abusive, and discriminatory care practices.[150–153] Lack of alignment between the health needs of women and the current system of maternity care may even drive women away from MNC.[135,136,154] To support the centring of women’s needs and preferences, shared decision making (SDM) is increasingly advocated.[155–158] Many tools have been developed to promote and support SDM,[159] but the uptake of these tools in MNC has been slow.[121,125,160] Studies of SDM show that it results in increased satisfaction among women.[161–165] However, women whoengage in SDM indicate that the risk focus of the biomedical discourse and the rhetoric of risk limit their choice resulting in a paradox where they are simultaneously assigned active and passive roles.[80] Within our contemporary neoliberal society, individuals are made aware of their responsibility as good citizens to conform to expert advice. Women’s individual responsibility is reduced to the need to respect biomedical recommendations, choosing what is least risky for the foetus.[166,167] While women want to be ‘goodmothers’,[25,167] and want to put their child’s needs before their own,[25] the heavy weight put on their responsibility to their child does not enable them to articulate their wishes. It also leaves them at risk of blame and censure if their choices are perceived to be the ‘wrong’ ones, positioning them as ‘badmothers’.[80,81,168] Thus, SDM within a professional-centred focus in risk selection situates women at the intersection of two powerful normative discourses: medical dominance and the patriarchal institution of motherhood.[131] This drives some women to non-compliance and unassisted pregnancy and birth.[135] Problematizing overuse of care It has been argued that centring women’s needs may contribute to rising referral rates because it is women whowant medical interventions.[130,169,170] However, studies show that women value a physiological approach that promotes normal processes and prevents complications.[4,170,171] Generally, they only want interventions if medically necessary. [171] Nevertheless, a minority of women gives birth without any medical intervention. [4,10,172] Studies indicate that care decisions are more often the result of professionals’ rather than women’s preference.[173] Women report that they do not always feel like the choice is theirs and feel pressured by midwives and obstetricians to make choices that fit their services.[174] Take for example the use of caesarean section (CS), which has risen globally.[5] Contrary to the opinion of some, the vast majority of women around the world, in the absence of current or previous complications, do not prefer a CS.[5,175,176] Furthermore, a study into the factors that influence decisions about CS found that professional factors – including professionals’ personal beliefs and fear of litigation – were the most likely reasons given for performing a CS.[5,169,177] Another study compared the risk that pregnant women would be prepared 168 7 CHAPTER 7
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