Elective caesarean delivery: a mixed method qualitative investigation

Conflicting attitudes between clinicians and women regarding maternal requested caesarean section: a qualitative evidence synthesis

BACKGROUND

Caesarean section (CS) can be a life-saving operation but might also negatively affect the health of both the woman and the baby. The aim of this study was to synthesize and contrast women's and clinicians' attitudes toward maternal-requested CS, and their experiences of the decision-making process around CS.

METHODS

The databases of CINAHL, MEDLINE, PsycInfo and Scopus were screened. All qualitative studies that answered the study question and that were assessed to have minor or moderate methodological limitations were included. Synthesised findings were assessed using GRADE-CERQual.

RESULTS

The Qualitative Evidence Synthesis included 14 qualitative studies (published 2000-2022), involving 242 women and 141 clinicians. From the women's perspectives, two themes arose: women regarded CS as the safest mode of birth; and women's rights to receive support and acceptance for a CS request. From the clinicians' perspectives, four themes emerged: clinicians were concerned about health risks associated with CS; demanding experience to consult women with a CS request; conflicting attitudes about women's rights to choose a CS; and the importance of respectful and constructive dialogue about birthing options.

CONCLUSION

Women and clinicians often had different perceptions regarding the right of a woman to choose CS, the risks associated with CS, and the kind of support that should be part of the decision-making process. While women expected to receive acceptance for their CS request, clinicians perceived that their role was to support the woman in the decision-making process through consultation and discussion. While clinicians thought it was important to show respect for a woman's birth preferences, they also felt the need to resist a woman's request for CS and encourage her to give birth vaginally due to the associated increases in health risks.

Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study

BACKGROUND

The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database.

METHODS

We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models.

RESULTS

Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital.

CONCLUSION

Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted.

Women's Experiences and Involvement in Decision-Making in Relation to Planned Cesarean Birth: An Interview Study

Actively engaging women in decision-making about their own care is critical to providing woman-centered maternity care. The aim was to understand women's mode-of-birth preferences and shared decision-making experiences during planned cesarean birth (CB). Semi-structured telephone interviews were conducted with 33 women who had planned CB at eight Australian metropolitan hospitals. Inductive thematic analysis was conducted using NVivo-12. Many women preferred a vaginal birth but were willing to have a CB if the clinician recommended. Most women looked to their clinicians for information and guidance. Although many women reported receiving enough information to make informed decisions, others felt pressured into having or not having a CB, or expected to make decisions themselves. Women wished for longer consultation times, more information, and care continuity.

The Use of Ethnography in Maternity Care

While the value of ethnography in health research is recognized, the extent to which it is used is unclear. The aim of this review was to map the use of ethnography in maternity care, and identify the extent to which the key principles of ethnographies were used or reported. We systematically searched the literature over a 10-year period. Following exclusions we analyzed 39 studies. Results showed the level of detail between studies varied greatly, highlighting the inconsistencies, and poor reporting of ethnographies in maternity care. Over half provided no justification as to why ethnography was used. Only one study described the ethnographic approach used in detail, and covered the key features of ethnography. Only three studies made reference to the underpinning theoretical framework of ethnography as seeking to understand and capture social meanings. There is a need to develop reporting guidelines to guide researchers undertaking and reporting on ethnographic research.

Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences

Background

Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS.

Methods

Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual.

Results

We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021.

Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence).

Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence).

Conclusions

A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS.

Factors associated with women's birth beliefs and experiences of decision-making in the context of planned birth: A survey study

OBJECTIVE

In many high-income countries, approximately half of all births are now planned regarding timing, either by elective Caesarean Section (CS) or induction of labour (IOL). To what degree this is explained by women's birth beliefs and preferences, and in turn, factors such as parity and ethnicity that may influence them, is contentious. Within a broader study on Timing of Birth by planned CS or IOL, we aimed to explore the association between demographic and pregnancy factors, with women's birth beliefs and experiences of planned birth decision-making in late pregnancy.

DESIGN

Survey study of women's birth beliefs and experiences of planned birth decision-making. Both univariate analysis and ordinal regression modelling was performed to examine the influence of; parity; cultural background; continuity of pregnancy care; CS or IOL; and whether CS was "recommended" or "requested", on women's stated birth beliefs and decision-making experience.

SETTING

8 Sydney hospitals PARTICIPANTS: Women planned to have an IOL or CS between November 2018-July 2019.

MEASUREMENT

The survey included four statements regarding birth beliefs and ten statements about experiences of decision-making on a 5-item Likert scale, as well as questions about demographic and pregnancy factors that might influence these beliefs.

FINDINGS

Of 340 included surveys, 56% regarded IOL and 44% CS. Women indicated strong belief both that they should be supported to make decisions about their birth and that their doctor/midwife knows what is best for them (over 90% agreement for both). Regarding decision-making, over 90% also agreed they had trust in the person providing information, understood it, and had sufficient time for both questions and decision-making. However only 58% were provided written information, 19% felt they "didn't really have a choice", and 9% felt pressure to make a decision. On both univariate and multivariate analysis, women having CS (versus IOL) expressed more positive views of their experience and involvement in decision-making, as did women experiencing a pregnancy continuity-of-care model. Women identifying as from a specific cultural or ethnic background expressed more negative experiences. On modelling, the studied factors accounted for only a small proportion of the variation in responses (3-19%).

CONCLUSIONS

Continuity of pregnancy care was associated with positive decision-making experiences and cultural background with more negative experiences. Women whose planned birth was IOL versus CS also reported more negative decision-making experiences.

IMPLICATIONS FOR PRACTICE

Attention to improving quality of information provision, including written information, to women having IOL and women of diverse background, is recommended to improve women's experiences of planned birth decision-making.

Women's experiences of decision-making and beliefs in relation to planned caesarean section: A survey study

BACKGROUND

The caesarean section (CS) rate is over 25% in many high-income countries, with a substantial minority of CSs occurring in women with low-risk pregnancies. CS decision-making is influenced by clinician and patient beliefs and preferences, and clinical guidelines increasingly stipulate the importance of shared decision-making (SDM). To what extent SDM occurs in practice is unclear.

AIMS

To identify women's birth preferences and SDM experience regarding planned CS.

MATERIAL AND METHODS

Survey of women at eight Sydney hospitals booked for planned CS. Demographic data, initial mode of birth preferences, reason for CS, and experiences of SDM were elicited using questions with multiple choice lists, Likert scales, and open-ended responses. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Responses of women who perceived their CS as 'requested' vs 'recommended' were compared.

RESULTS

Of 151 respondents, repeat CS (48%) and breech presentation (14%) were the most common indications. Only 32% stated that at the beginning of pregnancy they had a definite preference for spontaneous labour and birth. Key reasons for wanting planned CS were to avoid another emergency CS, prior positive CS experience, and logistical planning. Although 15% of women felt pressured (or were unsure) about their CS decision, the majority reported positive experiences, with over 90% indicating they were informed about CS benefits and risks, had adequate information, and understood information provided.

CONCLUSIONS

The majority (85%) of women appeared satisfied with the decision-making process, regardless of whether they perceived their CS as requested or recommended.

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.

Maternal request for cesarian birth without medical indication in a group of healthy women: A qualitative study in Jordan

OBJECTIVE

To explore women's reasons for requesting an elective cesarian birth without medical indication and to describe the factors that affect their decision to choose a cesarian birth.

DESIGN

A descriptive qualitative content analysis approach was used for the gathering and analysis of data. Interviews were held with 35 first-time mothers. The participants were recruited by using a purposive sampling method. Interviews were begun with the same question which sked about women's reasons for requesting cesarian birth without medical indication. Other questions were used to facilitate the interview and elicit the factors that led this group of first-time Jordanian mothers to choose a cesarian birth.

SETTING

A private hospital in Amman, the capital of Jordan, was selected as the location for the data gathering process. Data collection and analysis were conducted concurrently and interviews were discontinued when data saturation was reached.

PARTICIPANTS

The participants consisted of 35 first-time mothers recruited by using a purposive sampling method.

FINDINGS

Socio-demographic, economic status, and childbirth culture played an important role in influencing women's requests for an elective cesarian. Women made their decision based on the lived negative experience of other women and were driven and supported by their social network. Five themes that reflected the reasons for elective cesarian birth without medical indication were identified: (1) fear of vaginal birth process, (2) concerns about future sexual life, (3) need for humanized birth, (4) personal reasons, and (5) decision-making process.

CONCLUSIONS AND IMPLICATIONS

The women's reasons for choosing cesarian birth without medical indication and the factors influencing the women's decision-making process were complex and interrelated and reflect a lack of appropriate informed choice about elective cesarian. The findings therefore suggest that healthcare policy makers need to attend to the reasons and the factors that influence women's decision-making about cesarian birth in order to promote the trend of women having a vaginal birth. Evidence-based knowledge and strategies to reduce elective caesareans should be disseminated to healthcare providers in maternity settings. Future explorations of this issue should address obstetricians' and midwives' views and attitudes about cesarian birth without medical indication.

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.

Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis

OBJECTIVE

To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans.

DESIGN

Qualitative evidence synthesis.

SETTING

Studies undertaken in high-income, middle-income and low-income settings.

DATA SOURCES

Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar.

STUDY SELECTION

Qualitative or mixed-method studies reporting health professionals' views.

DATA EXTRACTION AND SYNTHESIS

Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed.

RESULTS

17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision.

CONCLUSION

For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans.

PROSPERO REGISTRATION NUMBER

CRD42017059455.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

OBJECTIVE

When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders' views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section.

METHODS

We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual.

RESULTS

8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993-2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes: Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.

CONCLUSIONS

Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms.

PROTOCOL REGISTRATION

PROSPERO: CRD42017059456.

Women's cesarean section preferences and influencing factors in relation to China's two-child policy: a cross-sectional study

OBJECTIVE

This study explored women's preference for cesarean section (CS) and the preference for cesarean sections' influencing factors, particularly nonmedical factors.

METHODS

A cross-sectional study was conducted in four tertiary hospitals in Hohhot. We recruited 1,169 pregnant women at ≥ 28 gestational weeks and classified subjects into three groups by delivery mode preference: vaginal birth (VB), CS, and "no clear preference". We identified the influencing factors of women's choices by multinomial logistic regression. The adjusted relative-risk ratios (aRRRs) for the factors affecting the preference for CS and "no clear preference" categories and their 95% CIs were computed, using the preference for VB as the reference group.

RESULTS

VB was preferred by 80.3% of the subjects, 8.8% preferred CS, and 10.9% had not decided yet. In the multinomial logistic regression, pregnant women intending to have more than one child were less likely to prefer CS (aRRR: 0.37; 95% CI: 0.22-0.61); choosing a lucky day for baby birth was the strongest factor for CS preference (aRRR: 12.36; 95% CI: 6.62-23.08), and other factors for CS preference were being aged 40 years and above (aRRR: 4.21; 95% CI: 1.43-12.40), being ethnic minority (aRRR: 2.00; 95% CI: 1.17, 3.41), feeling difficulty in getting pregnant (aRRR: 2.23; 95% CI: 1.20, 4.13), and having husband's preference for CS (aRRR: 7.62; 95% CI: 4.00-14.54). The top reasons for preferring CS were the belief that CS was safer (51.5%), associated with less pain (40.8%), and better for baby's and woman's health (24.3% and 22.3%, respectively).

CONCLUSION

Less than one-tenth of the study subjects preferred CS. The cultural beliefs had the strongest influence on the decision of delivery mode. Those intending to have two or more children following the two-child policy were less likely to choose CS.

Fear, Risk, and the Responsible Choice: Risk Narratives and Lowering the Rate of Caesarean Sections in High-income Countries

In Canada, as elsewhere in the world, caesarean sections are the most common surgical procedure performed in hospitals annually. Recent national statistics indicate 28% of infants in Canada are born by c-section while in the United States that number rises to 33%. This is despite World Health Organization recommendations that at a population level only 10-15% of births warrant this form of medical intervention. This trend has become cause for concern in recent decades due to the short and long-term health risks to pregnant women and infants, as well as the financial burden it places on public health care systems. Others warn this trend may result in a collective loss of cultural knowledge of a normal physiological process and, in the process, establish a new "normal" childbirth. Despite a range of interventions to curb c-section rates-enhanced prenatal care and innovation in pregnancy monitoring, change in hospital level policies, procedures and protocols, as well as public education campaigns-they remain stubbornly resistant to stabilization, let alone, reduction in high-income countries. We explore-through a review of the academic and grey literature-the role of cultural and social narratives around risk, and the responsibilization of the pregnant woman and the medical practitioner in creating this kind of resistance to intervention today.

Patterns and Associated Factors of Caesarean Delivery Intention among Expectant Mothers in China: Implications from the Implementation of China's New National Two-Child Policy

OBJECTIVE

This study explores the basic demographic characteristics of expectant mothers in the context of their intentions regarding mode of delivery, in particular, the preference for caesarean delivery, and analyzes the social and psychological factors that influence delivery preference.

METHOD

A cross-sectional survey of pregnant women was conducted during June to August in 2015. This study adopted a stratified sampling method, and 16 representative hospitals in five provinces of China were included.

RESULTS

1755 and 590 of expectant mothers in their first and second pregnancies, respectively, were enrolled in this study. 354 (15.10%) intended to deliver by caesarean section and 585 (24.95%) participants were uncertain prior to delivery. 156 (8.89%) of expectant mothers in their first pregnancy and 198 (33.56%) expectant mothers in their second pregnancy intended to deliver by caesarean section. Ordinal logistic regression analysis found that nationality, parity, trimester of pregnancy, and advanced maternal age were factors associated with intention to deliver by caesarean (ordered logistic regression/three-level caesarean delivery intention criterion; odds ratios p < 0.05).

CONCLUSIONS

8.89% of first pregnancy expectant mothers and 33.56% of second pregnancy expectant mothers intended to deliver by caesarean section. Any intervention program to reduce the rate of Caesarean delivery should focus on the Han population, older pregnant women, and expectant mothers in their second pregnancy, at an early gestation.

Caring for women wanting a vaginal birth after previous caesarean section: A qualitative study of the experiences of midwives and obstetricians

PROBLEM

One of the greatest contributors to the overall caesarean section rate is elective repeat caesarean section.

BACKGROUND

Decisions around mode of birth are often complex for women and influenced by the views of the doctors and midwives who care for and counsel women. Women may be more likely to choose a repeat elective caesarean section (CS) if their health care providers lack skills and confidence in supporting vaginal birth after caesarean section (VBAC).

AIM

To explore the views and experiences of providers in caring for women considering VBAC, in particular the decision-making processes and the communication of risk and safety to women.

METHODS

A descriptive interpretive method was utilised. Four focus groups with doctors and midwives were conducted.

FINDINGS

The central themes were: 'developing trust', 'navigating the system' and 'optimising support'. The impact of past professional experiences; the critical importance of continuity of carer and positive relationships; the ability to weigh up risks versus benefits; and the language used were all important elements. The role of policy and guidelines on providing standardised care for women who had a previous CS was also highlighted.

CONCLUSION

Midwives and doctors in this study were positively oriented towards assisting and supporting women to attempt a VBAC. Care providers considered that women who have experienced a prior CS need access to midwifery continuity of care with a focus on support, information-sharing and effective communication.

Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women's accounts of their birth choices

OBJECTIVE

To identify what women report influences their preferred mode of birth after caesarean section.

DESIGN

Systematic review of qualitative literature using meta-ethnography.

DATA SOURCES

Medline, EMBASE, ASSIA, CINAHL and PsycINFO (1996 until April 2013; updated September 2015). Hand-searched journals, reference lists and abstract authors.

STUDY SELECTION

Primary qualitative studies reporting women's accounts of what influenced their preferred mode of birth after caesarean section.

DATA EXTRACTION AND SYNTHESIS

Primary data (quotations from study participants) and authors' interpretations of these were extracted, compared and contrasted between studies, and grouped into themes to support the development of a 'line of argument' synthesis.

RESULTS

20 papers reporting the views of 507 women from four countries were included. Distinctive clusters of influences were identified for each of three groups of women. Women who confidently sought vaginal birth after a caesarean section were typically driven by a long-standing anticipation of vaginal birth. Women who sought a repeat caesarean section were strongly influenced by distressing previous birth experiences, and at times, by encouragement from social contacts. Women who were more open to information and professional guidance had fewer strong preconceptions and concerns, and viewed a range of considerations as potentially important.

CONCLUSIONS

Women's attitudes towards birth after caesarean section appear to be shaped by distinct clusters of influences, suggesting that opportunities exist for clinicians to stratify and personalise decision support by addressing relevant ideas, concerns and experiences from the first caesarean section birth onwards.

Decisions in Childbirth Reported by a Sample of U.S. Women

Increasing patient-centeredness in birth care partly involves understanding of women’s decision making. Toward that aim, we assessed how many women reported unanticipated decisions in childbirth, and we examined their written descriptions thereof. Of 70 women recruited in pregnancy, 64 (91.4%) completed a 1-month postpartum follow-up, and of those, 39 (61%) reported having been involved in an unanticipated decision in childbirth. Quantitative analysis revealed no differences between the decision and no-decision group on background characteristics or on pregnancy risk. Thematic analysis indicated that women’s views on agency in birth decisions ranged from having decisions made for them to their having had an active role. Nearly all reported decisions centered on a specific intervention tied to an identified medical cause. We discuss providing anticipatory guidance to prepare women for the likelihood of being involved in childbirth decisions while under labor stress.