Setting the frame: How midwives balance professional accountability with birth autonomy in Germany. A grounded theory...

Promoting birthing persons' autonomy is essential to woman-centred maternity care and associated with birthing persons' positive birth experiences. Although midwives play a crucial role in promoting or hindering birth autonomy, little is known about how they navigate birth autonomy in Germany. This study aimed to identify midwives' experiences and strategies of engaging with birthing persons' autonomy in different German settings.

Semi-structured interviews were conducted with 12 midwives from hospitals, birth centres, and home birth environments in Germany. The interviews were recorded, transcribed verbatim, and analysed according to Grounded Theory Methodology (GTM) developed by Strauss & Corbin. In total, 2944 codes were grouped into five categories ("Phenomenon", "Causal conditions", "Context", "Action strategies", and "Consequences") and integrated into one model. Elements of Reflexive GTM facilitated the reflection on researcher positionality.

Midwives continuously balance multiple, often competing, demands, among them the need to define a framework that gives them confidence to stand behind every aspect of the care they provide. The midwives achieve this by interpreting various contextual conditions, prioritising them, defining their professional boundaries and options, and matching maternal preferences with these. Throughout the birth process, they monitor changes and dynamically adjust established boundaries as needed.

The study results enhance our understanding of the evolving and context-sensitive process of decision-making during childbirth. Discourses around birth autonomy would benefit from adequate terminology that reflects this complexity. In sum, this study contributes to current discourses on midwifery practice, education, and policy.