Flemish women are in general satisfied with the received care during childbirth. Some aspects of care during labour and birth, such as sufficient preparation and information of good quality, have an important impact on the level of autonomy in decision making. Next to that, a couple of characteristics related to the course of labour and birth (e.g. epidural analgesia, mode of birth, complications) contribute to the perceived autonomy as well.
The experience of autonomy in decision making
This study shows that women experience higher scores of autonomy when participating in decision-making conversations with a midwife. This result was also found in earlier studies [17, 22]. When analysing the degree of autonomy according to the type of health care provider, it can be concluded that the participants of this study experienced lower autonomy (median = 30.85) when participating in decision-making conversations with a midwife compared to the participants from similar studies in Canada (median > 40) or the Netherlands (median = 35) [17, 22]. Current differences in models of care, health professional education, regulatory standards, and compensations for prenatal visits likely affect the time available for SDM and emphasis placed on the SDM process . It can explain the difference in results between Belgium, the Netherlands and Canada.
This also applies to autonomy with respect to decision making conversations with an obstetrician. Respondents in this study reported a score of autonomy (median = 19.5) that was lower than those in the study by Vedam et al.  (median > 29) and Feijen-de Jong et al.  (median = 31). In this study as well as in previous studies [17, 22], these differences in the degree of autonomy with respect to the type of caregiver were significant.
Since we did not find other studies on this topic, additional research is needed to be able to get more general statements about the degree of autonomy women experience worldwide during perinatal care.
In addition, the difference in the degree of autonomy with respect to the type of care provider confirms the need for specific research including determinants that could help explain these differences. One determinant might be the provided time for a consultation. Which is short in case of a visit with an obstetrician, resulting in handling medical aspects in particular, while midwives try to spend more time on the preparation of birth and on shared decision-making. The efforts of midwives in shared decision-making and “women-centred” care could be an explanatory factor for the findings in our study . Further research is necessary as it is not the intention of this study to compare the degree of autonomy women experience between different health care providers.
Important factors in the experience of autonomy in decision-making
Women who perceived low self- control (LAS) reported significantly lower autonomy scores. Nieuwenhuijze et al.  established that a positive experience contributes to women’s sense of accomplishment, self- esteem, feelings of competence and well- being. Women with a high degree of self- control, are more likely to feel able to participate in decision making. Furthermore, pain and anxiety during labour may affect the autonomy in decision making . This may also explain why women, who gave birth with epidural analgesia in our study, experienced higher scores of autonomy when participating in decision making with an obstetrician compared to participants who did not receive analgesia. In Belgium a high number of women choose for EDA .
Another factor when women may feel “loss of control” is the case when quick decisions have to be made . Our study also found lower MADM – scores in interaction with the care providers when complications occurred during childbirth and in the postpartum period. The lower MADM-scores in interaction with the midwife may be explained, because women count on the midwife to explain the actions that are taken in the event of complications, while they expect this to a lesser extent from the obstetrician as he/she is busy taking care of complications. We need to pay attention to possible traumatic events. Literature shows that women who underwent “traumatic” experiences felt less autonomous when participating in decision-making [25, 26]. Therefore it is important to address possible complications in preparatory sessions as well as after birth the reason behind and actions taken should be discussed. Understanding what happened reduces the chance of post-traumatic stress . As the ‘complications’ in this study were self-reported, the perception can have been subjective. Feelings of stress and additional actions to cope with the complications may feed the perception of less autonomy in decision making.
Preparation for childbirth, particularly the quality of the information received, appears to have an important influence on the extent to which women experience autonomy in decision making as well. This was also the case for women who received sufficient information about the normal course of childbirth. As described by Tully, & Ball  care providers should pay attention that the provided information should not only be based on scientific data (“evidence based”) but also communicated in a simple, comprehensive manner . These sessions/moments can also serve to educate women about their right in autonomy and respect for their choices and preferences, which can help avoid disrespectful perinatal concerns .
Furthermore both midwives and obstetricians should pay attention to the process of shared decision-making and show respect for the decisions women make. The integration of shared decision making in perinatal care has shown to have a positive effect on the birth experience and on satisfaction with the care provided . The introduction of a birth plan and dialogue between mother and health care provider in the prenatal phase could be an important action in this matter. A birth plan is a written plan in which women express their wishes and preferences for labour, birth and the post-partum. Studies show that women who have a birth plan felt more involved in decision-making and felt more respected [29,30,31]. Elwyn, G., et al.  indicates that SDM consists of three steps (choice talk, option talk and decision talk). Both preparing for childbirth using extensive information (choice and option talk) and preparing a birth plan (decision talk) contribute to the application of SDM in midwifery care [13, 29].
A last element found in our study is the result of higher perceived quality of care (PCQ) in relation to, women experiencing more autonomy. Women experience a positive sense of self from receiving positive affirmations, effective communication with care- givers and experiencing mutually trusting relationships . The results of this study may be useful at the micro level in formulating or modifying local protocols and guidelines promoting respectful perinatal care.
Findings from international literature also reveal that highly medicalized models of care and some features of midwifery care (performing interventions without providing clear indications or explanations to the women receiving them) can diminish women’s sense of self . Investment in a more integrated, centralized childbirth care may also require adjustment of the financing system, in that healthcare providers should be paid in a different way and not merely by performance. This could ensure that healthcare providers feel less pressure and have more time available to pay attention to the decision-making process.
The training of doctors (obstetricians) and midwives can also be an important “tool” for acquiring knowledge and skills about respectful maternity care, women’s autonomy and shared decision-making. The integration of SDM in daily practice demands for modification of communication practices of health care providers .
Strengths and weaknesses
To the best of our knowledge, this is the first study on this topic in Flanders and in Belgium, which makes future comparison possible.
The findings show that the degree to which women experience autonomy when participating in decision-making discussion with health care providers is not higher in Flanders than in other high-income countries, on the contrary it seems lower. This confirms that autonomy, in particular the respect for women’s choices and preferences, is not yet fully respected in Flemish perinatal care.
The focus on two main care providers, midwife and obstetrician, during childbirth is what makes this study unique. Examining factors not previously analyzed in relation with autonomy in decision making, especially in a fairly recent topic in scientific literature such as quality of care; sense of control; quality of information, … are an important contribution of this study.
A limitation of this study is the mode of sampling, recruitment by social media, and as such, this study is subject to selection bias. Long questionnaires can also lead to lower response rates. Furthermore, as the recruitment channels used were mainly social networks such as Facebook, Instagram and LinkedIn, women with no access to the internet of women who have no social media accounts were excluded from this study. However, the number of participants are comparable to other studies in the field and also in studies where women are directly invited often certain groups (e.g. women with lower level of education) decline participation.
One in three women in our study had a cesarean section; as this mode of birth has been discussed with the woman during pregnancy, the large proportion of women with a cesarean section may bias the results related to the MADM-scale in a positive way. As indicated in the results, certain personal and obstetric characteristics of the study population are underrepresented compared to the general Flemish population. This can be attributed to the specific way of recruitment.
The questionnaire referred to experiences during labour and birth. It is not clear to what extent experiences during pregnancy impacted the answers of participating women.
The questionnaire was constructed based on the current organization of obstetric care in Belgium. Labour and birth usually take place in the presence of one midwife and one obstetrician in a hospital setting. Women who gave birth at home (0.7% of deliveries) were excluded from the study.
Another limitation of the study is the adaptation of the MADM and SDM-Q9 with the inclusion of an additional ‘neutral’ response category. Reliability and validity could therefore not be fully guaranteed. However, we do believe the impact of this change will be marginal, since the value assigned to that item was the mean of the preceding and succeeding item, resulting in a same minimum and maximum for both scales.
We chose to work with validated existing scales. The current, known limitations of these scales remain.
Part of our study took place during the COVID-19 pandemic. In Belgium the COVID-19 pandemic started in the second half of March 2020, which was the final month of data collection. As such, only a limited number of women (32 of the 617) gave birth in this period. To be able to find any differences between the period before and during the COVID-19 pandemic would lack from statistical power. Therefore, we decided to leave this variable out of the analysis. Nevertheless, it was observed that other studies indicated an effect of the COVID- 19 pandemic on the perception of quality of care and the degree of autonomy in shared decision making [34, 35].