Maternal Mental and Physical Health in Birth Decision-Making: A Systematic Qualitative Review from Tamil Nadu, India Short Running Title: "Maternal Health and Birth Decisions in Tamil Nadu."

Abstract; Background: This review explores how maternal mental and physical health interact to shape childbirth decision-making in Tamil Nadu, India. Methods: Following PRISMA 2020 guidelines, qualitative studies published from 2015 to 2025 were reviewed using the PEOS framework. Sixteen studies involving approximately 825 participants were synthesised through thematic analysis. Results: Six major themes emerged: perceived medical necessity, fear and trauma, autonomy, recovery concerns, family support, and institutional trust. Findings highlight that women’s psychological safety often outweighs clinical advice in birth decisions.Conclusion: Maternal decision-making reflects an ongoing negotiation between physical health and emotional control. Integrating trauma-informed, person-centered care in Tamil Nadu’s maternal programmes is recommended.