Autonomy undermined: how NHS institutional culture fails pregnant patients

Maternity care in the UK continues to confront profound and systemic failings, despite decades of legal and ethical commitments to patient-centred care. This article demonstrates that these failings are not simply operational or episodic but stem from an entrenched institutional culture of paternalism that routinely suppresses women's autonomy. Drawing on major maternity inquiries alongside empirical studies documenting women's experiences of pregnancy and childbirth, the paper illustrates how women's voices are silenced, alternatives withheld, and concerns minimized-particularly for those from racialized or otherwise marginalized groups. These patterns reveal that autonomy, as currently conceived and practiced, remains largely procedural and illusory. The article argues that the dominant 'individualistic' model of autonomy cannot withstand the relational, emotional, and structural realities of pregnancy and childbirth, nor counter the gendered and hierarchical assumptions embedded within NHS practice. It proposes instead a shift towards a relational understanding of autonomy-one that recognizes vulnerability, prioritizes communication and trust, and situates decision-making within wider social and institutional contexts. Only by transforming the cultural foundations of maternity care can the promise of genuine autonomy and safe, respectful care be realized.