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Decisions about health and care are rarely uncomplicated, and in maternity, they are no less so. In England, choice is at the forefront of maternal health policy, which maintains that women with straightforward pregnancies should have a choice of place of birth. A growing body of evidence shows that midwifery-led settings, such as midwifery units and home birth, are as safe as obstetric units (OUs), and that women planning their births in these settings have better outcomes with reduced chances of medical interventions and caesarean sections. However, a majority of those eligible for midwifery-led care are still giving birth in OUs. Policymakers, clinicians and stakeholders are now focused on augmenting 'informed' choice about place of birth among parents as a means for improving services and uptake, zeroing in on decision-making as the crucial point in which it is initiated and formed. What delineates an informed choice, and how does decision-making during pregnancy engender such a choice? Creating decisions aids or rolling out models of 'shared decision-making' are popular solutions for augmenting informed choice, with the intention of easing the burden of decision-making for parents. Researchers commonly approach each from a disembodied standpoint, assuming rationality in complex, lived phenomena that are in actuality neither linear nor uniform. This thesis, instead, explores decision-making and choice as a process, building an ethnographic account of parents' place of birth decision-making experiences in East London and investigating the feasibility of research related to decision aids and informed choice. To achieve this, I conducted two studies over nearly two years: a community based study situated in the boroughs of Newham, Tower Hamlets and Waltham Forest; and a feasibility study based in Barts Health NHS Trust, which offers all four birthplace options for women with straightforward pregnancies. I argue, contrary to long-held decision theory, that decision-making about place of birth is an embodied practice, one that has corporeal, temporal and affective modalities and involves enskilment built up before, during and after pregnancy. Modern English maternity continues to be a nexus of biomedical and obstetric dominance, uncertainty in terms of risk and safety and notions of good motherhood, all of which are layered through women's decision-making and reified by the frameworks that shape it. My analysis illuminated that informed choice, in the context of place of birth decision-making, is a culmination of skilled practice, a phenomenological and embodied event. Its establishment, in maternity policy and care, is marked by silences concerning knowledge and services. Current conceptions of choice in English maternity are built on a market ideology, which places the onus of improvements to services on women and their families; however, in seeing parental decisionmaking and informed choice as embodied, we can begin to envision future policy and practice based on a platform of human rights.

Background: There were approximately 63,097 known asylum seekers in England in 2002 (Heath et aL 2003). Women asylum seekers may be more seriously affected by displacement than men, leading to increased isolation, poverty, hostility and racism (Burnett and Peel, 2001a). In England, Black African including asylum seekers and newly arrived refugees had a seven times greater chance of maternal modality than White women (CEMACH, 2004 p244). Furthermore, women from ethnic groups other than white are twice as likely to die as women in the white group. In the CEMACH report a large number of women who died spoke little English. Access to local information about asylum seekers and refugees was difficult to obtain and suggested a disorganised service provision for this group of women. Aim: It was the intention of this study to explore and synthesise the experience of midwifery care by women asylum seekers and refugees in one large maternity unit in England. Design: Longitudinal exploratory case study research utilising a series of interviews. Sample: Four women from: Afghanistan, Rwanda, Somalia and Zaire. Three women were asylum seekers and one was a refugee. One woman spoke fluent English. Setting: Liverpool Women's Hospital and the women's homes. Years: The study took place from December 2002 - July 2003. Methodology: The research was developed from a constructionist paradigm which identifies that multiple realities can exist for individuals who experience 10 a similar phenomenon. Truth within this perspective is constructed by the individual. The researcher (LB) was the main instrument of data collection. Interpretation was generated via the researcher and was verified by the women at the final interview. The underpinning foundation for this study emerged as symbolic interaction theory (Mead, cited in Morris, 1967 p43; Blumer, 1969). Methods: Following ethical approval consent was obtained with the help of professional interpreters. Exploration was facilitated by in-depth interviews at five time points throughout the antenatal and postnatal period. Photographs taken by the women themselves were used as a prompt for conversation. Analysis: The researcher's interpretation of the data identified emerging themes and categories. The process of analysis involved decontextualisation, display, data complication and re-conceptualisation (Miles and Huberman, 1994 p10). Three key themes were generated: the influence of social policy, understanding in practice and the perception of 'self. Results: Synthesis of the results suggested that social policy directly affected the lives of the women. At times, "taken for granted" communication created a barrier to understanding for the women. Stereotype was socially constructed and pervaded the care environment. The women perceived 'self as a response to social interaction. The midwife-woman relationship relied heavily on gestures and symbols and the women's descriptions are related to symbolic interaction theory. Midwives capable of understanding the subtle cues in communication may be able to negotiate negative stereotypical images generated by society. Women had little or no information around childbirth. Recommendations: Midwifery care would benefit from a deeper understanding of how the women in this study perceived 'self. An advisory post may provide the link between maternity care and broader public health issues. Midwives should engage with asylum seekers and refugees to develop partnerships in care. A collaborative partnership may assist in creating relevant information around childbirth for other asylum seekers and refugees. Innovative methods of dissemination of information related to childbirth should be facilitated by a collaborative approach with non-governmental and community organisations.