Qualitative study of evidence based leaflets in maternity care

OBJECTIVE: To examine the use of evidence based leaflets on informed choice in maternity services. DESIGN: Non-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care. SETTING: Women's homes; antenatal and ultrasound clinics in 13 maternity units in Wales. PARTICIPANTS: Childbearing women and health professionals who provide antenatal care. INTERVENTION: Provision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use. MAIN OUTCOME MEASURES: Participants' views and commonly observed responses during consultations and interviews. RESULTS: Health professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of “right” and “wrong” choices rather than “informed” choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women's trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced. CONCLUSIONS: The way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

研究目的：探讨基于证据的知情选择（Informed Choice）宣教手册在产科服务中的应用情况。
研究设计：对886次产前会诊开展非参与式观察，并对使用产科服务的女性及提供产前护理的卫生专业人员进行383次深度访谈。
研究场景：研究地点涵盖威尔士13家产科单元的孕妇住所、产前检查诊室及超声检查诊室。
研究对象：育龄产妇及提供产前护理的卫生专业人员。
干预措施：为服务使用者与医护人员提供10套知情选择宣教手册，并开展针对其使用方法的培训课程。
主要结局指标：研究对象的观点，以及会诊与访谈过程中常见的行为反应。
研究结果：医护人员对该宣教手册及其助力女性做出知情选择的潜力持肯定态度，但临床环境中的多重竞争需求削弱了其有效应用。时间压力限制了沟通讨论，实践中往往无法为女性提供自主选择空间。普遍存在一种认知：若发生医疗诉讼，技术干预会被视为正向应对举措，这强化了"正确"与"错误"选择的观念，而非"知情"选择。层级化权力结构使得产科医师定义了临床实践规范，进而限定了可被接受的选择范畴。产妇对医护人员的信任使其遵从专业人员界定的选择方案，仅在极少数情况下被观察到提出疑问或提出替代性诉求。助产士极少讨论宣教手册的内容，也未将其与其他妊娠相关文献加以区分。因此，该宣教手册作为循证决策辅助工具的可见性与应用潜力被大幅削弱。
研究结论：宣教手册的传播方式影响了产科护理中知情选择的推广。宣教手册所融入的临床文化，延续了既有护理规范模式，最终促成了知情依从而非知情选择。