data collection
SDM? This study was conducted and reported according Focus groups were considered the most appropriate
to the guidelines of the Consolidated Criteria for Report- qualitative technique due to the exploratory nature of
ing Qualitative Research (COREQ) [27]. the research question, as well as the richness of dis-
course elicited on account of the synergistic effects that
Study site and population result from interactions among participants [32].
In Catalonia, the average number of children per woman From September to December 2018, three focus
was 1.27 and the average maternal age reached 31.2 groups were conducted by two female researchers (ML,
years for the year 2019 [28]. In the same year, 99.4% of as moderator and AL, as observer). To facilitate partici-
childbirths were attended at care facilities, principally pant attendance, these varied in terms of time and loca-
hospitals, as home birth is not offered by the Spanish tion; two groups were conducted at the HCB, and
National Health System [29]. The Hospital Clínic of Bar- another at a community health centre. Women were in-
celona (HCB) provides the highest level of complexity of vited to attend focus groups with their babies if they
care at the obstetric unit and attends more than 3000 wished to. The languages used were Spanish and Cata-
births per year, almost 70% of which are considered high lan. Participants’ sociodemographic characteristics and
or very high-risk. The risk classification used at the HCB type of childbirth were obtained from hospital records,
is based on the recommendations made by the Depart- as approved by the Clinical Research Ethics Committee.
ment of Health of Catalonia in its pregnancy care guide- There was no relationship between the women and the
line, published in 2018 [30]. This guideline defines four researchers prior to the focus groups. To minimise the
levels of risk during pregnancy: low-risk, medium-risk, possible influence of researchers’ preconceptions on the
high-risk and very high-risk. At HCB, childbirths are development of the focus groups and the analysis, a
generally attended by midwives except when complica- semi-structured topic guide was used and the three re-
tions occur or women have been diagnosed with high- searchers made an exercise of bracketing as recom-
or very high-risk pregnancies, in those cases obstetri- mended by Tufford and Newman along the research
cians attend the childbirth with the support of midwives. process [33]. The topic guide (Table 1) was designed
based on the literature review findings, previous experi-
Participant recruitment ence of researchers in the field and suitability to the re-
Inclusion criteria were first-time mothers aged 18 years or search question. The methodology described by Krueger
older who had given birth at HCB in the previous 12 and Cassey was followed to elaborate it [34].
months. Only first-time mothers were included because Focus groups were audio-recorded and transcribed
previous experiences of childbirth could improve their in- verbatim by one researcher (ML). Transcripts were
volvement in SDM and their sense of control [31]. Exclu- anonymised to guarantee confidentiality and texts were
sion criteria were the mother having given the newborn verified three times against the audio, by two researchers
up for adoption, having had a pregnancy which resulted in independently, to assure accuracy of transcription. Dur-
a stillbirth, or feeling uncomfortable/not emotionally pre- ing focus groups, the observer made notes that were in-
pared to share their birth experience in focus groups. The cluded in the analysis. After the third focus group, the
sample was built using convenience sampling, and some research team considered that data saturation had been
women were enrolled through snowball sampling. reached, as no new information was identified [35].
Women were recruited in-person at the obstetric unit
of HCB and at postpartum groups of two community Data analysis
health centres in the hospital area. Information regard- The data were analysed following the six-phase inductive
ing the research question and the aim of the study was thematic analysis process described by Braun and Clarke
provided face-to-face by one researcher (ML). [36], as follows: 1) becoming familiar with the data by
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Table 1 Semi-structured topic guide used in focus groups

Topic Questions
Experience of birth care 1. What did you think was useful and not useful during the antenatal classes for yourself and for your
partner?
2. What skills do you think a woman and her partner should learn for childbirth and immediate
postpartum?
3. How did you feel during childbirth? How do you think your partner felt? What role do you think
healthcare professionals had in making you feel this way?
4. What do you think about birth plans? Did you use one?
Quality of information and treatment 5. What is your opinion about the information that healthcare professionals gave you during childbirth?
received
6. How would you describe the treatment that you received from healthcare professionals in childbirth?
Opportunities for improvement 7. What do you consider that healthcare professionals should know about you to provide you the best
regarding participation quality of care during childbirth?
8. What skills do you believe that a healthcare professional should have to provide you the best quality
of care during childbirth?
9. If you think of your childbirth and the decisions you made, how do you think this participation could
be improved?
10. What do you think that healthcare professionals should do to promote women’s participation in
decision-making during childbirth?

reading and re-reading the entire dataset and taking 7, and 10 participants, respectively); each one lasted be-
notes of initial ideas; 2) generating initial codes and col- tween 90 and 120 min. Sociodemographic characteristics
lating the data relevant to each code, carried out by two of participants and the type of childbirth they experi-
researchers independently; 3) compiling the codes into enced are described in Table 2. The majority of women
potential themes, carried out by the same two re- were in the age range of 30 to 40 years old, had been
searchers independently, and then discussing them until born in Spain and had completed university studies.
consensus was reached; 4) reviewing the themes in rela- Older and higher educated women were over-
tion to the coded extracts and the entire dataset to en- represented in comparison with the average for Catalo-
sure they were consistent with the data; 5) refining and nia. Almost 60% of the sample (n = 13) had a high-risk
naming themes using words and phrases; 6) selection of or a very high-risk pregnancy, 11 of them had an induc-
data extracts to illustrate the themes and relating the tion of labour. Given that nearly 70% of the births
analysis back to the research question and the literature. attended at the HCB are of women diagnosed with high-
A third researcher validated and supervised each of the or very high-risk pregnancies, this sample could be con-
steps and the final structure of themes. Throughout the sidered representative of the population attended at the
thematic analysis, a process of triangulation was per- HCB in this respect, but not representative of the whole
formed by the three authors to ensure consistency in population. In total, 60% of participants (n = 14) had on-
analysis and findings. The first two phases of the analysis set of labour by induction and all but one woman used
were supported by Atlas.ti v7 software. epidural anaesthesia.
After analysis, in-person member checking was de- After the analysis, three themes and six sub-themes
signed based on the Synthesized Member Checking emerged from the data (Table 3). The themes are set
methodology [37]. All participants were invited to a forth below with illustrative data using the participants’
face-to-face session at the HCB where two of the re- own words. All quotations are suffixed by the participant
searchers (ML and AL) presented the findings of the number assigned to each woman, her age, the risk of her
study. Then, ML moderated a discussion with the fol- pregnancy, the kind of onset of labour and the type of
lowing questions: 1) Are you surprised by anything that birth.
we have presented? 2) Does it correspond to your ex-
perience? 3) Is there something that you miss or that Women’s low participation in shared decision making
you would add? 4) Have we presented something that Women’s expectations for and obstacles to participation in
you do not agree with? Six women attended and their shared decision making
comments were collected and added to the final analysis. Some women expressed that they did not make any de-
cisions during their childbirth, and women who were
Results willing to take an active role in decision-making encoun-
From September to December 2018, a total of 23 first- tered obstacles to achieving this. These women felt that
time mothers participated in three focus groups (with 6, they needed to be well prepared and active to be able to
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Table 2 Sociodemographic characteristics and type of participate and described the experienced as a ‘fight’ to
childbirth of focus group participants (n = 23) be involved in decision-making.
Women (n = 23)
n % “I feel that I didn’t decide anything. They [health
Age in years (x ¼ 35.45 (σ= 6.23)) professionals] decided.” (W5, 42 years, medium-risk
20–29 2 9
pregnancy, spontaneous onset, caesarean section)
30–40 17 74
“I feel that if I hadn’t prepared myself so much, I
41–46 4 17 would have had a much worse birth, because they
Origin wouldn’t have let me make decisions that I believe I
Catalonia and rest of Spain 18 78 decided because I fought.” (W17, 30 years, high-risk
Rest of Europe 1 4 pregnancy, spontaneous onset, vaginal birth)
Latin America 4 18
“I had the feeling of fighting from the beginning [ … ]
Highest educational level achieved
with decisions that were being made where there
Secondary school 4 17 was no other choice, but I couldn’t put more energy
University degree 19 83 into imposing my will, you know, I wore myself out
Pregnancy risk in that.” (W2, 35 years, low-risk pregnancy, spon-
Low 5 22 taneous onset, vaginal birth)
Medium 5 22
Other women expressed a high confidence in profes-
High 9 39
sionals and accepted a passive role in decision-making.
Very high 4 17 Some of the women who took a passive role described
Gestational age in weeks (x ¼ 39.89 (σ= 1.27)) themselves as “insufficiently prepared to make certain
Preterm (< 38) 4 17 decisions”, as opposed to professionals, who were de-
Term (> = 38) 19 83 scribed as the appropriate individuals to make them.
Type of birth
Some women with high-risk pregnancies felt that they
had less space to participate in SDM and they were more
Vaginal 18 78
steered to follow hospital protocols.
Instrumental 2 9
Caesarean section 3 13 “I came here [hospital] and I let myself go … ‘Do
Onset of labour whatever you have to do, because you are profes-
Spontaneous 9 39 sionals, I trust in you’”. (W10, 31 years, low-risk
Induced 14 61
pregnancy, spontaneous onset, vaginal birth)
Use of epidural anaesthesia 22 96
“Like when you go to an architect and the architect
designs your home, you don’t question every step. [ …
] I said: ‘I trust my gynaecologist, for she has studied,
and she knows’”. (W7, 41 years, medium-risk preg-
nancy, onset by induction, vaginal birth)

Table 3 Themes and subthemes that emerged from the data

Theme Sub-themes
Women’s low participation in shared decision-making Women’s expectations for and obstacles to participation in shared decision-
making
Lack of clinician engagement with the birth plan
Lack of information provision for shared decision-making Insufficient content
Inappropriate timing
Suggestions to improve women’s participation in shared decision- Establishment of mutually respectful relationships between clinicians and
making women
Continuity of coordinated, personalised perinatal care
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“I would rather have had a natural birth, but I “They asked me ‘Natural birth? OK!’ And they left
didn’t have the chance to choose, I didn’t choose the the birth plan there. ‘Well, but within natural birth
caesarean, nor the induction … According to the you can choose options.’ They didn’t look at it.”
protocol, I had to undergo induction [ … ] I thought, (W17, 30 years, high-risk pregnancy, spontaneous
‘With my age, with diabetes, I am not going to argue onset, vaginal birth)
anything’ [ … ] If there is a possibility to choose, they
should demonstrate it to you, because if not, you feel “I understand that the birth plan is a tool so that at
totally steered towards it.” (W9, 40 years, high-risk home you can think about it and have in mind what
pregnancy, onset by induction, caesarean) you want, and you can work on it with your part-
ner.” (W18, 35 years, high-risk pregnancy, spontan-
Lack of clinician engagement with the birth plan eous onset, vaginal birth)
During focus groups, 16 women actively referred to
their experience using the birth plan. They had com- Lack of information provision for shared decision-making
pleted birth plans with their partners and brought Insufficient content
them to the hospital on the day of delivery. However, Most women described the information offered by
in almost all of the cases, health professionals did not health professionals at prenatal care, antenatal classes,
ask them for their plan, and neither did they read it and during birth, as insufficient to participate in the
when the women or their partners offered it. More- decision-making process. This lack of information was
over, in high-risk pregnancies, their use was directly particularly notable regarding induction, in terms of the
rejected by professionals. risks, duration, pain, and side effects; thus, women felt
the need to search the internet or seek advice from other
“I handed the birth plan from the week … I don’t professionals or relatives.
know, very, very early. I was concerned, I studied it, I
discussed it with my partner … It doesn’t matter, be- “I thought: ‘I feel so insecure about what is going to
cause it remained in the folder, just like it went into happen because I don’t have any information, so I
the hospital, it came out.” (W2, 35 years, low-risk have to search on Google.’ [ … ] I asked: ‘What is go-
pregnancy, spontaneous onset, vaginal birth) ing to happen? Why … ? Which risks do I have … ? I
asked every doctor I came across.” (W8, 41 years,
“The birth plan is useless. Nobody read it, there were very high-risk pregnancy, onset by induction, vagi-
three shift changes, people who were there didn’t nal birth)
even know my name and by no means knew my
birth plan.” (W5, 42 years, medium-risk pregnancy, In addition to individual appointments, many women
spontaneous onset, caesarean) obtained information from antenatal classes. Public
community health centres and hospitals offer prenatal
“I underwent an induction, and it was like at the be- group classes led by midwives to every pregnant woman,
ginning, I couldn’t say anything [ … ] I had my birth regardless of pregnancy risk. Those classes were de-
plan, I wanted to do those things … nothing. They scribed as useful but sparse in content with regard to in-
considered it was a birth with risk because of the duction, breastfeeding, and postpartum; especially
weight of my baby.” (W15, 30 years, very high-risk regarding inductions, women found a high disparity be-
pregnancy, onset by induction, vaginal birth) tween expectations of birth created at these classes and
their real experiences.
Sometimes, health professionals asked questions to
women during childbirth instead of using the birth plan. “I feel induction is like another kind of birth and
This was described by some participants as adequate, as they only prepare you for a natural birth. So, I
they thought that health professionals covered with their would have made more decisions, or I would have
questions all the information needed for attending their been more conscious of decisions to make, had I been
childbirth. But other participants described that as insuf- better informed by professionals.” (W19, 39 years,
ficient due to professionals limiting these questions to high-risk pregnancy, onset by induction, vaginal
asking if they wanted a “natural birth” or an “epidural”. birth)
Some participants justified this use of the birth plan, de-
scribing it as a document enabling women to be in- Some women felt neglected and uninformed when a
formed in advance about the different options offered by complication arose during childbirth or there was a sep-
the hospital, rather than to be used during childbirth or aration from the newborn. In some cases, professionals
enhancing their participation. talked with each other without addressing the woman.
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“My childbirth [ … ] was complicated at the end but the use of birth plans to high-risk pregnancies or creat-
they didn’t explain to me why. I heard them saying ing a caesarean section plan, and increase their skills of
that they were not going to give me the baby, but good treatment, communication, and training to support
they didn’t explain anything to me. [ … ] A total lack women’s participation in shared decision-making.
of information.” (W19, 39 years, high-risk pregnancy,
onset by induction, vaginal birth) “What you need is a bit of empathy, they could ask
you looking you in the face ‘Are you alright?’. They
Inappropriate timing may hold your hand, calm you, say to you ‘Don’t
Participants reported that information had been given at worry, we are going to see what is happening’. They
inappropriate times, when they could not assimilate it to should work on non-verbal communication when
make informed decisions. This applied in the case of in- they face a problem.” (W22, 37 years, very high-risk
formed consent for several procedures, which partici- pregnancy, onset by induction, instrumental birth)
pants reported not having had the opportunity to read
and understand. Sometimes, information was given to “During childbirth, they should follow step-by-step
women at the time of contractions, for instance concern- your emotional state. [ … ] They should use expres-
ing pain management, leaving them unable to decide or sions like “How are you? How do you feel? What do
make a judgement on the information presented. you need? How can I help you? What do you want?”
(W2, 35 years, low-risk pregnancy, spontaneous on-
“Sometimes they come up to you in the operating set, vaginal birth)
room and say, “Sign here”, but what validity does
this have? It could have been signed by another “They should pay attention to your birth plan [ … ]
woman.” (W20, 32 years, very high-risk pregnancy, and to make it more applicable, even when there is
onset by induction, vaginal birth) a high-risk pregnancy.” (W20, 32 years, very high-
risk pregnancy, onset by induction, vaginal birth)
“The midwife offered me a lot of different things for “And a caesarean plan, it seems that women who
anaesthesia, eventually we decided epidural, but for a undergo caesarean section have no choices, but they
moment I thought, “Between contraction and contrac- can also make decisions.” (W17, 30 years, high-risk
tion, making decisions about what kind of anaesthesia pregnancy, spontaneous onset, vaginal birth)
is the most appropriate … ” [...] You aren’t in the mo-
ment to decide.” (W22, 37 years, very high-risk preg- In regard to their partners, women expect them to be pre-
nancy, onset by induction, instrumental birth) pared and take part in the process of pregnancy and birth.
HCB allows two people of women’s choice to support them
Suggestions to improve women’s participation in shared during childbirth, which was highly appreciated by women.
decision-making Moreover, women appreciate that partners or family mem-
Establishment of mutually respectful relationships between bers give them emotional support, remain calm and act, if it
clinicians and women were to be necessary, as representatives of their will.
Professionals, partners and other family members were
described as key people to promote women’s participa- ‘I was feeling very lonely. But my mother came, and
tion in decision-making during childbirth. Women only she helped me a lot, changed the sheets, helped me
knew the professionals who attended their birth if they to vomit … I really liked that two people were
had happened to meet them at any of the prenatal ap- allowed in the delivery room. For me, my mother
pointments but knowing health professionals beforehand was the light.’ (W2, 35 years, low-risk pregnancy,
was highly valued by women to feel secure about the spontaneous onset, vaginal birth)
process.
“I almost lost consciousness but he [partner] was man-
“‘Midwife 1’ attended me at one of the hospital ap- aging. Besides, he knew my preferences and she [midwife]
pointments. And it was very important for me to see had the knowledge about the options that there were [ …
her in the delivery room. When she told me ‘I am ]. They helped me at a time when I had so much pain
‘Midwife 1’, I thought ‘OK, everything is fine. Now I that I wasn’t able to make decisions.” (W6, 46 years,
can give birth.’” (W10, 31 years, low-risk pregnancy, high-risk pregnancy, onset by induction, vaginal birth)
spontaneous onset, vaginal birth)
Continuity of coordinated, personalised perinatal care
Participants consider that professionals should im- Women felt that coordination among professionals
prove the use of the birth plan, for example by extending within the hospital and also in community centres could
López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 8 of 12

be improved. For instance, transferring more informa- stand that”. And they came in and said, “Oh yes, she
tion between shifts or in medical records. Also, partici- is in labour”. But, if he hadn’t, no one would have
pants proposed that “communication protocols” be appeared.’ (W11, 35 years, high-risk pregnancy, on-
created to standardise what information should be of- set by induction, vaginal birth)
fered to women and when.
“When you know the professional and they make the
“There isn’t a rule for explaining when to give infor- shift change … I was afraid that she [Midwife]
mation or not, I think it would be interesting to de- would look at me to see how everything was, that she
sign protocols to say: “In this situation, we offer that would examine me, it made me feel scared. Even
information, in that situation, we give this other in- though you trust them a lot, you have this feeling.”
formation” so that the patient’s experience doesn’t (W10, 31 years, low-risk pregnancy, spontaneous
depend on what professional she meets.” (W8, 41 onset, vaginal birth)
years, very high-risk pregnancy, onset by induction,
vaginal birth) “I hoped that the midwife who attended my child-
birth would come to explain to me what had hap-
Women requested more tailored attention from pro- pened [ … ] but nobody came to explain anything.
fessionals that could personalise and discuss hospital One day, I came to the hospital to look for her and
protocols on an individual basis. This could be achieved then she explained it to me. But if they had ex-
through the creation of mutual respect and a trusting plained it to me when I was hospitalised, they would
relationship. have saved me a lot of suffering, a lot of crying [ … ]
and a lot of anxiety.” (W5, 42 years, medium-risk
“Why does a person who has known me for one day pregnancy, spontaneous onset, caesarean)
have to prescribe an induction on week 41? I needed
the information to be only for me, with my context, Discussion
with my characteristics and those of my baby [ … ] This study explored women’s experiences of participa-
each birth is different, and we need individualised tion in SDM during hospital childbirth. Women had few
information.” (W10, 31 years, low-risk pregnancy, experiences of and opportunities for participation in
spontaneous onset, vaginal birth) decision-making; thus, most decisions were made by
others, considering neither the women’s needs and pref-
“If you don’t agree with hospital protocols [ … ] they erences for participation nor their birth plans. The infor-
[health professionals] should be more flexible. If mation needed to take an active role during childbirth
there is a risk they should inform you, but without was perceived as missing or given to women at an in-
looking down on you, because maybe you are not appropriate time, so their participation became less feas-
making that decision knowing the risks that you are ible. On the other hand, potential improvements that
assuming.” (W2, 35 years, low-risk pregnancy, spon- were identified as able to promote women’s participation
taneous onset, vaginal birth) were having a mutually respectful relationship with their
care providers, the support of partners and other mem-
In addition to coordination and personalisation, the bers of the family, and receiving continuity of a coordi-
women suggested that continuity of care both during nated, personalised perinatal care.
childbirth and postpartum have scope for improvement. This study showed that women who had expected to
Some women highlighted that the lack of availability of take an active role during childbirth, encountered bar-
midwives prevented them from feeling supported during riers to doing so. Feeling out of control and little in-
childbirth. Moreover, shift changes were experienced as volved in medical decisions has been associated with a
a sensitive moment. Besides, some women pointed out negative and traumatic experience of the birth process
the need of having a visit during the postpartum period [38–40]. Some participants complied with medical deci-
with some of the professionals that attended them, in sions without the need to inquire about offered proce-
order to solve doubts, share and understand information dures, partly because they had a high level of trust in
and have a complete narrative of their childbirth. clinicians and described themselves as poorly prepared
to make such decisions. To achieve an effective patient-
‘They [health professionals] sent me to the room for provider partnership through SDM, it is needed for both
the induction, and there, you are alone, you don’t professionals and patients to value the patient’s views,
have anyone. It was at night, and the nurses didn’t preferences, and expertise in their own lived process [41,
move from the counter until my husband went and 42]. In our study, some women who had been diagnosed
said to them “Please, my wife is in labour, I can’t with a high or very high-risk pregnancy seemed to have
López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 9 of 12

less confidence to question clinicians’ decisions and to The interviewed women reported that health profes-
participate in SDM, perhaps because they felt that if they sionals should follow their emotional state and provide
made decisions other than those advised by health pro- support when needed. The evidence shows that having a
fessionals they would be putting their babies and them- supportive environment facilitates patient participation
selves at risk. Likewise, a recent metasynthesis found in SDM [41] and women’s emotional well-being during
that women’s attitudes towards childbirth decisions are childbirth could be considered as important for women
heavily affected by a medical diagnosis of “risk” [24]. as their physical health or that of their newborns [53,
The birth plan was experienced as a deficient method 54]. Effective tools should take into account these needs
to promote women’s participation, largely because health and promote means for women to convey their emotions
professionals neither looked at it, nor took its content and, ultimately, to increase the quality of care. Moreover,
into account at the time of childbirth or conversations to promote women’s involvement in SDM, women sug-
about decision-making. Instead, the birth plan was used gested that professionals should improve their commu-
to inform women about different birth care options that nication and relational skills. Relational and risk
the hospital offered. This finding is consistent with other communication skills can help health professionals to ef-
studies which have reported that the birth plan has been fectively promote patient participation [55] and meet the
“institutionalised”, meaning that it is used as a hospital emotional and communicative demands of childbearing
document to present service options rather than a docu- women.
ment for women to express their preferences and needs Finally, women stressed the need to receive continuous
[13–16]. Other uses of birth plans, complemented with support and a coordinated, personalised care during
other communication tools, should be explored in order pregnancy and childbirth. Evidence supports midwife-led
to promote effective communication, thus enabling continuity of care models as the best standard of care
women’s participation in SDM [13]. for pregnancy and childbirth [56–58]. Furthermore, co-
Women reported that they often did not have sufficient ordination, continuity of care, and interdisciplinary
information to make decisions in and about childbirth, teamwork has been highlighted as essential for a patient-
despite their efforts to seek and gather this information centred care, a model that strongly promotes patients’
during pregnancy and around the time of birth. Informa- participation in SDM [59]. The study participants re-
tion and knowledge have been described as key factors for ported the low availability of midwives during hospital
patient involvement in SDM [43]. Health professionals admission. A recent study from midwives’ perspectives
should draw on all of their knowledge and expertise in suggested that Catalonian hospitals do not have suffi-
order to reduce knowledge asymmetry between women cient resources to make midwife-led continuity of care
and clinicians and therefore facilitate women’s engage- feasible, and also that some hospitals present a highly
ment in decision-making [44]. Specifically, the participants hierarchical work environment that hampers coordin-
reported a lack of information provision with regard to ation [60].
birth complications and procedures during birth, such as Fulfilment of women’s expectations of participation
induction, a finding which has been reported previously should be a priority of maternity health services. A com-
[45, 46]. Additionally, the women experienced a consider- prehensive approach to facilitating women’s involvement
able shortage of information regarding informed consent in SDM during hospital childbirth should include a train-
before undergoing various procedures, such as an epidural ing programme for health professionals and women, ac-
or a caesarean section, and they highlighted the import- companied by an effective communication tool to
ance of information being given at an appropriate time. enhance women’s participation. An example of an effect-
Some authors have highlighted that, even though obtain- ive training programme for women was an educational
ing informed consent during childbirth could be challen- intervention implemented during prenatal classes. It
ging, especially when an obstetric emergency arises [47], aimed to reduce rates of elective induction of labour by
health professionals should persist in their efforts to in- providing information to women and empowering them
form women about the benefits and risks of obstetric to initiate conversations about risks and alternatives with
practices in order to preserve their right to autonomy and health professionals [61, 62]. Our study demonstrates that
self-determination [48–50]. Previous research has pointed the use of only a single tool, such as the birth plan, as least
out the importance of initiating an information exchange in its current format and implementation, is insufficient to
in antenatal care where there is sufficient time to explain promote women’s participation as long as the knowledge
and discuss the different options and to anticipate com- asymmetry remains, and stakeholders are poorly prepared.
plex situations that may occur during birth [11]. For this
purpose, various evaluated patient decision aids could be Limitations and further research
used during prenatal care [51, 52] to promote women’s in- To our knowledge, this is the first study that explores
volvement in SDM. women’s experiences of participation in SDM during
López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 10 of 12

hospital childbirth in Spain. The qualitative methodology further involve women, and help them to revisit deci-
provided a deep and broad insight into women’s experi- sions if the childbirth takes a different course. Further-
ences, however, this study has intrinsic limitations. Al- more, birth plans could be complemented with the use
though focus groups allowed for rich interactions among of other communication tools, such as patient decision
participants and fostered discourse around participation aids [63]. Additionally, in the context of this study, birth
in SDM during childbirth, an uncommon topic to most plans were not amended for women with high-risk preg-
women in our context, the data gathering using inter- nancies. Promoting means of participation for women
views in addition to focus groups could have provided diagnosed with high-risk pregnancies should be a prior-
deeper understanding about women’s experiences, but ity, considering the demographic characteristics of the
this was beyond the possibilities of this study. As data pregnant women population in Spain [64]. Policy-
was collected from women who attended one particular makers should foster the implementation and evaluation
hospital in Spain, their experiences may not represent of interventions to promote women’s participation in
the vast majority of women giving birth in the country. SDM during childbirth, which would include training
Moreover, the sample was self-selecting and, therefore, programmes and changes in organisational models to
women with a higher educational level were over- trigger an ideological shift from paternalistic healthcare
represented. Thus, extrapolation of findings should be to an increasingly participation-based healthcare.
done cautiously. Besides, due to convenience sampling,
there is a risk that women with less satisfaction regard- Conclusions
ing their involvement in SDM were overly represented This study has shown that women who were willing to
in the study. However, their experiences may provide take an active role in SDM during hospital childbirth
relevant lessons as opportunities for improvement con- faced difficulties in doing so. The information needed to
cerning this topic. take an active role during childbirth was perceived as
Although this research identified some specific and missing or given to women at an inappropriate time. Po-
crucial decisions in which women wanted to be involved, tential improvements identified as enablers of women’s
such us undergoing an induction or the methods of pain participation were having a mutually respectful relation-
management to use, more research is needed to define ship with their care providers, the support of partners
which decisions are the most important for women to and other members of the family, and receiving continu-
participate in, also taking into account professionals’ ity of a coordinated and personalised perinatal care. En-
perspectives. Moreover, further research should include hancing women’s participation requires the acquisition
women with lower socio-economic status, different ori- of skills by health professionals and women and the de-
gins, and mental or physical disabilities and take into ac- velopment, implementation, and evaluation of interven-
count partners’ views and their experiences of tions to facilitate women’s engagement in SDM.
involvement in SDM during childbirth. Furthermore, in-
dividual interviews with women would provide deeper Abbreviations
SDM: Shared decision-making; HCB: Hospital Clinic of Barcelona
insights on women’s narratives and would overcome
possible effects of peer pressure. These findings should Acknowledgements
help to rethink birth plans and increase their real-world We gratefully thank the participants of this study for sharing their intimate
value. Besides, this information would facilitate the de- experiences of childbirth and for the time they gave to the study. We thank
the professionals of the maternity unit of HCB, especially Dr. F. Figueras and
velopment, implementation, and evaluation of appropri- Dr. A. Arranz, for giving their full support to this research. We would like to
ately contextualised interventions to truly promote express our gratitude to the community health centre midwives for their
women’s participation in SDM during hospital help regarding the participant recruitment. We also thank A. Borràs, L.
Granès, and C. Marín-Carballo for their help in preparing the topic guide and
childbirth. organising the focus groups. And, last but not least, we especially thank J.
Gorospe for his technical and unconditional support.
Implications for policy and practice
Authors’ contributions
Clinical implications of this work include the need to de-
AL conceived the study and ML, PB, and AL designed it. AL and ML
velop strategies to promote women’s participation in collected the data and carried out the thematic analysis. PB supported
SDM, such as improving the use of birth plans and the analysis and AL, ML, and PB interpreted the findings. ML drafted the
manuscript and PB and AL revised it critically for intellectual content. All the
further development of other communication tools.
authors read and approved the final manuscript.
When given the opportunity to complete a birth plan,
women and their families may form expectations about Funding
participation and involvement. However, according to This study did not receive any specific funding.
the participants, the use of birth plans thus far amounts
Availability of data and materials
to mere procedure, with no clinical significance. Health The datasets used and/or analysed during the current study are available
professionals could explore birth plans as a tool to from the corresponding author on reasonable request.
López-Toribio et al. BMC Pregnancy and Childbirth (2021) 21:631 Page 11 of 12

Declarations 12. Lothian J. Birth plans: the good, the bad, and the future. J Obstet Gynecol
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study complied with the basic ethical principles contained in the Helsinki https://doi.org/10.1016/j.ajog.2016.09.087.
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Not applicable. Dec 4.
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1
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