Psychosocial impact of cesarean section on the family: a literature review

The "Quiet Revolution" and the cesarean section in the United States

This paper estimates how changes in family structure and women's labor market attachment during the last fifty years have affected the incidence of cesarean delivery in the United States. Both sets of factors are strongly related to cesarean utilization, and have generally changed so as to increase the rate of cesarean delivery over time. Altogether, changes in these factors, complemented by demographic changes, raised the U.S. cesarean section rate by eleven percentage points since the late 1970s, nearly two-thirds of the increase over that period. Today's elevated cesarean section rate is in part a social phenomenon.

Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth

BACKGROUND

Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth.

METHODOLOGY

In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth.

FINDINGS

The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care.

CONCLUSION

By listening to women's experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers' wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.

Mother's mental health after childbirth: Does the delivery method matter?

The dramatic increase in the utilization of caesarean section has raised concerns on its impact on public expenditure and health. While the financial costs associated with this surgical procedure are well recognized, less is known on the intangible health costs borne by mothers and their families. We contribute to the debate by investigating the effect of unplanned caesarean deliveries on mothers' mental health in the first nine months after the delivery. Differently from previous studies, we account for the unobserved heterogeneity due to the fact that mothers who give birth through an unplanned caesarean delivery may be different than mothers who give birth with a natural delivery. Identification is achieved exploiting exogenous variation in the position of the baby in the womb at the time of delivery while controlling for hospital unobserved factors. We find that mothers having an unplanned caesarean section are at higher risk of developing postnatal depression and this result is robust to alternative specifications.

Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: A nationwide cohort study

BACKGROUND

Women who undergo cesarean birth might have an increased risk for poor mental health after childbirth, possibly because of maternal and neonatal physical problems, low parental confidence, and decreased levels of oxytocin. However, this relationship remains controversial and requires further examination. The study aimed to examine the effect of cesarean birth on postpartum stress, anxiety, and depression.

METHODS

This nationwide population-based cohort study was conducted using the Taiwan National Health Insurance Database. A total of 12 619 women who underwent cesarean birth and 12 619 control women who underwent vaginal birth were matched by propensity score based on age, socioeconomic status, residential urbanicity, antepartum comorbidity, and index year of delivery. We compared the incidence of stress, anxiety, and depression during the first postpartum year between cesarean and comparison groups by calculating incidence rate ratios (IRRs).

RESULTS

The cesarean group showed a significantly higher risk for stress symptoms (IRR 1.4 [95% confidence interval {CI} 1.02-1.92]), but not anxiety (IRR 1.14 [95% CI 0.95-1.38]) or depression (IRR 1.32 [95% CI 0.94-1.87]), although the IRRs were also greater than one. The cesarean group had a significantly higher risk of any of the above-listed three disorders than the comparison group (incidence 27.6 vs 23.4 per 1000 person-years; IRR 1.18 [95% CI 1.01-1.38]).

CONCLUSIONS

Cesarean birth was associated with an increased risk of postpartum stress symptoms. Health professionals should avoid unnecessary cesarean birth, pay attention to women who deliver by cesarean, and intervene appropriately in an attempt to improve mental health among postpartum women.

The Relationship Between Body Image, Female Genital Self-Image, and Sexual Function Among First-Time Mothers

The purpose of this cross-sectional study was to examine the extent to which perceived changes in weight, body satisfaction, body-image self-consciousness, and genital self-image could be used to predict sexual function scores. A total of 168 primiparous women completed the cross-sectional, web-based survey. Significant correlations were found between body satisfaction, body-image self-consciousness, and female genital self-image and sexual function. Multivariate regression analysis suggests body image and genital self-image combined account for 14.1% of the variance in overall sexual function. Women should have opportunities to discuss body changes throughout pregnancy.

Nurses and midwives professional support increases with improved attitudes - design and effects of a longitudinal randomized controlled process-oriented intervention

Background

Becoming parents for the first time is challenging. Mothers need both social and professional support to handle these challenges. Professionals’ attitudes affect quality of care and support. So to improve professional support, an intervention consisting of a process-oriented training was performed. Due to the positive results of the intervention there is a need to illuminate the methodological approach further. The overall aim was therefore to describe a methodological approach to improve and evaluate health care professionals’ attitudes toward breastfeeding and parental support in order to improve quality of care in childbearing.

Methods

This study was a longitudinal randomized control intervention study, in which groups of mothers received care in childbearing from midwives and child health nurses. These health professionals had gone through a process-oriented training, or not. In order to improve attitudes of health professionals the training was based on evidence, practical skills and reflective processes (both private and professional experiences) in relation to breastfeeding and parental support. Included in the longitudinal study were health professionals from five intervention municipalities n = 36 and health professionals from five control municipalities n = 45. All mothers who fulfilled the inclusion criteria were consecutively identified from the hospital register and asked to participate in the study. Mothers who accepted to participate were included in the interventions group (n = 206) or control groups (n = 162, n = 172 respectively) based on which municipality they belonged to.

Results

The results of the process-oriented training improved the professionals’ attitudes toward breastfeeding and parental support. These improved attitudes in health professionals increased intervention-group mother’s satisfaction with professional and social support. Intervention-group mother’s relation to and feelings for their baby as well as breastfeeding was also improved.

Conclusion

These results stress the importance of professionals’ attitude in quality of care during childbearing, as well as pointing to the possibility to improve professionals’ attitudes with a process-oriented training.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR), trial registration: ACTRN12611000354987.

Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian University students

OBJECTIVE

to examine attitudes towards birth that may be common among young adults who have been socialised into a medicalised birth culture. Specifically, we were interested in examining factors that might be associated with fear of birth and preferences for elective obstetric interventions among the next generation of maternity care consumers.

DESIGN

secondary analysis of an online survey of university students.

SETTING

British Columbia, Canada.

PARTICIPANTS

students from the University of British Columbia (n=3680). A quarter of the sample comprised Asian students, which allowed for analysis of cultural differences in attitudes towards birth. Both male and female students participated in the study; results are reported for the full sample, and by gender.

MEASUREMENTS

a six item fear of childbirth scale was developed, as well as a 4 item index that measures students' concerns over physical changes following pregnancy and birth and a 2 item scale that assesses students' attitudes towards obstetric technology.

FINDINGS

as we hypothesised, students who were more fearful of birth preferred epidural anaesthesia and birth by CS. Worries over physical changes following pregnancy and birth, favourable attitudes towards obstetric technology, and exposure to pregnancy and birth information via the media were also significantly associated with a preference for CS. Fear of birth scores were highest among students who reported that the media had shaped their attitudes towards pregnancy and birth. Asian students had significantly higher fear of birth scores and were more likely to prefer CS, compared to Caucasian students.

IMPLICATIONS FOR PRACTICE

young adults are contemplating pregnancy and birth in an increasingly technology-dependent society. Educational programmes aimed at reducing fear of childbirth and concerns over physical changes following pregnancy and childbirth might contribute to vaginal birth intentions among young adults. Midwives may use the findings to identify and counsel nulliparas who exhibit fear of birth and other childbirth attitudes that may predispose them to choose elective obstetric interventions.

A qualitative investigation into the pregnancy experiences and childbirth expectations of Australian fathers-to-be

AIM

To explore and describe men's experiences of pregnancy and childbirth expectations.

BACKGROUND

There remains limited work exploring expectant father's perspectives.

DESIGN

Qualitative descriptive design. Twelve Australian expectant fathers participated in between 1 and 2 interviews during pregnancy and 1 after childbirth (32 in total). Six fathers also chose to submit a number of diary entries via e-mail. Thematic analysis was used to analyse the data set.

FINDINGS

Five themes emerged from the data. The themes pregnancy news: heralds profound change adjusting to pregnancy, and birth looming described how men processed the news of pregnancy, worked to accept their changed circumstances and negotiated the final week of the pregnancy. A fourth theme, labelled Feeling sidelined, outlined men's experiences of antenatal care and their feeling of isolation as a result of largely feeling ignored by health care professionals. The fifth theme represents men's childbirth expectations.

CONCLUSION

Adjusting to the news of a pregnancy was a potentially unsettling time for an expectant father that was often associated with increased apprehension and anxiety. Regardless of whether they were a first or once again father most men engaged in a level of emotional work to come to terms with and accept the pregnancy. Understanding men's antenatal experiences and anxieties is an important step in the development of preventative paternal perinatal mental health measures. The significance of this work is situated within the reality that men's wellbeing is associated with maternal psychological well-being, positive peri-natal experiences and child development.

Diet and social disadvantage: the 'Medical Home' improves nutrition in childhood and diminishes likelihood of disease in adult life

It is well appreciated that malnutrition in early life has an adverse impact on the overall health of adults. In this review, we address the impact of malnutrition, social disadvantages, and poverty on the lives of children. An integrated response to these difficulties associated in the lives of children, families and the communities in which they live - the "Medical Home" - is suggested as a means to promote health for all ages. The four types of malnutrition delineated by the World Health Organization are discussed, as are differences between "socioeconomic status" and "social gradient." The latter construct is more meaningful from a health care standpoint as differences within each of the socioeconomic groupings are greater than differences between them. Poverty affects food choices with a profound impact on nutritional status. This review suggests how providing a "Medical Home" can improve dietary habits, improve overall nutrition and prevent disease.

The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia

We examined the experience of cesarean birth among 67 Cambodian, Lao and Vietnamese women who are now living in Melbourne, Australia, based on a larger ethnographic research project on childbearing, childrearing and motherhood among Southeast Asian women in Australia. We found a range of responses in the discourses of the women: some women preferred cesarean birth, but others resisted it. Women's social construction of their feelings stemmed from three interpretive frameworks: trust in medical knowledge, expectations (personal ideology of reproduction and motherhood) and communication with an understanding of their caregivers' preferences (as opposed to choice). Our findings have ramifications for health care providers working in multicultural settings. An effective dialogue between women and their health caregivers is required to keep the cesarean section rates down. In the case of immigrant women in a multicultural society like Australia, it is not the passive receipt of information but a two-way communication with adequate interpreter support that will lead to informed choice, fewer cesarean births, more satisfaction and less regret.

'With woman' philosophy: examining the evidence, answering the questions

'With woman', 'woman centred' and 'in partnership with women' are new terms associated with midwifery care in Australia, and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women's experiences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women, those with 'high risk' pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to initiate a discussion of 'with woman' midwifery care as it applies to Australian practice.

The Vanishing Mother: Cesarean Section and ?Evidence-Based Obstetrics?

The philosophy of "evidence-based medicine"--basing medical decisions on evidence from randomized controlled trials and other forms of aggregate data rather than on clinical experience or expert opinion--has swept U.S. medical practice in recent years. Obstetricians justify recent increases in the use of cesarean section, and dramatic decreases in vaginal birth following previous cesarean, as evidence-based obstetrical practice. Analysis of pivotal "evidence" supporting cesarean demonstrates that the data are a product of its social milieu: The mother's body disappears from analytical view; images of fetal safety are marketing tools; technology magically wards off the unpredictability and danger of birth. These changes in practice have profound implications for maternal and child health. A feminist project within obstetrics is both feasible and urgently needed as one locus of resistance.

The impact of cesarean birth on subsequent fertility

PURPOSE OF REVIEW

Recently, the rate of cesarean delivery has increased to 25-30% of all births, the highest rate ever reported in the USA. Primary cesarean deliveries, especially elective procedures, mainly contribute to this increase. Currently, controversy concerning elective cesarean delivery is an area of growing debate. Women should be well informed about the benefits and risks of on-demand cesarean delivery. This may be problematic, however, due to the limited current scientific data on the benefits and risks. One of the issues causing debate is the association between cesarean section and subsequent infertility. In the present review, we aim to analyze the evidence for the impact of cesarean delivery on subsequent fertility.

RECENT FINDINGS

Cesarean section has been reported to be associated with decreased subsequent fertility. Recent studies, which have tried to explain this association, suggest that this is most probably voluntary or due to some other biases, or possible confounding factors, which are due to organic or psychosocial effects of an emergency cesarean section or labor preceding the cesarean delivery.

SUMMARY

Elective cesarean section does not appear to cause infertility. What we need now, however, are more qualitative studies to determine the contribution of cesarean section per se on fecundity.

Cesarean delivery on request: reproductive consequences

OBJECTIVE

The objective of this review is to examine the long term reproductive health consequences of cesarean delivery on maternal request.

FINDINGS

In the first delivery, cesarean delivery appears to hold small risk of reproductive complications compared to vaginal delivery. Primary cesarean delivery can affect subsequent pregnancies. The most serious reproductive health consequences of prior cesarean delivery occur in subsequent pregnancies. These complications include: unexplained fetal death apparent from 34 weeks gestation onward; abnormalities of placentation which increase with a greater number of cesarean deliveries; risk of uterine rupture and uterine scar dehiscence.

CONCLUSIONS

Primary cesarean delivery carries risk for subsequent pregnancies. While the studies reviewed do not specifically refer to cesarean delivery on request, it is likely that the results would be similar. Overall, in considering the specific question of long term reproductive health, the risks of maternal request cesarean delivery outweigh the benefits.

Postpartum emotional distress: a controlled study of Nigerian women after caesarean childbirth

The study investigated postpartum emotional distress including depression among 47 Nigerian women who had a caesarean section by comparing them at 6-8 weeks following childbirth with 47 matched controls who had normal vaginal delivery. Analysis of scores on the General Health Questionnaire (GHQ-30) and the Beck Depression Inventory (BDI) showed that women that delivered by caesarean section were significantly different from the controls on the GHQ and BDI scores in the postpartum period. Apart from marital status, other sociodemographic variables did not significantly contribute to psychopathology in this group of women. This observation is in support of the view that caesarean childbirth may predispose Nigerian women to adverse psychological sequelae.

Cesarean section and postpartum depression: a review of the evidence examining the link

OBJECTIVE

The objective of this study was to examine the evidence for an association between cesarean section and postpartum depression.

METHODS

Medline and PsychInfo databases were searched. All studies on cesarean section that evaluated maternal mood between 10 days and 1 year after delivery were reviewed. Nine methodologically superior studies, including the only randomized, controlled trial (RCT), were analyzed separately. The nine studies that provided adequate summary statistics were combined in a meta-analysis.

RESULTS

Of the 24 studies that have examined the association between cesarean section and postpartum depression, five found a significant adverse association, 15 found no significant association, and four found mixed results. With only one exception, methodologically superior studies found either no significant association or mixed evidence for an association between cesarean section and postpartum depression. Meta-analyses of suitable studies failed to find evidence for a significant association between cesarean section and postpartum depression. Possible reasons why different studies have obtained different results are critically evaluated.

CONCLUSION

A link between cesarean section and postpartum depression has not been established.

Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section

BACKGROUND

The primary aim was to investigate whether preoperative anxiety in women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Other factors that might influence postoperative satisfaction were also explored.

METHOD

In 85 women awaiting elective caesarean section, anxiety, social support and aspects of preparation were measured in the 24 hours preceding surgery. Maternal satisfaction and perceptions of recovery were assessed around the third postoperative day. Satisfaction with the preoperative information from the anaesthetist and postoperative pain relief were also measured at this time. Medical notes were used to gather information on analgesia use and length of hospital stay.

RESULTS

Preoperative anxiety scores were comparable with those of general surgical/medical patients. Preoperative trait anxiety and state anxiety were inversely associated with postoperative maternal satisfaction. State anxiety was also inversely associated with better recovery. Preoperative anxiety was not associated with analgesic use or length of hospital stay. Linear regression analysis indicated the degree of satisfaction with information from the anaesthetist and perceived emotional support from the partner explained 52% of the variance in postoperative maternal satisfaction.

CONCLUSION

Lower preoperative anxiety is associated with greater maternal satisfaction with elective caesarean section and better recovery. Information provided by anaesthetists and perceived emotional support are also of importance. It may be possible to identify women with high anxiety and facilitate satisfaction and recovery through providing additional supportive input.

The development and process evaluation of an information-based intervention for pregnant women aimed at addressing rates of caesarean section

OBJECTIVE

Few strategies aimed at addressing rising rates of caesarean section have explicitly involved information-based approaches for pregnant women. This study describes the development and evaluation of such an intervention for pregnant women, encompassing pamphlets and a peer support network (PSN).

DESIGN

Process evaluation.

SETTING

The study was undertaken at a metropolitan teaching hospital in Adelaide, South Australia.

POPULATION

A consecutive sample of pregnant women attending the ultrasound clinic over a two-month period, recruited at 18 weeks of gestation.

METHODS

Participants received two pamphlets at 18 weeks of gestation and information on a PSN at around 28 weeks of gestation. A questionnaire was sent to women at seven weeks postnatal, asking them to evaluate the intervention.

MAIN OUTCOME MEASURES

The extent to which the intervention resources were used and participants were satisfied with the resources they received.

RESULTS

Ninety-two women returned questionnaires (response rate of 62%). Women generally resisted engaging with the informational resources, citing irrelevance to their situation, for example, 53% (49/92) read all of the pamphlets. None of the women used the PSN. Women who had experienced childbirth previously and those of higher education were significantly more likely to read the pamphlets. While generally satisfied with pamphlet content, one in five women reported feeling distressed by some of the information.

CONCLUSIONS

This exploratory study casts doubt on the notion of information provision for pregnant women as a panacea for addressing rising rates of caesarean section.

Support from a prenatal instructor during childbirth is associated with reduced rates of caesarean section in a Mexican study

OBJECTIVE

to assess the association between non-clinical factors and the incidence of caesarean section (CS); to estimate the effect of a prenatal instructor's presence during childbirth on birth outcome (vaginal or CS).

DESIGN

cross-sectional study from a register of women who attended prenatal classes. Multivariate logistic regression was used to measure the effects of each variable on whether the birth was vaginal or CS.

SETTING

Mexico City, Mexico.

PARTICIPANTS

992 births to 847 women from the register of the Birth Education Centre (CEPAPAR) between 1987 and 2000.

FINDINGS

the incidence of CS was 33%. The most commonly reported (by the women) reason for performing a CS was dystocia (53%). Most women were middle or upper-middle class professionals, and 85% of the women gave birth in private institutions. Odds of having a CS were higher among women who gave birth in a large hospital, women who were over 25 years of age, primigravidae, and women who were not supported by a prenatal instructor during childbirth.

CONCLUSIONS

non-clinical factors considerably affect the type of birth outcome (vaginal vs. CS). A system in which a prenatal instructor provided support to the woman during childbirth could contribute significantly to reducing initial and repeat CS.

Protocol for the evaluation of a decision aid for women with a breech-presenting baby [ISRCTN14570598]

BACKGROUND: There is now good evidence about the management options for pregnant women with a breech presentation (buttocks or feet rather than head-first) at term; external cephalic version (ECV) - the turning of a breech baby to a head-down position and/or planned caesarean section (CS). Each of these options has benefits and risks and the relative importance of these vary for each woman, subject to her personal values and preferences, a situation where a decision aid may be helpful.Decision aids are designed to assist patients and their doctors in making informed decisions using information that is unbiased and based on high quality research evidence. Decision aids are non-directive in the sense that they do not aim to steer the user towards any one option, but rather to support decision making which is informed and consistent with personal values.The ECV decision aid was developed using the Ottawa Decision Support Framework, including a systematic review of the evidence about the benefits and risks of the options for breech pregnancy. It comprises an audiotape with a supplementary booklet and worksheet, a format that can be taken home and discussed with a partner. This project aims to evaluate the ECV decision aid for women with a breech presenting baby in late pregnancy. STUDY DESIGN: We aim to evaluate the effectiveness of the decision aid compared with usual care in a randomised controlled trial in maternity hospitals that offer ECV. The study group will receive the decision aid in addition to usual care and the control group will receive standard information on management options for breech presentation from their usual pregnancy care provider. Approximately 184 women with a single breech-presenting baby at greater than 34 weeks gestation and who are clinically eligible for ECV will be recruited for the trial.The primary outcomes of the study are knowledge, decisional conflict, anxiety and satisfaction with decision-making that will be assessed using self-administered questionnaires. The decision aid is not intended to influence either the uptake of either ECV or planned CS, however we will monitor health service utilisation rates and maternal and perinatal outcomes.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.

Making choices for childbirth: development and testing of a decision-aid for women who have experienced previous caesarean

This paper presents the development and pilot testing of an evidence-based decision-aid for pregnant women who have experienced previous caesarean section and who are considering options for birth in a subsequent pregnancy. The Ottawa Decision Support Framework (DSF) has been utilised and modified in the development of a tailored booklet entitled "Birth Choices: What is best for you...vaginal or caesarean birth?" Development included a review by women who had experienced previous caesarean birth as well as obstetric, midwifery and educational experts. The booklet was also reviewed for acceptability by 21 pregnant women who were facing this birth decision. Pre- and post-booklet preferences for birth were elicited and compared to actual birth outcomes. This decision-aid shows promise in facilitating informed decision-making in pregnancy. It is currently undergoing an evaluation in a multi-centre randomised controlled trial.

Prevention of urinary and anal incontinence: role of elective cesarean delivery

PURPOSE OF REVIEW

Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking.

RECENT FINDINGS

Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor.

SUMMARY

Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.

Cesarean section on demand

The safety of cesarean section has improved dramatically over the past 50 years. During the past 20 years a greater awareness of and discussion about the symptomatic morbidity that can result for women following vaginal delivery has occurred and women's expectations for the outcome of pregnancy for them and their babies has increased. A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by cesarean section rather than the reverse. With the balance in favor of benefit for the baby from delivery by cesarean section, it is now difficult to sustain the argument favoring vaginal delivery rather than planned cesarean section, using maternal morbidity and mortality statistics. A critical evaluation of the costs indicates that there are probably few grounds for denying women their request for cesarean section for economic reasons. It seems likely, therefore, that in the near future those advising women on the options for delivery will need to ensure that the risks of vaginal delivery are explained as well as those for planned cesarean section.

Postpartum depression: prevalence and determinants in Lebanon

This study assesses the prevalence and determinants of postpartum depression (PPD). 396 women delivering in Beirut and a rural area (Beka'a Valley) were interviewed 24 hours and 3-5 months after delivery. During the latter visit, they were screened using the Edinburgh postnatal depression scale. The overall prevalence of PPD was 21% but was significantly lower in Beirut than the Beka'a Valley (16% vs. 26%). Lack of social support and prenatal depression were significantly associated with PPD in both areas, whereas stressful life events, lifetime depression, vaginal delivery, little education, unemployment, and chronic health problems were significantly related to PPD in one of the areas. Prenatal depression and more than one chronic health problem increased significantly the risk of PPD. Caesarean section decreased the risk of PPD, particularly in Beirut but also in the Beka'a Valley. Caregivers should use pre- and postnatal assessments to identify and address women at risk of PPD.

Strategies to address global cesarean section rates: a review of the evidence

BACKGROUND

The steadily increasing global rates of cesarean section has become one of the most debated topics in maternity care. This paper reviews and reports on the success of strategies that have been developed in response to this continuing challenge.

METHODS

A literature search identified studies conducted between 1985 and 2001 from the Cochrane Database of Systematic Reviews, Medline, Sociofile, Current Contents, Psyclit, Cinahl, and EconLit databases. An additional search of electronic databases for Level 1 evidence (systematic reviews), Level 2 (randomized controlled trials), Level 3 (quasi-experimental studies), or Level 4 (observational studies) was performed. Selection criteria used to identify studies for review included types of study participant, intervention, outcome measure, and study.

RESULTS

Interventions that have been used in an attempt to reduce cesarean section rates were identified; they are categorized as psychosocial, clinical, and structural strategies. Two clinical interventions, (external cephalic version, vaginal birth after a previous cesarean) and one psychosocial intervention (one-to-one trained support during labor) demonstrated Level 1 evidence for reducing cesarean section rates.

CONCLUSIONS

Although the evidence for one-to-one care and external cephalic version came from both developed and developing settings, the systematic review for vaginal birth after a cesarean was restricted to studies conducted in the United States. The effective implementation of the preceding strategies to reduce cesarean rates may depend on the social and cultural milieu and on associated beliefs and practices.

Women's perceptions and experiences of childbirth in United Arab Emirates

AIMS

To determine women's perceptions and experiences of childbirth in United Arab Emirates [UAE].

METHODS

A consecutive sample of 715 women who delivered during a 3 month period wer interviewed on the third postnatal day about their experience and satisfaction with maternity care using a structured questionnaire.

RESULTS

95 (13.2%) women had negative feelings including fear, anger, sorrow and regret, guilt, jealousy, sense of failure and disappointment while the rest felt that childbirth was enjoyable and that they had been well-informed, especially by nurses, about their perinatal care. Subjects delivered by cesarean (N = 104, 14.5%) were significantly less satisfied with the information provided by their caregivers and their involvement in decision-making before the operation than the vaginal group (p = 0.001). Irrespective of mode of delivery, most participants strongly agreed that cesarean is worse than vaginal delivery whatever the reason and should be performed only for medical reasons. Adverse maternal experiences were significantly more frequent with cesarean delivery (p = 0.00001), older age (p = 0.04), primiparity (p = 0.03), higher education (p = 0.03), lack of antenatal care (p = 0.03) and prolonged labor (p = 0.04).

CONCLUSIONS

Childbirth experience and the prevalence and correlates of postnatal psychosocial morbidity in UAE are not different from those observed elsewhere.

Psychological aspects of caesarean section

This chapter gives an overview of research relating to psychological aspects of caesarean section. It focuses on four main questions: *What are the psychological effects of caesarean section on the mother, her partner and her relationship with her infant? *What factors (obstetric, psychological, attitudinal, and health care-related) make women more vulnerable to adverse psychological outcomes after a caesarean section? *What are women distressed about when they have had a caesarean section? *How can post-caesarean psychological distress be prevented or managed?A methodological critique of existing studies on psychological aspects of caesarean section is also given. In conclusion, recommendations for practice and for future research are made.

Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study

BACKGROUND

To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio-economic background, predict disappointment with delivery and the risk of puerperal depression.

METHODS

Two hundred and eleven women filled in questionnaires measuring personality traits, socio-economic factors, and marital satisfaction once before and once after the 30th week of pregnancy, and 2 3 months after delivery, when obstetric data about pregnancy and delivery was also collected.

RESULTS

The women who were disappointed with their delivery or suffered from puerperal depression had been more depressed already in early pregnancy. Regression analysis showed that the strongest predictors of disappointment with delivery were labor pain (increase in R2 = 0.14, p<0.001) and emergency Cesarean (increase in R2 = 0.18, p<0.001). Puerperal depression was predicted by depression (increase in R2 = 0.16, p<0.001), and by personal traits such as general anxiety, vulnerability and neuroticism (increase in R2 = 0.32, p<0.001), both before 30 weeks of pregnancy and prior to the delivery (for depression increase in R2 = 0.05, p<0.001, and for anxiety and vulnerability increase in R2 = 0.04, p<0.01). The strongest predictors were depression at both time points before delivery (beta = 0.51, p<0.001, and beta = 0.39, p<0.001). Pregnancy- and delivery-related anxiety prior to the delivery also predicted puerperal depression, but complications of the pregnancy and delivery did not.

CONCLUSIONS

Depression in early pregnancy predicts disappointment with the delivery and is a strong predictor of puerperal depression.

Women's request for a cesarean section: a critique of the literature

BACKGROUND

The consistently high cesarean section rate in most developed Western countries has been attributed in part to maternal request. This controversial view demands critical analysis. This paper provides a critique of published research relating to women's request for cesarean delivery.

METHOD

A search of the major databases was undertaken using the search term "cesarean section" with "maternal request," "decision-making," "patient-participation," "decision-making-patient," "patient-satisfaction," "patient-preference," and "maternal-choice." Ten research articles examining women's preferred mode of birth were retrieved, nine of which focused on women's preference for cesarean delivery.

RESULTS

The methodology of some studies may result in overreporting women's request for a cesarean delivery. The role of the woman's caregiver in the generation, collection, and entry of data, and the occurrence of post hoc rationalization, recall bias, and women's tendency to be less critical of their care immediately after birth are possible areas of concern. Due consideration is rarely given to the influence of obstetric risk for women who may be requesting a cesarean section or to the information women used in making their decision. Women's perceptions of their involvement in decision-making regarding cesarean section are used to draw conclusions regarding women's request.

CONCLUSIONS

Few women request a cesarean section in the absence of current or previous obstetric complications. The focus on women's request for cesarean section may divert attention away from physician-led influences on the continuing high cesarean section rates.

Caesarean section delivery in Kerala, India: evidence from a National Family Health Survey

Ensuring safe pregnancy and motherhood occupies a pivotal role and has been considered as one of the key issues in the framework of reproductive and child health programmes. Evidence from research studies indicate that there is a growing tendency for caesarean section deliveries especially during complications confronted at the time of pregnancy and delivery. The present study focuses on the demographic, antenatal care, spatial and socio-economic variables associated with caesarean section delivery in Kerala, India. The data from the National Family Health Survey has been utilised for this purpose. The results from logistic regression models indicate that maternal age, birth order, current age, births in health institutions and spatial differences were significantly associated with caesarean section deliveries in Kerala. The older cohorts of mothers were found at higher risk to have caesarean section when compared to their younger counterparts. When controlled for demographic variables, the odds for caesarean section was about 1.7 times more likely to occur in private health institutions. The inclusion of spatial and socio-economic variables has neither influenced the demographic and antenatal care variables nor showed any significant association with caesarean section delivery in the state. The present study calls for that a detailed investigation on behavioural aspects of both the physician and the patient with regard to type of delivery in the state. Information related to pregnancy and health related aspects needs to be monitored more accurately, both in the public and private hospitals, to understand the determinants associated with caesarean section.

Inter-hospital variations in caesarean sections. A risk adjusted comparison in the Valencia public hospitals

BACKGROUND

The aim of this study was to describe the variability in caesarean rates in the public hospitals in the Valencia Region, Spain, and to analyse the association between caesarean sections and clinical and extra-clinical factors.

METHODS

Analysis of data contained in the Minimum Basic Data Set (MBDS) compiled for all births in 11 public hospitals in Valencia during 1994-1995 (n=36 819). Bivariate and multivariate analyses were used to evaluate the association between caesarean section rates and specific risk factors. The multivariate model was used to construct predictions about caesarean rates for each hospital, for comparison with rates observed.

RESULTS

Caesarean rates were 17.6% (inter-hospital range: 14.7% to 25.0%), with ample variability between hospitals in the diagnosis of maternal-fetal risk factors (particularly dystocia and fetal distress), and the indication for caesarean in the presence of these factors. Multivariate analysis showed that maternal-fetal risk factors correlated strongly with caesarean section, although extra-clinical factors, such as the day of the week, also correlated positively. After adjusting for the risk factors, the inter-hospital variation in caesarean rates persisted.

CONCLUSIONS

Although certain limitations (imprecision of some diagnoses and information biases in the MBDS) make it impossible to establish unequivocal conclusions, results show a high degree of variability among hospitals when opting for caesarean section. This variability cannot be justified by differences in obstetric risks.

Women's perceptions of caesarean section: reflections from a Turkish teaching hospital

Caesarean section as a contentious topic has attracted attention world-wide and different dimensions of the issue has been investigated. The primary reason behind these initiatives have been the upsurge of caesarean sections both in the developed and developing world and the realisation that the operation may not always contribute positively to the mother's and baby's health. By contrast, several studies have demonstrated both the short and long term negative effects. Research has also revealed that factors other than medical necessity play an important role in the decision to perform a caesarean section. Turkey, although reliable data does not exist, can be classified among the countries experiencing the caesarean epidemic, at least among highly educated and wealthy mothers. This research, exploring the perceptions of mothers in a teaching hospital with a high caesarean rate, is a rare example of its kind in Turkey. The main finding is the dissatisfaction of the mothers undergoing caesareans during their stay in the hospital.

Sequelae of cesarean and vaginal deliveries: psychosocial outcomes for mothers and infants

Mother-infant dyads grouped according to whether the infants had been delivered vaginally (n = 74) or by planned (n = 37) or unplanned cesarean (n = 56) were compared on psychosocial outcomes at 4 and 12 months postpartum. Hypotheses were that unplanned cesarean delivery would be related to less optimal outcomes and that this relationship would be mediated by mother's appraisal of the delivery and would attenuate over time. No delivery-related differences in mother-infant interactions were found at 4 or 12 months postpartum with one exception: Women low in neuroticism who delivered by unplanned cesarean showed less positive affect toward their infants at 4 months than did women high in neuroticism who delivered by unplanned cesarean or women in any other group. There was some evidence of the mediating role of maternal appraisal of the delivery on these effects. In general, the results indicate little cause for concern about the quality of mother-infant interactions following cesarean deliveries.

Subsequent obstetric performance related to primary mode of delivery

OBJECTIVE

To relate subsequent obstetric performance with primary mode of delivery.

DESIGN

Postal questionnaire survey of women who delivered their first child five years ago.

SETTING

Huddersfield Royal Infirmary.

POPULATION

Women who were delivered of their first baby in 1991: 250 by normal vaginal delivery; 250 by instrumental vaginal delivery; and 250 by caesarean section.

MAIN OUTCOME MEASURES

Answers to fixed choice questions on fear of future childbirth, number of subsequent children and reasons for no further children.

RESULTS

The response rate was 64%. Overall, 222 (46.6%) women were initially frightened about future childbirth. According to mode of delivery: 93 (57.1%) after instrumental vaginal; 79 (47.9%) after caesarean section; and 50 (33.8%) after normal vaginal delivery. Five years after the primary delivery, 99 women (20.8%) were still frightened about future childbirth: instrumental vaginal group 41 (25.2%); caesarean section group 43 (26.1%); and normal vaginal group 15 (10.1%). In the group of women who were delivered by caesarean section 13% more women had not had a second child after five years compared with the normal vaginal delivery group ((P < 0.03, relative risk 1.46 (1.07-1.99)). In the group of women who had a vaginal instrumental delivery 6% more had not had a second child after five years compared with normal vaginal delivery group. Of the women who had no further children, 30% who had caesarean section and 28% vaginal instrumental delivery had involuntary infertility.

CONCLUSIONS

Caesarean section or vaginal instrumental delivery leaves many mothers frightened about future childbirth. Primary caesarean section and to some extent vaginal instrumental delivery is associated with an increased risk of voluntary and involuntary infertility.

Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study

OBJECTIVE

This paper reports the findings of a prospective longitudinal study of 272 nulliparous pregnant women, which investigated as one of its objectives the psychological sequelae of obstetric procedures.

METHOD

Participants completed structured interviews and standardised, published psychometric questionnaires, including the Rosenberg Self-Esteem Scale and the Profile of Mood States late in pregnancy and again early in the postpartum period.

RESULTS

Little evidence was found to support the notion that the total number of obstetric interventions was linked to a deterioration in postpartum mood. Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem.

CONCLUSIONS

The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression.

College students' knowledge and attitudes about cesarean birth

BACKGROUND

Numerous clinicians and researchers have expressed concern about the necessity and potential adverse consequences of many cesarean births in the United States. The purpose of this study was to explore college students' attitudes and beliefs about cesarean section.

METHODS

One hundred two college students (66% women) completed a 20-item questionnaire that asked if they viewed cesarean delivery as a potentially negative experience, as a normal or acceptable method of childbirth, and as medically necessary, and asked about their beliefs concerning risk and prevention of cesarean birth.

RESULTS

The number of "undecided" responses in the study was striking (7.8% to 69.6% across the 20 items). In general, women and men responded similarly, although women were significantly more likely than men to say they would be profoundly disappointed if their babies had to be delivered by cesarean section. Despite expressing cynicism about the cesarean birth rate (40% agreed that many unnecessary cesarean births occurred) and not viewing the procedure as a normal way of giving birth (47%), most respondents (over 70%) disagreed that giving birth by cesarean would be a negative experience or would make a woman feel like a failure.

CONCLUSION

A high level of uncertainty exists about certain aspects of cesarean birth among young women and men, highlighting the need for information for prospective parents. Most college students did not view the cesarean birth experience as either potentially negative or normal. Future research should explore coverage of cesarean birth in childbirth education classes and the roles physicians, nurses, and midwives play in preparing expectant parents for the possibility of cesarean delivery.

Explaining excessive rates of cesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development

The current rate of cesarean sections in the U.S. is too high. Numerous mothers and babies are being placed at unnecessary risk of medical, behavioral and psychological complications. The problem has proven resistant to solution on a large scale, despite serious efforts on the part of a variety of individuals and groups. This paper considers reports on the interactions between obstetricians and mothers in labor in light of findings and theory in the areas of gender and psychosocial development. Examination of processes and standards of care in light of these findings and theory leads to the conclusion that the present model of obstetric services is consistent with a masculine style, and offers far less than optimal care for women. In fact, the gender-inappropriate elements of the model itself probably contribute to the excessive rates of interventions in labor. Social, political and historical factors are seen to support the obstetric model as is, leading to some pessimism about the possibility that the model could be modified sufficiently without major social change. The obstetric model is compared briefly with the more gender appropriate model of care provided by midwives.

Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births?

In studies using matched or adjusted cohorts, U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals. This cesarean reduction involved no compromise in mortality and morbidity outcome measures. Moreover, groups of women at elevated risk for adverse perinatal outcomes have attained excellent outcomes and cesarean rates well below the general population rate with these care arrangements. How do midwives and out-of-hospital birth settings so effectively help women to avoid unnecessary cesareans? This paper explores this question by presenting data from interviews with midwives who work in home settings. The midwives' understanding of and approaches to major medical indications for cesarean birth contrast strikingly with prevailing medical knowledge and practice. From the midwives' perspective, many women receive cesareans due to pseudo-problems, to problems that might easily be prevented, or to problems that might be addressed through less drastic measures. Policy reports addressing the problem of unnecessary cesarean births in the U.S. have failed to highlight the substantial reduction in such births that may be expected to accompany greatly expanded use of midwives and out-of-hospital birth settings. The present study--together with cohort studies documenting such a reduction, studies showing other benefits of such forms of care, and the increasing reluctance of physicians to provide obstetrical services--suggests that childbearing families would realize many benefits from greatly expanded use of midwives and out-of-hospital birth settings.

Medically unnecessary cesarean section births: introduction to a symposium

Between 1965 and 1986, the United States cesarean section rate increased from 4.5 to 24.1%. Increasingly, childbearing women and their advocates, along with many others, have recognized that a large proportion of cesareans confers a broad array of risks without providing any medical benefit. A growing literature examines the diverse causes of medically unnecessary cesareans and the diverse effects of surgical birth on women, infants, and families. Various programs and policies have been proposed or implemented to reduce cesarean rates. In recent decades, many other nations have also experienced a sharply escalating cesarean section rate. It is reasonable to conclude that a largely uncontrolled international pandemic of medically unnecessary cesarean births is occurring. The level of political, analytic, and programmatic activity that has occurred in the U.S. regarding medically unnecessary surgical births does not seem to be paralleled in other nations with sharply escalating rates. This symposium was organized with the objective of presenting the U.S. experience with various dimensions of the problem of medically unnecessary cesareans to an international audience. Although preliminary and inadequate, it is hoped that this experience will encourage policy leaders and investigators throughout the world to recognize and address the problem of run-away cesarean section births. The first section of this introduction summarizes the U.S. experience with medically unnecessary cesareans from the perspective of trends, causes, consequences, and solutions. The second section covers the same topics, presenting selected material from various other nations throughout the world. In the course of these overviews, I introduce the symposium's seven contributions, most of which focus on circumstances in the U.S.