Cesarean section on request in a developing country

Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries

OBJECTIVE

To measure the proportion of women's preferences for CS in hospitals with high caesarean section rates and to identify related factors.

DESIGN

A cross-sectional hospital-based postpartum survey was conducted. We used multilevel multivariate logistic regression and probit models to analyse the association between women's caesarean section preferences and maternal characteristics. Probit models take into account selection bias while excluding women who had no preference.

SETTING

Thirty-two hospitals in Argentina, Thailand, Vietnam and Burkina Faso were selected.

PARTICIPANTS

A total of 1,979 post-partum women with no potential medical need for caesarean section were included among a representative sample of women who delivered at each of the participating facilities during the data collection period.

FINDINGS

The overall caesarean section rate was 23.3 %. Among women who declared a preference in late pregnancy, 9 % preferred caesarean section, ranging from 1.8 % in Burkina Faso to 17.8 % in Thailand. Primiparous women were more likely to prefer a caesarean section than multiparous women (β=+0.16 [+0.01; +0.31]; p = 0.04). Among women who preferred caesarean section, doctors were frequently cited as the main influencers, and "avoid pain in labour" was the most common perceived benefit of caesarean section.

KEY CONCLUSIONS

Our results suggest that a high proportion of women prefer vaginal birth and highlight that the preference for caesarean section is linked to women's fear of pain and the influence of doctors. These results can inform the development of interventions aimed at supporting women and their preferences, providing them with evidence-based information and changing doctors' behaviour in order to reduce the number of unnecessary caesarean sections.

CLINICAL TRIAL REGISTRY

The QUALI-DEC trial is registered on the Current Controlled Trials website (https://www.isrctn.com/) under the number ISRCTN67214403.

Exploring Vaginal Birth After Cesarean: Success Rates and Cultural Decisions in the United Arab Emirates

OBJECTIVE

This study explores the success rates and cultural influences on the decision-making process for vaginal birth after cesarean (VBAC) in the United Arab Emirates (UAE).

METHODOLOGY

An observational cohort study was conducted at a hospital in the UAE accredited by Joint Commission International, enrolling 263 women eligible for VBAC from March 1, 2018, to February 28, 2019. The study focused on maternal-fetal outcomes, the proportions of women opting for trial of labor after cesarean (TOLAC) versus elective repeat cesarean section (ERCS), and the impact of cultural backgrounds on these decisions.

RESULTS

The study found significant cultural variations in VBAC acceptance and success rates. Among local Emirati/Omani women, 86% (152 out of 177) opted for TOLAC, with an 83% success rate (126 out of 152). In contrast, lower TOLAC uptake and success rates were observed among other nationalities, such as Egyptian and other Arab women. The study also noted higher VBAC success rates in women with prior vaginal deliveries and those who experienced spontaneous labor. NICU admissions and maternal readmissions were lower in the TOLAC group (1% NICU admissions and 2% maternal readmissions) compared to the ERCS group (8.2% NICU admissions).

CONCLUSION

The study underscores the influence of cultural factors in VBAC decision-making and outcomes, highlighting the need for culturally tailored counseling and care. It also confirms the safety and efficacy of VBAC in appropriately selected cases, advocating for more research into counseling practices and long-term outcomes in culturally diverse populations. Impact statement: This research adds to the understanding of how cultural and ethnic backgrounds influence VBAC decisions and outcomes, offering critical insights for clinical practice, especially in multicultural societies like the UAE. It emphasizes the role of tailored counseling and suggests avenues for future research in this domain.

Caesarean Section on Maternal Request-Ethical and Juridic Issues: A Narrative Review

In recent decades, the rate of caesarean deliveries has increased worldwide. The reasons for this trend are still largely misunderstood and controversial among researchers. The decision often depends on the obstetrician, his beliefs and experience, the characteristics of the patients, the hospital environment and its internal protocols, the increasing use of induction of labor, the medico-legal implications, and, finally, the mother's ability to request delivery by caesarean section without medical indication. This review aims to describe the reasons behind the increasing demand for caesarean sections by patients (CDMR) and strategies aimed at reducing caesarean section rates and educating women about the risks and benefits of CS.

Pentazocine with rectal diclofenac versus pentazocine alone for pain relief following caesarean delivery in Enugu, Nigeria: A randomized controlled trial

Objective

To measure postoperative pain relief following the use of rectal diclofenac combined with intramuscular pentazocine compared with intramuscular pentazocine alone in patients undergoing a caesarean delivery.

Methods

This single-blind randomized controlled trial enrolled pregnant women that had a caesarean section at the Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria. Study participants were randomized to receive either 100 mg of rectal diclofenac given every 12 h plus 30 mg of intramuscular pentazocine given every 6 h (group A) or 60 mg of intramuscular pentazocine given every 6 h (group B). The primary outcome was the level of pain as measured using a visual analogue scale. The secondary outcomes were the level of satisfaction with pain relief and need for rescue analgesia.

Results

A total of 200 participants were randomized equally into the two groups. Participants in group A had significantly better pain control and satisfaction over the 48 h after surgery compared with group B. Significantly more of group B required rescue analgesia for breakthrough pain compared with group A.

Conclusion

Rectal diclofenac combined with intramuscular pentazocine was significantly better at controlling pain compared with pentazocine alone in the first 48 h following caesarean section.

Trial registration number: PACTR202107706925314 at www.pactr.org on 28 July 2021.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BACKGROUND

A high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the "Two-child Policy" in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.

METHODS

Data were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.

RESULTS

The rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984-9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116-14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311-0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007-16.455).

CONCLUSIONS

"Maternal request" has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement

Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.

Global incidence of caesarean deliveries on maternal request: a systematic review and meta-regression

BACKGROUND

Caesarean delivery on maternal request (CDMR) is considered a significant contributor to the unprecedented increase in caesarean deliveries (CDs) for nonclinical reasons. Current literature lacks a reliable assessment of the rate of CDMR, which hinders the planning and delivery of appropriate interventions for reducing CDMR rates.

OBJECTIVES

To conduct a systematic review of the literature and meta-regression to explore the global incidence of CDMR.

SEARCH STRATEGY

PubMed, Embase, CINAHL, Medline, Google scholar and grey literature were searched from January 1985 to May 2019.

SELECTION CRITERIA

Observational studies that report CDMR data were included. We excluded non-English articles, case notes, editorial reviews and articles reporting elective CDs from pregnancy risk factors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. The weighted average of CDMR over total deliveries (absolute proportion) and by total CDs (relative proportion) were generated. Quality-effects meta-regression was used to explain the variability of the CDMR estimates by moderators, including study methodology and demography of study participants.

MAIN RESULTS

We identified 31 articles from 14 countries that include 5 million total births. The absolute proportion of CDMR varies between 0.2 and 42.0%, with significant variations across studies and subgroups. The economic status of the country and study year together explained 84% of the absolute and 76% of the relative proportion of CDMR variation.

CONCLUSIONS

An appropriate reporting of CDMR should be a key priority in maternal health policies and practices.

TWEETABLE ABSTRACT

Globally, the proportion of maternal requested caesarean delivery has mostly been influenced by the economic status of the country.

Reasons for elective cesarean section on maternal request: a systematic review

Background: Given the increasing rate of cesarean delivery and request without maternal or fetal indication among pregnant women, this systematic review was conducted to obtain the reasons for maternal request for elective cesarean section.Methods: We searched published studies from the first year of records through August 2018 in PubMed, Scopus, and Web of Science. The quality assessment of the studies was performed by the improved Newcastle-Ottawa Scale. Due to data heterogeneity; no meta-analysis was performed.Results: Twenty-eight studies met the inclusion criteria and were included in the review. The results of studies on the reasons of maternal request for elective cesarean section were fear of labor pain, anxiety for fetal injury/death, fear of childbirth, urinary incontinence, pelvic floor and vaginal trauma, doctors suggestion, time of birth, experience of prior bad delivery, previous infertility, infertility, anxiety for gynecologic examination, anxiety for loss of control, avoid long labor, anxiety for lack of support from the staff, fear of fecal, emotional aspects, body weight of the infant at birth and abnormal prenatal examination. The results of studies on the demographic reasons of maternal request for elective cesarean section were advanced maternal age, parity, occupation, education, maternal obesity, family status, decreasing level of religiosity, household income, number of living children and age at marriage.Conclusions: Our study proposed that the comprehensive programs and the interventions of health promotion should be designed to reduce unnecessary cesarean section and improve the performance of vaginal delivery.

How is women's demand for caesarean section measured? A systematic literature review

Background

Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women’s demand for caesarean sections.

Question

The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies.

Methods

This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women’s demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed.

Findings

The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found.

Discussion

Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries.

Conclusion

We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.

B Butterfly Campaign: A social marketing campaign to promote normal childbirth among first-time pregnant women

PROBLEM

The steep increase and inappropriateness of caesarean birth represent a healthcare problem in Iran.

AIM

The purpose of study was to evaluate the effect of a campaign based on social marketing to promote normal childbirth.

METHOD

The study was designed as a prospective case control study. The social marketing campaign was implemented from March 2016 to January 2017. A demographic data questionnaire, obstetrical history questionnaire, maternal knowledge assessment questionnaire, and maternal health belief questionnaire comprised the instruments for this study. Only women planning a caesarean birth without any medical indications for the caesarean were enrolled in the study as a case. Those who met the same inclusion criteria and did not want to participate in the campaign were assigned to the control group.

FINDINGS

In total, 350 first-time pregnant women who composed the campaign group (n=194) and control group (n=156) completed the study. The mean baseline level of knowledge and Health Belief Model component score did not differ between the two groups at baseline. However, after the campaign, knowledge scores, perceived severity, perceived susceptibility, self-efficacy, and cues to action scores differed significantly between the campaign and control groups. The follow-up of all participants in both groups showed that 35.6% (n=69) of participants in the campaign group chose natural birth as their birth method, whereas only 13.5% (n=21) in the control group delivered their newborn vaginally.

CONCLUSION

The B Butterfly social marketing campaign successfully targeted first-time pregnant women who chose to have unnecessary elective cesarean births.

Socio-cultural factors, gender roles and religious ideologies contributing to Caesarian-section refusal in Nigeria

Background

The death of women from pregnancy-related causes is a serious challenge that international development initiatives, including the Millennium Development Goals, have been trying to redress for decades. The majority of these pregnancy-related deaths occur in developing countries especially in Sub-Saharan Africa. The provision of Emergency Obstetric Care (EmOC), including Caesarean section (CS) has been identified as one of the key ingredients necessary for the reduction of high maternal mortality ratios. However, it appears that creating access to EmOC facilities is not all that is required to reduce maternal mortality: socio-cultural issues in Sub-Saharan countries including Nigeria seem to deter women from accepting CS. This study seeks to explore some of the socio-cultural concerns that reinforce delays and non-acceptance of CS in a Nigerian community.

Methods

This is a mixed method study that combined both qualitative and quantitative strategies of enquiry. The hospital’s delivery records from 2006–2010 provided data for quantitative analysis. This quantitative data was supplemented with prospective data collected during one month. Semi-structured interviews, focus group discussions (FGD) and informal observations served as the sources of data on the qualitative end.

Results

In total, 22 % of maternity clients refused CS and more than 90 % of the CSs in the focal hospital were emergencies which may indicate late arrival at the hospital after seeking assistance elsewhere. The qualitative analysis reveals that socio-cultural meanings informed by gender and religious ideologies, the relational consequences of having a C-section, and the role of alternative providers are some key factors which influence when, where and whether women will accept C-section or not.

Conclusion

There is need to find means of facilitating necessary CS by addressing the prevailing socio-cultural norms and expectations that hinder its acceptance. Engaging and guiding alternative providers (traditional birth attendants and faith healers) who wield much power in their communities, will be important to minimize delays and improve cultural acceptability of CS.

Effect of multiple repeat cesarean sections on maternal morbidity: data from southeast Turkey

BACKGROUND

Cesarean section (CS) is one of the most common obstetric procedures worldwide and an increased rate of cesarean section has been observed in recent studies. Maternal and fetal mortality and morbidity associated with cesarean section is an important health problem worldwide. This requires the evaluation of the effect of repeated cesarean delivery on maternal morbidity.

MATERIAL/METHODS

A total of 2460 patients who underwent delivery by CS at a center in southeast Turkey between January 2012 and January 2014 (24 months) were included in the study. The patients were divided into 5 groups according to the number of CSs, and the maternal and neonatal outcomes of the groups were retrospectively evaluated.

RESULTS

A statistically significant difference was found between the groups in terms of maternal age, education level, time of hospitalization, operating time, the presence of dense adhesions, bowel and bladder injury, the presence of placenta previa, hysterectomy, blood transfusion requirements, and need for intensive care (p<0.05). Placenta previa (OR, 11.7; 95% CI, 2.6-53.2) and placenta accreta (OR, 12.2; 95% CI, 3.9-37.8) were found to be important risk factors in terms of the need for hysterectomy. No statistically significant difference was found between the groups for gestational age at birth, birth weight, fifth-minute APGAR score, preoperative and postoperative hemoglobin levels, uterine rupture, wound infection, wound dehiscence, placenta accreta, maternal death, and endometritis (p>0.05). A total of 4 or more CSs was identified as the critical level for most of the major complications.

CONCLUSIONS

An increasing number of CSs is accompanied by serious maternal complications. Four or more CSs are of especially critical importance. Decreasing the number of cesarean sections is required to decrease relevant complications. Vaginal birth after CS is an option that should be recommended to the patient.

A Randomized Study Comparing Skin Staples with Subcuticular Sutures for Wound Closure at Caesarean Section in Black-Skinned Women

This study aimed to compare patients' satisfaction and outcome of caesarean section wound closure by skin staples and subcuticular suture at discharge and 6 weeks of postoperation. It was a randomized controlled trial of pregnant women scheduled for caesarean section at the University College Hospital, Ibadan, Nigeria, allocating them to wound closure by skin staples or subcuticular suture. Pain was assessed using the box numeric pain scale. Scar assessments were by patient, research nurse, and independent observers using the visual analogue scale, modified patient observer scar assessment scale, and patient satisfaction scale. Operation time (minutes) was significantly shorter in the staple group, 40.26 (±16.53) compared to 47.55 (±14.55) in the suture group (P = 0.025). Skin closure time (seconds) was significantly less in the staple group, 118.62 (±69.68) versus 388.70 (±170.40) in the suture group (P ≤ 0.001). There was no difference in pain experienced, wound assessment by the participants, and patients' satisfaction. Participants in the staple group scored higher on both scar assessment scales by the nurse (P = 0.044). Cost comparison analysis showed that staple use costs significantly more than suture use (P < 0.001). The perceived benefit of subcuticular suture over skin staples was not observed and participants were satisfied with both wound closure techniques.

Cesarean section on maternal request: the viewpoint of expectant women

PURPOSE

To determine the women's perception and factors influencing willingness to have cesarean section on maternal request (CSMR) in the absence of medical or obstetric indication.

METHODS

A cross-sectional questionnaire-based survey of 752 antenatal clinic attendees at Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti. Pre-tested questionnaires were used to elicit information on socio-demographic and obstetric variables, awareness and perspective of CSMR and the willingness to request CS without physician's recommendation. Frequency tables were generated and univariate and multivariate logistic regression were used to determine factors that influenced CSMR using SPSS software version 16.0.

RESULTS

Forty-eight (6.4 %) of the respondents reported willingness to request CS. The most common motivations for the request were fear of losing the baby during labor, delay in conception and fear of labor pains. Analysis by simple logistic regression and multiple regression showed age, parity and educational status were not significantly related to the decision for CSMR.

CONCLUSION

CSMR is an evolving entity in obstetrics practice in the developing countries. Delay in conception, fear of labor pain and loss of baby during labor appear to be strong motivations.

Late better than early elective term Cesarean section

AIM

  Caesarean section (CS) deliveries have increased, mostly because of patient/obstetrician preference. Although CS decreases the risk of delivery-related injuries, it increases the risk for respiratory and neurological complications. Complication rates are reportedly higher for elective CSs for term infants performed at 37-38 gestational weeks than later. We investigated this difference in an Israeli cohort.

METHODS

  Data on all births in our medical centre during 2007-2009 were reviewed. Those on elective CSs for term infants were retrieved and divided into 'early' (37-38 gestational weeks) or 'late' (week 39 or later) groups whose epidemiological and outcome characteristics were compared.

RESULT

  Of the 12,276 births, 596 were early and 454 were late elective CSs. There were no differences in gender, ethnicity, Apgar score or length of hospital stay. Twenty-six infants from the early group and 11 infants from the late group were transferred to the neonatal intensive care unit. Within them, compared with all elective CSs, the morbidity rate was higher for the former infants than for the latter.

CONCLUSION

  Morbidity was higher among infants who were delivered at 37-38 gestational weeks by elective CS. We recommend postponing elective CSs to ≥39 weeks.

Maternal demand for cesarean section: perception and willingness to request by Nigerian antenatal clients

Background

Contrary to the widely reported aversion to cesarean section in the West African subregion, maternal demand for cesarean section (MDCS) seems to be on the increase, and there is little evidence to explain this trend. The purpose of this study was to determine the perception and attitudes of Nigerian antenatal clients towards MDCS, their willingness to request MDCS, and the relationship between willingness to request MDCS and sociodemographic characteristics.

Methods

A cross-sectional survey was undertaken among 843 antenatal clients at Agbongbon/Orayan primary health care centers (PHCs), Adeoyo Maternity Hospital (SHC), and UCH Ibadan (THC), representing the three different levels of health care in Nigeria, ie, primary, secondary, and tertiary.

Results

The proportion of women aware of MDCS was 39.6%. Predictors of awareness were education and type of health facility. Women from THC and those with tertiary education and above were more likely to be aware of MDCS than others (P = 0.001). Doctors were major sources of information on MDCS (30.8%) as well as friends (24.3%). Common reasons reported for MDCS were fear of labor pains (68.9%), and fear of poor labor outcome (60.1%), and fear of fecal (20.2%) and urinary incontinence (16.8%). More women from the THC than other facilities believed that requests for MDCS should be granted (P < 0.001). However, willingness to request MDCS was low (6.6%). More than 50% of those willing to request MDCS would likely be criticized, mainly by their husbands. On multiple logistic regression, respondents at the THC were significantly more likely than those at the SHC or the PHCs to request cesarean section and to favor a woman’s right of autonomy to choose her mode of delivery.

Conclusion

The decision for MDCS is a difficult one, because willingness is low and criticism by partners of those who choose MDCS is high. Provision of epidural anesthesia and improved safety of vaginal delivery is recommended. This may prevent Nigerian women from making a difficult choice for MDCS based on fear of pain and poor labor outcome. The role of the male partner should be taken into consideration in order to make sustainable policies or guidelines for MDCS in developing countries.

'Safe passage': pregnant Iranian Kurdish women's choice of childbirth method

AIM

This article is a report of a grounded theory study of the influence of emotions on women's selection of a method of childbirth.

BACKGROUND

There is substantial evidence to indicate that a pregnant woman's emotions play an important role in the decision-making process of selecting a child delivery method. Despite this, however, there is a notable lack of research about the relationship between pregnant women's emotions and their choice of a childbirth method in developing countries.

METHODS

A qualitative study using the grounded theory approach was conducted. The data were collected from 22 Iranian Kurdish pregnant women in their third trimester using semi-structured interviews. Concurrent data collection and analysis took place between 2008 and 2009. A cumulative process of theoretical sampling and constant comparison was used to identify concepts and then expand, validate, and clarify them.

FINDINGS

The substantive grounded theory that was identified from data analysis was 'safe passage'. 'Safe passage' involved five phases that were not mutually exclusive in their occurrence. The five phases of the 'safe passage' theory that were identified from the data analysis were: 'safety of baby', 'fear', 'previous experience', 'social support' and 'faith'. The goal of 'safe passage' was to achieve a healthy delivery and to ensure the health of the newborn.

CONCLUSION

'Safe passage' was a process used to determine how the emotions of pregnant Iranian Kurdish women influenced their choice of the mode of child delivery. More research is needed in this field to develop a body of knowledge beneficial to midwifery education and practice.

Obstetricians' attitudes to caesarean delivery on maternal request in Nigeria

The study was done to determine obstetricians' attitude to and factors predicting obstetricians' acceptance of caesarean delivery on maternal request in Nigeria. Nigerian obstetricians were asked to respond to case scenarios depicting caesarean delivery on maternal request without medical indications and the reasons for their responses. The case scenarios were designed from previously published reasons for caesarean delivery on maternal request from Nigeria. Multiple logistic regressions analysis was done to determine factors predicting obstetricians' acceptance of caesarean delivery on maternal request out of respect for maternal autonomy. The majority (53.1%) of the respondents would accept caesarean delivery on maternal request out of respect for maternal autonomy. Caesarean requests backed up by social mitigating circumstances of previous childlessness and previous negative labour experience received significantly higher acceptances than requests with no back-up mitigating circumstances (p < 0.0001). A good proportion (48.8%) of Nigerian obstetricians had performed at least one caesarean on maternal request. Obstetricians' bio-professional characteristics do not influence their attitude to request caesarean delivery on maternal request. Some obstetricians expressed fear of legal consequences from caesarean delivery on maternal request.

Women's preference for cesarean delivery and differences between Taiwanese women undergoing different modes of delivery

BACKGROUND

The rate of cesarean delivery was 35% in 2007 in Taiwan. It is unclear how many of the cesarean deliveries were without medical indications. Women's preference for cesarean delivery during their course of pregnancy has rarely been studied and therefore our objectives were to examine rate of cesarean deliveries without medical indications, to explore women's preference for cesarean delivery as their gestation advances, and to compare background and perinatal factors among women who underwent different modes of delivery in Taiwan.

METHODS

This prospective study applied a longitudinal design. The study participants were 473 women who received prenatal care at four hospitals in Taipei and answered structured questionnaires at 20 to 24 weeks of pregnancy, 34 to 36 weeks of pregnancy, and 5 to 7 weeks after delivery.

RESULTS

Of the 151 women (31.9%) who had cesarean deliveries, 19.9% were without medical indication. Three indications: malpresentation, prior cesarean section, and dysfunctional labor together accounted for 82.6% of cesarean section with medical indications. The prevalence of maternal preference for cesarean delivery was found to be 12.5% and 17.5% during the second and third trimester, respectively. Of the women who preferred cesarean delivery during the second trimester, 93.2% eventually had a cesarean delivery. Women who were older, with older spouses, and who had health problems before or during pregnancy were more likely to have cesarean deliveries.

CONCLUSIONS

About 20% of cesarean deliveries were without medical indications. Women's preference for cesarean delivery during the second trimester predicts subsequent cesarean delivery. Counseling regarding mode of delivery should be offered early in pregnancy, especially for women who are older or with older spouses, have health problems, or had a prior cesarean section.

[Aspects related to choice of type of delivery: a comparative study of two maternity hospitals in São Luís, State of Maranhão, Brazil]

This study aimed to analyze aspects related to choice of type of delivery in two maternity hospitals, one public and the other private, in São Luís, Maranhão State, Brazil. This cross-sectional study compared 163 primiparous women in a public maternity hospital and 89 in a private hospital, with mean ages of 21.63 +/- 5.24 and 28.8 +/- 5.41 years, respectively. In the public hospital, 79.1% of the women reported preferring vaginal deliveries, while in the private hospital 67.4% of the women preferred cesareans (p < 0.0001). Cesareans were performed in 46% of the women in the public maternity hospital and 97.8% of those in the private hospital (p < 0.0001). Patient satisfaction was high for both modes of delivery, but the desire to repeat the same mode was reported more frequently by women with vaginal deliveries (71.6% vs. 41.3% in the public maternity hospital and 100% vs. 65.5% in the private). In the public maternity hospital, the cesarean subgroup included more white and higher-income women. The cesarean rate was thus high in both maternity hospitals and was significantly higher in the private hospital; the study also showed a preference for vaginal delivery in the public hospital and cesareans in the private.

A 4-year analysis of caesarean delivery in a Nigerian teaching hospital: One-quarter of babies born surgically

Between January 2001 and December 2004, a total of 2,922 deliveries were conducted at the University of Nigeria Teaching Hospital , Enugu. Caesarean section accounted for 740 deliveries, an incidence of 25.3%. A total of 62.2% of caesarean sections were done as emergencies, while 37.8% were done as elective procedures and 64.8% were booked patients. Repeat caesarean sections accounted for 59.2% of elective cases and 18.7% of emergency cases. Fetal distress was responsible for 11. 6% of emergency cases, however 35.6% of babies delivered for clinically diagnosed fetal distress had Apgar scores 7 and above. A total of 85.6% of patients were between 25 - 29 years of age; 31% were primigravida, while 54.4% were Gravida 2 - 4. There were seven (0.6%) maternal deaths and 73 (9.2%) stillbirths. It was concluded that reduction of primary caesarean section rate and repeat caesarean rates should be the main target of any strategy to reduce caesarean section rate. Other measures to reduce the caesarean section rate and recommendations are discussed.

Women's opinions and experiences with induction of labor and cesarean delivery on request in south eastern Nigeria

OBJECTIVE

To assess the opinions and experiences of women regarding induction of labor and cesarean delivery on request in south eastern Nigeria.

METHOD

Women were interviewed using questionnaires on their awareness of their right to request labor induction and/or a cesarean delivery, and of their experience and opinion of the procedures.

RESULTS

Of the 15.1% of the respondents who knew they could request a cesarean delivery, 2.4% had requested one; and of the 56.3% who knew they could request labor induction, 6.9% had requested one. Only 5.3% and 11.3% of the respondents who would chose the former or the latter procedure, respectively, said that they would insist on receiving it. Fear of their physicians' negative attitude regarding the procedures, and/or abandonment of care, ranked highest among their reasons for not insisting.

CONCLUSION

In south eastern Nigeria few women are aware of their right to a cesarean delivery on request and the rate of refusal to perform such deliveries is high among physicians; more women are aware of their right to receive induction of labor on request and the acceptance rate is higher among physicians; and most women are unwilling to insist that their physician respect their choice.

Attitudes towards mode of delivery and cesarean on demand in Turkey

OBJECTIVE

To assess the attitudes of healthcare providers and the public in Turkey towards mode of delivery and cesarean delivery on demand.

METHODS

A written questionnaire was given to female healthcare providers and women from the general public, and their answers were analyzed.

RESULTS

A total of 329 female healthcare providers and 347 women from the public group completed the survey. In response, 48.1% of healthcare providers and 69.6% of the public group chose vaginal delivery as the preferred mode of delivery (P<0.001). Some 45.3% of healthcare providers and 20.6% of the public group had undergone a cesarean delivery without any medical indications (P<0.001). In addition, 37.8% of healthcare providers and 36.2% of the public group believed that women should have the right to a cesarean delivery on demand.

CONCLUSIONS

In the two groups studied the preference for cesarean delivery is higher in Turkish healthcare providers than in the public population. In both groups the attitude towards cesarean delivery on demand is high.

Induction of labor on request in a resource-poor setting

OBJECTIVE

To determine the prevalence of and reasons for induction of labor on maternal request in a setting where aversion to induction of labor is the norm.

METHOD

Women undergoing induction of labor on maternal request at three maternity centers in Enugu, Nigeria were interviewed by means of pre-tested self-administered questionnaires. The outcomes of labor in these women were also compared with those of a control group consisting of women who had induction of labor for medical reasons.

RESULTS

The prevalence of induction of labor on maternal request was 7.4%. Maternal convenience was the commonest reason for request induction. The outcomes of labor were similar between the subjects and their controls.

CONCLUSION

Nigerian women are beginning to request induction of labor without medical indications and have comparable outcomes with those who have medical indications. There is need for appropriate regulatory guidelines.