Reproductive identity expression, reinforcement and defence: A constructivist grounded theory of non‑normative pregnancy and childbirth decisions in the UK.

Increasingly, women in the United Kingdom decline routine or recommended maternity care, give birth outside clinical guidelines, or make other non-normative choices. Despite policy commitments to personalised, rights-based care, such decisions often generate anxiety within maternity systems. Understanding women's motivations is essential for safe, rights-respecting care and informed policy. Existing approaches are predominantly shaped by clinician and system perspectives, often assuming motivations without evidence from women themselves. Current evidence frequently reduces lived experiences to discrete phenomena, trauma, or media narratives, failing to capture their complexity and underlying motivations AIM: To develop a substantive theory explaining how and why women make non-normative maternity decisions in the UK METHODS: Charmaz's constructivist grounded theory methodology was applied, incorporating all core methodological components FINDINGS: The Theory of Reproductive Identity Expression, Reinforcement and Defence explains how tacit and overt reproductive identities shape non-normative childbearing decisions. Four interrelated categories show how choices express, reinforce, or defend identity in response to institutional pressures, coercion, stigmatisation, and power dynamics. Decisions were intentional, values-driven, and informed, often arising from perceived or experienced threats to bodily autonomy and from disrespectful care CONCLUSION: Non-normative decisions highlight persistent misalignment between women's reproductive identities and system priorities. They frequently serve to assert, reinforce, or defend identity against institutional constraints. The national maternity strategy must continue to recognise women's rights to decline care and to exercise informed choice, while providing practical strategies to operationalise personalised, rights-based care amid contemporary systemic challenges.