BACKGROUND: Medicalization has led to the standardization of American maternity care and limited the choices of pregnant women by restricting their access to alternative types of care. While there is evidence that women are dissatisfied with this trend, very little is known about how pregnant women make decisions in the current maternity care environment. OBJECTIVE: To describe the conceptual frameworks women use in making maternity care and birth decisions by exploring the context in which these choices are made. METHODS: In-depth, semi-structured interviews were conducted with 22 women between March and December of 2010. RESULTS: Three major themes emerged from the data. The first theme is that women take an active role in their own maternity care through the formation of goals, some of which were better served by the maternity care system than others. Second, women articulated underlying birth philosophies and discussed the philosophies of their caregivers. Dissonance between a patient's birth philosophy and that of her provider led to tension and mistrust. The final theme is a discussion of choice and barriers in maternity care. The lack of choice that many women experienced led to difficulties in receiving the type and amount of maternity care that was most appropriate for them and resulted in frustration and dissatisfaction with the provision of their care. CONCLUSION: These findings call for expanded access to nonstandard maternity care, the removal of barriers to alternative care, and more vigilant observation of fully informed consent. Quality maternity care must provide support for meaningful choices whether or not those decisions reflect current maternity care norms. PUBLIC HEALTH SIGNIFICANCE: Over four million women become pregnant and give birth in the United States each year. Pregnancy and birth account for one in every five female hospitalizations and a quarter of all hospital stays. Given its magnitude, the quality of maternity care services is an important measure of overall healthcare quality and thus a critical public health concern.
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