Elective Cesarean births: are women making emancipated decisions?

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Informed Decision Making Regarding Prenatal Aneuploidy Screening

OBJECTIVE

To explore informed decision making for prenatal aneuploidy screening (PAS) by investigating the relationships among women's understanding of PAS, their health literacy, and their satisfaction with their decisions regarding PAS.

DESIGN

A descriptive, cross-sectional, correlational study.

SETTING

Southeastern United States.

PARTICIPANTS

Ninety-five adult women who were at least 18 weeks pregnant; most were White non-Hispanic (n = 75, 78.9%) and college educated (n = 56, 59.0%).

METHODS

Potential participants were invited to complete an online survey that was distributed via e-mail to recipients of an electronic pregnancy and parenting newsletter. The survey included questions about women's understanding of PAS, their health literacy, and their satisfaction with their decisions regarding PAS based on three validated instruments. I used descriptive statistics, bivariate correlational analysis, and multiple linear regression to analyze the data.

RESULTS

Higher level of education (β =.225, p = .038) and higher scores from the Health Literacy Questionnaire's scale Ability to Actively Engage With Health Care Providers (β =.317, p = .004) were significantly associated with increased understanding of PAS. Higher scores on two scales from the Health Literacy Questionnaire, Feeling Understood andSupportedby Health Care Providers (β =.329 , p = .004) and Ability to Find Good Health Information (β = .402, p = .013), were significantly associated with greater satisfaction with decisions regarding prenatal aneuploidy screening. Forty-two percent (n = 40) of participants did not report satisfaction with PAS.

CONCLUSION

A woman's health literacy and her ability to actively engage with health care providers are critical for informed decision making about PAS. Findings highlight the need for woman-centered strategies to promote open and intentional communication about PAS.

Is it the decision of women to choose a cesarean section as the mode of birth? A review of literature on the views of stakeholders

BACKGROUND

A debate on the decision of women to choose a cesarean section as the mode of birth in uncomplicated pregnancies from the views of relevant stakeholders.

MAIN TEXT

Using five electronic databases, a literature search was conducted for studies published from January 2003 to December 2016. Studies on a woman's right to request or to choose a cesarean section as the mode of birth in uncomplicated pregnancies were included. Fifty-five articles were identified (39 research studies and 16 opinion-based articles). Among health professionals, obstetricians were the most supportive of this right. It is argued that although women reported wanting to choose the mode of birth, with the safety of their babies as the priority, they also relied on the advice of their maternity care provider and considered it the responsibility of their obstetrician to make the decision. A higher proportion of the general public in countries with well-developed private healthcare accepted that a woman should have the freedom to choose the mode of birth.

CONCLUSIONS

This review provided a debate on the choice of pregnant women in uncomplicated pregnancies on the mode of birth from various stakeholders. Further research is required to explore what the meanings of autonomy of pregnant women to choose the mode of birth, and the process that they go through when making this decision.

First-Time Mothers' Experiences of a Planned Cesarean Birth

Even though a cesarean birth is planned, women may experience physical and psychological difficulties. This qualitative study explored the overall experience of first-time mothers having a planned cesarean birth, which was any cesarean in which the decision was made prior to the onset of labor or labor induction. Eleven primipara postpartum mothers shared their stories. Data were analyzed using Riessman's method of thematic narrative analysis. Seven overarching themes revealed a need to accept a cesarean birth and create realistic expectations. Education and support specific to planned cesarean births need to be provided to the woman and her support person both before and after the birth. Realistic expectations will improve the adaptation process.

Development and revision of the Wittmann-Price Emancipated Decision-Making Scale

BACKGROUND AND PURPOSE

The original Emancipated Decision-Making (EDM) scale was revised to test 3 subconcepts (flexible environment, personal knowledge, and awareness of social norms) of an emancipated decision-making process.

METHODS

The original EDM scale was significantly related to the Satisfaction with Decision (SWD) scale in two separate studies (r = 0.79, r = 0.59). Two of the original 5 subconcepts showed a lack of contribution. The third study (N = 50) had good total scale reliability (r = 0.89).

RESULTS

The revised EDM (EDM-r) scale was then leveled to the SWD scores and quantified into 2 categories and the subscales for the 3 subconcepts were reanalyzed for reliability and scale-if-item contribution.

CONCLUSION

The final EDM-r is a generically worded, 20-item, 3-subscale instrument with good total and individual subscale reliability.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).

Women's decision-making regarding medication use in pregnancy for anxiety and/or depression

AIM

To increase understanding of women's decision-making process concerning the medication use for anxiety and/or depression while pregnant.

BACKGROUND

Anxiety and depression affects many pregnant women, yet the decision to take psychotropic medication is complex and possibly subject to social oppression.

DESIGN

Cross-sectional descriptive survey design.

METHODS

A web-based survey was used to collect data from a convenience sample of 143 pregnant women over 3 months beginning in early 2011. An independent t-test was conducted to determine differences in satisfaction between women with high and low levels of emancipated decision-making (EDM). A multiple regression analysis was conducted to determine which subscales of the emancipation scale best predict level of satisfaction with the decision.

FINDINGS

The majority of respondents were White, between 25-34 years of age. The group with lower levels of emancipation reported lower mean satisfaction scores compared with those with higher levels of emancipation. Regression analysis showed that the three subscale emancipation model was a statistically significant predictor of satisfaction with the decision and accounted for 54% of the variance in satisfaction. The subconcept of personal knowledge was most predictive of satisfaction with decision.

CONCLUSIONS

Women may be able to overcome oppressive forces by using an EDM process. EDM allows them to make a decision that feels right for them and to feel satisfied with the decision.