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Choice is a central tenet of maternity care; its importance is emphasised in policy documents, clinical guidelines, and the law. However, the lived experience is often rather different and that is particularly the case in the context of pregnant women with a severe mental illness (SMI). The biomedical discourse is powerful and has successfully constructed pregnancy and birth as risky, as a procedure to be managed by experts using technology to ensure that nothing goes wrong. Within that already risky process, women with SMI are constructed as risky, rather than at risk, posing a risk to themselves and the foetus they carry, as well as to the healthcare professionals who care for them. It is not merely their treatment decisions that are questioned, but their very ability to make those decisions. The consequence of this is reduced choice for women with SMI who are cautioned to act responsibly, but where they fail to …