Experiences of Maternal Autonomy in Childbirth and Perinatal Care in the United States: A Systematic Review and Meta-Synthesis of Qualitative Studies.

backgroundOver the past decade, major legal and policy shifts have reconfigured the reproductive health landscape in the United States (US), renewing interest in reproductive and bodily autonomy. While much of this attention has focused on abortion access, autonomy during labor, delivery, and the immediate postpartum period remains underexamined. This review aimed to synthesize qualitative evidence on experiences of maternal autonomy in childbirth and the factors that influence perinatal care decision-making.

methodsWe searched Ovid MEDLINE, EMBASE, Scopus, JSTOR, and ClinicalTrials.gov for studies published between 2014 and February 2025. Eligible studies were appraised using the COREQ framework, and findings were extracted, meta-summarized, and thematically synthesized.

results39 studies including 4919 participants were synthesized. Most were conducted in urban areas of the US South and Upper-Midwest, with limited representation from rural or other regions. Participants frequently cited structural barriers as limiting autonomy and access to preferred care. Clinical power dynamics and racial inequities further constrained decision-making. Mothers navigated these challenges using strategies such as hiring doulas, modifying the birthing environment, or pursuing alternative birth settings.

conclusionMaternal autonomy in childbirth and perinatal care is shaped by complex structural, relational, and experiential factors that extend beyond individual "choice." Persistent barriers underscore the need to integrate reproductive and maternal autonomy across the full pregnancy continuum. Linking decisions about "whether" and "when" to have children with decisions about "how" to deliver them can support cross-specialty approaches in obstetrics that better reflect the temporal, lived experience of decision-making across fertility, pregnancy, and postpartum care.