Cesarean section for non-medical reasons

Public-private differentials in health care delivery: the case of cesarean deliveries in Algeria

Akin to other developing countries, Algeria has witnessed an increasing role of the private health sector in the past two decades. Our study sheds light on the public-private overlap and the phenomenon of physician dual practice in the provision of health care services using the particular case of cesarean deliveries in Algeria. Existing studies have reported that, compared to the public sector, delivering in a private health facility increases the risk of enduring a cesarean section. While confirming this result for the case of Algeria, our study also reveals the existence of public-private differentials in the effect of medical variables on the probability of cesarean delivery. After controlling for selection in both sectors, we show that cesarean deliveries in the private sector tend to be less medically justified compared with those taking place in the public sector, thus, potentially leading to maternal and neonatal health problems. As elsewhere, the contribution of the private health sector to the unmet need for health care in Algeria hinges on an appropriate legal framework that better coordinates the activities of the two sectors and reinforces their complementarity.

Trends of caesarean section deliveries in Pakistan: secondary data analysis from Demographic and Health Surveys, 1990-2018

BACKGROUND

Pakistan is among those countries where the number of caesarean section births has increased unusually in the past two decades. Therefore, the aim of the present study is to analyse the trend of caesarean section deliveries among child-bearing women (aged 15-49 years) in Pakistan and to identify maternal socio-demographic factors and pregnancy-related variables associated with the change in caesarean deliveries from 1990 to 2018.

METHODS

Secondary data from Pakistan Demographic and Health Surveys (1990-2018) were analysed. The analysis of data was confined to child-bearing mothers. Sample sizes were 4029, 5721, 7461 and 8287 for the time periods of 1990-91, 2006-07, 2012-13 and 2017-18, respectively. Socio-demographic information of the mothers and pregnancy-related variables were taken as independent variables for the present study. The association between independent variables and caesarean deliveries was measured in terms of unadjusted odds ratios (OR) and adjusted OR (AOR).

RESULTS

The percentages of the mothers who had at least one delivery during the 5 years prior to each survey who had caesarean deliveries increased continuously from 3.2% in 1990-91 to 19.6% in 2017-18. Results indicate that mothers over 24 years of age, located in Punjab, from the richest socio-economic class and living in urban areas were more likely to have delivered by caesarean section. Mothers with a first child in birth order and who had five and more children, as well as mothers who had more antenatal care visits and delivered babies in private hospitals showed a higher probability of caesarean section births.

CONCLUSIONS

The findings of the present study confirm the gradual upsurge in the percentage of mothers delivering by caesarean section during the past two decades in Pakistan. Against this backdrop, some measures need to be taken by health departments to regulate the number of caesarean deliveries. Awareness among women about pregnancy complications and elaborated details by gynaecologists about the medically indicated reasons for caesarean delivery are a few important steps in Pakistan that can help in reducing caesarean deliveries which are not medically indicated.

Why the Elective Caesarean Lottery is Ethically Impermissible

In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman's informed request for MRCS (elective caesarean in the absence of any clinical indications) should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman's life cannot be understated. It is, therefore, concerning that women are having their wishes ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents' sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice.

Secular changes in body height predict global rates of caesarean section

The massive global variation in caesarean-section (C-section) rate is usually attributed to socio-economic, medical and cultural heterogeneity. Here, we show that a third of the global variance in current national C-section rate can be explained by the trends of adult body height from the 1970s to the 1990s. In many countries, living conditions have continually improved during the last century, which has led to an increase in both fetal and adult average body size. As the fetus is one generation ahead of the mother, the fetus is likely to experience better environmental conditions during development than the mother did, causing a disproportionately large fetus and an increased risk of obstructed labour. A structural equation model revealed that socio-economic development and access to healthcare affect C-section rate via multiple causal pathways, but the strongest direct effect on C-section rate was body height change. These results indicate that the historical trajectory of socio-economic development affects-via its influence on pre- and postnatal growth-the intergenerational relationship between maternal and fetal dimensions and thus the difficulty of labour. This sheds new light on historic and prehistoric transitions of childbirth and questions the World Health Organization (WHO) suggestion for a global 'ideal' C-section rate.

An ecological study of geographic variation and factors associated with cesarean section rates in South Korea

BACKGROUND

Korea is in a condition where the impact of patient and supplier factors on cesarean section rates can be clearly described. The cesarean section rates in Korea are among the highest in the world while the number of obstetricians is decreasing sharply. This study aimed to investigate the geographic variation in cesarean section rates in Korea and its factors.

METHODS

The data were obtained from the National Health Insurance database in Korea in 2013. We calculated the age-standardized and crude cesarean section rates of 251 districts in Korea and variation statistics. A linear regression analysis was performed to determine factors for cesarean section rates.

RESULTS

The overall cesarean section rate in Korea was 364.6 cases per 1000 live births. The deprivation index score was strongly associated with the increase in the cesarean section rate while the density of hospital obstetricians and hospital beds showed a negative association. Average maternal age and total fertility rate showed a negative relationship with the cesarean section rate.

CONCLUSIONS

Korea is suffering from a continuing decrease in obstetricians. Our study shows that this decline has more of an effect on mothers in the disadvantaged areas. Securing equal access to obstetric care among areas is necessary, and measures to encourage obstetricians and mothers not to opt for cesarean section are required.

Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh Demographic and Health Survey 2014 Data

BACKGROUND

Caesarean section (CS) has been on the rise worldwide and Bangladesh is no exception. In Bangladesh, the CS rate, which includes both institutional and community-based deliveries, has increased from about 3% in 2000 to about 24% in 2014. This study examines the association of reported complications around delivery and socio-demographic, healthcare and spatial characteristics of mothers with CS, using data from the latest Bangladesh Demographic and Health Survey (BDHS).

METHODS

The study is based on data from the 2014 BDHS. BDHS is a nationally representative survey which is conducted periodically and 2014 is the latest of the BDHS conducted. Data collected from 4,627 mothers who gave birth in health care institutions in three years preceding the survey were used in this study.

RESULTS

Average age of the mothers was 24.6 years, while their average years of schooling were 3.2. Factors like mother being older, obese, residing in urban areas, first birth, maternal perception of large newborn size, husband being a professional, had higher number of antenatal care (ANC) visits, seeking ANC from private providers, and delivering in a private facility were statistically associated with higher rates of CS.

CONCLUSIONS

Bangladesh health system urgently needs policy guideline with monitoring of clinical indications of CS deliveries to avoid unnecessary CS. Strict adherence to this guideline, along with enhance knowledge on the unsafe nature of the unnecessary CS can achieve increased institutional normal delivery in future; otherwise, an emergency procedure may end up being a lucrative practice.

Assessment of the efficacy of group counselling using cognitive approach on knowledge, attitude, and decision making of pregnant women about modes of delivery

The choice of casarean deliveries by mothers is highly influenced by inadequate knowldge and negative attitudes towards vaginal birth. In this semi-experimental study, we compared knowledge, attitude, and decision making about modes of delivery between nulliparous pregnant women who received eight sessions of group consultation and those who took routine prenatal education. Contrary to the control group, the improvement of knowledge and attitudes were significant in the consultation group (p < 0.001), as well as mothers' decisions for vaginal birth (p = 0.03). Group consultation is an appropriate approach to improving knowledge, attitudes, and tendencies of mothers toward natural birth.

Exploring First-time Pregnant Women's Motivations for Planning Vaginal Delivery: A Qualitative Study

Background:

In spite of medical indications, preferences for the mode of delivery are influenced by several factors. However, as the literature suggests, the underlying motivation of women choosing vaginal delivery is rarely attended to. The current study aimed to explore first-time pregnant women's motivation for planning vaginal delivery.

Materials and Methods:

An exploratory design with in-depth interviews was employed from September 2015 to March 2016. Participants were asked key questions about their beliefs about vaginal delivery, perceived outcomes of vaginal delivery, the impact of others perspectives on their decision, and factors that might inhibit or facilitate vaginal delivery. A community advertisement was placed in obstetricians' offices, public health departments, as well as beauty salons throughout the city of Bandar Abbas, Iran, to enroll target participants. All interviews were tape-recorded, transcribed, and subsequently analyzed.

Results:

Twelve pregnant women within the age range of 19–33 years volunteered to participate. Ninety four initial codes were obtained. These codes were then summed up into three themes as well as six subthemes. The three themes specified were personal beliefs, deliberation and risk assessment, and personal autonomy.

Conclusions:

A number of key motivating factors such as fast recovery after vaginal delivery, immediate breastfeeding, and powerful bonding were identified, which were influential in choosing vaginal delivery. Awareness of the fact that the provided information shapes women's beliefs and can lead to attitude changes, midwives played a key role in shaping positive and healthy attitudes toward natural birth giving as well as empower them to make autonomous decision.

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial

Background

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean.

Methods/design

The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis.

Discussion

The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management.

Trial registration

Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.

Frequency and evaluation of the perceptions towards caesarean section among pregnant women attending public hospitals in Pakistan and the implications

OBJECTIVES

There is increasing prevalence of caesarean sections (CS) worldwide; however, there are concerns about their rates in some countries, including potential fears among mothers. Consequently, we aimed to determine the frequency of CS, and explore patient's perception towards CS attending public hospitals in Pakistan, to provide future guidance.

METHODS

A two-phased study design (retrospective and cross sectional) was adopted. A retrospective study was conducted to assess the frequency of CS over one year among four public hospitals. A cross sectional study was subsequently conducted to determine patients' perception towards CS attending the four tertiary care public hospitals in Quetta city, Pakistan, which is where most births take place.

RESULTS

Overall prevalence of CS was 13.1% across the four hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8% perceived CS as dangerous, influenced by education (p = 0.004), locality (p = 0.001) and employment status (p = 0.001), 74.5% of patients were in agreement that this is the best approach to save mother's and baby's lives if needed. 62% of respondents reported they would like to avoid CS if they could due to post-operative pain, and 58.9% preferred a normal delivery. There was also a significant association with education (p = 0.001) and locality (p = 0.001) where respondents considered normal vaginal delivery as painful.

CONCLUSION

The overall frequency of CS approximates to WHO recommendations, although there is appreciable variation among the four hospitals. When it comes to perception towards CS, women had limited information. There is a need to provide mothers with education during the antenatal period, especially those with limited education, to accept CS where needed.

From therapeutic to elective cesarean deliveries: factors associated with the increase in cesarean deliveries in Chiapas

BACKGROUND

Cesarean deliveries have increased over the past decade in Mexico, including those states with high percentages of indigenous language speakers, e.g., Chiapas. However, the factors contributing to this trend and whether they affect indigenous languages populations remain unknown. Thus, this work aims to identify some of the factors controlling the prevalence of cesarean sections (C-sections) in Chiapas between the 2011-2014 period.

METHODS

We analyzed certified birth data, compiled by the Subsystem of Information on Births of the Secretary of Health and the National Institute of Statistics and Geography, and information regarding the Human Development Index (HDI), assembled by the United Nations Development Program. A descriptive analysis of the variables and a multilevel logistics regression model were employed to assess the role of the different factors in the observed trends.

RESULTS

The results show that the factors contributing to the increased risk of C-sections are (i) women residing in municipalities with indigenous population and municipalities with high HDIs, (ii) advanced schooling, (iii) frequent prenatal checkups, and (iv) deliveries occurring in private health clinics. Furthermore, C-sections might also be associated with prolonged hospital stays.

CONCLUSIONS

The increasing frequency of C-sections among indigenous populations in Chiapas seems to be related to public policies aimed at reducing maternal mortality in Mexico. Therefore, public health policy needs to be revisited to ensure that reproductive rights are being respected.

Evaluation of Geographic Indices Describing Health Care Utilization

Objectives

The accurate measurement of geographic patterns of health care utilization is a prerequisite for the study of geographic variations in health care utilization. While several measures have been developed to measure how accurately geographic units reflect the health care utilization patterns of residents, they have been only applied to hospitalization and need further evaluation. This study aimed to evaluate geographic indices describing health care utilization.

Methods

We measured the utilization rate and four health care utilization indices (localization index, outflow index, inflow index, and net patient flow) for eight major procedures (coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, surgery after hip fracture, knee replacement surgery, caesarean sections, hysterectomy, computed tomography scans, and magnetic resonance imaging scans) according to three levels of geographic units in Korea. Data were obtained from the National Health Insurance database in Korea. We evaluated the associations among the health care utilization indices and the utilization rates.

Results

In higher-level geographic units, the localization index tended to be high, while the inflow index and outflow index were lower. The indices showed different patterns depending on the procedure. A strong negative correlation between the localization index and the outflow index was observed for all procedures. Net patient flow showed a moderate positive correlation with the localization index and the inflow index.

Conclusions

Health care utilization indices can be used as a proxy to describe the utilization pattern of a procedure in a geographic unit.

The differences between pregnant women who request elective caesarean and those who plan for vaginal birth based on Health Belief Model

BACKGROUND

Although vaginal birth is the safest type of childbirth, sometimes caesarean is necessary for the safety of the mother or the infant. The problem is that low-risk, healthy women are choosing caesarean as a birth option despite the fact that it is fraught with possible complications.

AIM

To determine the differences and identify the predictors for the way women plan their childbirth based on Health Belief Model.

METHODS

A cross-sectional study was conducted in Bandar abbas city, Iran, from May to October 2015. The study recruited eligible women who self identified themselves as requesting a caesarean or vaginal birth in their response to a questionnaire.

FINDINGS

Of 470 recruited women, 183 (38.9%) planned to have a caesarean without medical indication. Maternal characteristics (age, level of education, occupational status, involvement in a medical profession, and household income) and obstetric variables (health provider type, place of prenatal care, and the number of children planned for the future) influenced the decisions made by the women. There was a significant difference between women planning a caesarean and those planning vaginal birth in terms of childbirth knowledge. Significant differences were observed regarding maternal self-efficacy, with women planning a caesarean reporting significantly lower self-efficacy than women planning a vaginal birth. Women planning a caesarean birth were also significantly less likely to perceive themselves as being at risk for caesarean-related side effects than women planning a vaginal birth.

CONCLUSION

Comprehensive childbirth knowledge can lead to positive maternal attitude towards vaginal birth and may improve birth confidence.

Patient Involvement in Safe Delivery: A Qualitative Study

INTRODUCTION

Patient involvement in safe delivery planning is considered important yet not widely practiced. The present study aimed at identifythe factors that affect patient involvementin safe delivery, as recommended by parturient women.

METHODS

This study was part of a qualitative research conducted by content analysis method and purposive sampling in 2013.The data were collected through 63 semi-structured interviews in4 hospitalsand analyzed using thematic content analysis. The participants in this research were women before discharge and after delivery. Findings were analyzed using Colaizzi's method.

RESULTS

Four categories of factors that could affect patient involvement in safe delivery emerged from our analysis: patient-related (true and false beliefs, literacy, privacy, respect for patient), illness-related (pain, type of delivery, patient safety incidents), health care professional-relatedand task-related factors (behavior, monitoring &training), health care setting-related (financial aspects, facilities).

CONCLUSION

More research is needed to explore the factors affecting the participation of mothers. It is therefore, recommended to: 1) take notice of mother education, their husbands, midwives and specialists; 2) provide pregnant women with insurance coverage from the outset of pregnancy, especially during prenatal period; 3) form a labor pain committee consisting of midwives, obstetricians, and anesthesiologists in order to identify the preferred painless labor methods based on the existing facilities and conditions, 4) carry out research on observing patients' privacy and dignity; 5) pay more attention on the factors affecting cesarean.

Factors influencing the decision that women make on their mode of delivery: the Health Belief Model

Background

Childbirth is regarded as an important life event for women, and growing numbers of them are making the choice to give birth by Caesarean Delivery. The aim of this study was to identify the factors influencing the decision that women make on their mode of delivery, underpinned by the Health Belief Model.

Methods

This was a cross-sectional study. Hong Kong Chinese women aged 18–45, who were pregnant or had given birth within the last three years were recruited. The participants were asked to complete a structured self-administered questionnaire consisting of 62 questions.

Results

A total of 319 women were recruited, of whom 73 (22.9%) preferred to have a cesarean section delivery (CD). The results showed that women preferred CD because they were concerned about being pregnant at an advanced age, were worried about labor pain and perineum tearing, wanted to have a better plan for maternity leave, had chosen an auspicious date to deliver, and perceived that CD is a more convenience way to deliver. The perceived benefits and severity of a vaginal birth (VB), and the perceived benefits, severity, and cues to action of CD, affected the decision to undergo either a VB or CD.

Conclusions

The data indicated that the constructs of the Health Belief Model – perceived benefits, perceived severity, and cues to action – affect the decision that women make on their mode of delivery. This research indicates that there is value in designing educational programs for pregnant women to educate them on the benefits, risks, and severity of the two different modes of birth based on the constructs of HBM. This will enable women to be active participants in choosing the mode of birth that they believe is right for them.

Cesarean section in Shanghai: women's or healthcare provider's preferences?

BACKGROUND

Cesarean section (CS) rate has increased rapidly over the past two decades in China mainly driven by non-medical factors. This study was to compare recalled preferences for CS among first-time mothers in early and late pregnancy with actual delivery mode; to explore factors related to CS preference and CS performed without medical indications; and to consider the role of healthcare providers in delivery mode preferences.

METHODS

An anonymous questionnaire survey, combined with data on CS indications taken from the patient record, was conducted among 272 first-time mothers having their first postnatal check-up in one university affiliated obstetrics and gynecology hospital in Shanghai, China, between September 2006 and January 2007. Logistic regression was used to study factors related to the recalled preference for CS and CS performed without medical indication, adjusting for maternal age, education and income.

RESULTS

The CS rate was 57% (151/263) among all women, 17% with medical indications and 40% without medical indications. For women without medical indications for CS (n = 215), there was no significant difference between women's preference for CS in early (25%) and late pregnancy (28%); 48% of women actually had CS. Women recalled preferring a vaginal delivery but who had CS were more likely to have had a CS suggested by a prenatal care doctor [OR (95% CI): 20 (3.88-107.1)] or by a delivery obstetrician [OR (95% CI): 26 (6.26-105.8)]. Among women recalled preferring and having CS, a suggestion from the prenatal care doctor to have CS was very common.

CONCLUSIONS

In the primiparous women without a medical indication for CS, women recall of a provider suggestion for CS was a strong predictor of CS both among women who recalled a preference for CS and among women who recalled a preference for vaginal delivery. Public health education needs strengthening, including discussion of the risks associated with CS and psychological and social support given to women to help them prepare for and cope with childbirth.

Cesarean section in a high-parity community in Saudi Arabia: clinical indications and obstetric outcomes

BACKGROUND

The study of the indications for cesarean section (CS) and its outcomes are useful for hospitals, clinicians, and researchers in determining strategies to lower the primary and repeat CS rate. The aim of this study was to identify the indications for CS and the incidence of adverse maternal/fetal outcomes in a tertiary care setting.

METHODS

A retrospective cohort study of women (n = 4305) who gave birth by CS at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia (June 2008 to February 2011), was performed. All of the women's medical records were reviewed by two consulting physicians to obtain the primary indications for CS and determine the maternal characteristics, type of CS (emergency or elective), and birth weight. All adverse maternal and fetal outcomes were recorded. The point and interval estimates of the odds ratios were calculated using a logistic regression model to identify the significant predictors of adverse maternal and/or fetal outcomes.

RESULTS

Of a total of 22,595 deliveries from 2008 to 2011, 4,305 deliveries were CS deliveries (19.05%). Two-thirds (67%) of all CS deliveries were emergency CSs, and the remaining deliveries were elective CSs (33%). Difficult labor (35.9%), fetal distress (21.9%) and breech presentation (11.6%) were the most frequent indications of emergency CS, while previous CS (54.3%), breech presentation (20.4%) and maternal request (10.1%) ranked first for elective CS. Adverse maternal and fetal outcomes were diagnosed in 5.09% and 5.06% of deliveries, respectively, with a significantly higher incidence in the emergency (6.06% & 5.51% respectively) than in elective CS (3.10 & 4.16% respectively). Blood transfusion was the most frequent adverse maternal outcome (3.72%), followed by ICU admission (0.63%), HELLP (0.51%), and hysterectomy (0.30%), while IUGR (3.25%) was the most frequent adverse fetal outcome, followed by IUFD and the need for ICU admission (0.58% each). Adverse maternal outcomes were significantly predicted by high gravidity (OR = 2.84, 95% CI:1.26-6.39, p = 0.011) and preeclampsia (OR = 2.84, 95%CI:1.83-4.39, p < 0.001), while adverse fetal outcomes were predicted by: twinning (OR = 1.81, p = 0.002), hydramnios (OR = 6.70, p < 0.001), and preeclampsia (OR = 2.74, p < 0.001). Preterm delivery was a significant predictor for both adverse maternal and fetal outcomes (OR = 2.39, p < 0.001 & OR = 4.57, p < 0.001, respectively).

CONCLUSIONS

Difficult labor and previous CS were the main indications for CS in Saudi Arabia. High gravidity was a significant predictor of adverse maternal outcomes. Encouraging Saudi women to consider embarking on fewer pregnancies could act as a safeguard against mandatory CSs for subsequent births in multigravida and grand-multigravida Saudi females. Future prospective study that addresses women with repeat CSs and their association with adverse maternal and fetal outcomes is recommended.

Managing the pain of labour: factors associated with the use of labour pain management for pregnant Australian women

BACKGROUND

Despite high rates of women's use of intrapartum pain management techniques, little is known about the factors that influence such use.

OBJECTIVE

Examine the determinants associated with women's use of labour pain management.

DESIGN

Cross-sectional survey of a substudy of women from the 'young' cohort of the Australian Longitudinal Study of Women's Health (ALSWH).

SETTING AND PARTICIPANTS

Women aged 31-35 years who identified as being pregnant or recently given birth in the 2009 ALSWH survey (n = 2445) were recruited for the substudy. The substudy survey was completed by 1835 women (RR = 79.2%).

MAIN VARIABLES STUDIED

Determinants examined included pregnancy health and maternity care [including complementary and alternative medicine (CAM)] for their most recent pregnancy and any previous pregnancies. Participants' attitudes and beliefs related to both CAM and maternity care were also included in the analysis.

MAIN OUTCOME MEASURES

The outcome measures examined were the use of both pharmacological and non-pharmacological pain management techniques (NPMT).

RESULTS

Differences were seen in the effects of demographics, health service utilization, health status, use of CAM, and attitudes and beliefs upon use of intrapartum pain management techniques across all categories. The only variable that was identified as a determinant for use of all types of pain management techniques was a previous caesarean section (CS).

DISCUSSION AND CONCLUSIONS

The effect of key determinants on women's use of pain management techniques differs significantly, and, other than CS, no one determinant is clearly influential in the use of all pain management options.

Natural birth-induced UCP2 in brain development

The prevalence of convenience-driven delivery via Caesarian-section (C-section) has been steadily increasing in Western as well as in developing societies. Today, significantly more deliveries occur via surgical means than medical necessity mandates. Despite tremendous advances in surgical techniques and pre- and post-operative surgical care, there remains to be limited understanding on the physiological influence of vaginal birth with particular emphasis on long term outcome on the offspring. Serendipitously, we recently uncovered in mice that vaginal birth induces significantly higher level of Ucp2 mRNA expression in the hippocampus than experimental C-section. We showed that during the early postnatal period, UCP2 expression promotes neuronal differentiation, axonal outgrowth and synapse formation in the hippocampus. We also observed that Ucp2 knockout animals show adult behaviors associated with the hippocampal formation that is different from wild type littermates. Taken together these observations suggest that vaginal birth may play a crucial role in determining adult brain structure and function that is different from that of the effect of surgically assisted birth.

Predicting birth outcomes: together, mother and health care provider know best

OBJECTIVE

To examine contributors to perceived risk in pregnancy and its utility in predicting lower birth weight and earlier delivery in conjunction with health care providers' assessment of obstetric risk.

METHODS

165 pregnant women at high (n=34) or low (n=131) obstetric risk completed assessments of perceived risk, stress, optimism, and health behaviors using well-validated instruments and measures designed for this study. Medical charts were abstracted for gestational age at delivery and birth weight.

RESULTS

40% of the sample perceived their risk status differently than their health care provider. Stress, poor reproductive history, provider assigned risk, and unhealthful behaviors were significant, independent predictors of perceived risk (R(2)=.37). The greatest difference in birth weight (p=.003) and gestational age (p=.05) was between women considered at low risk by both self and provider and women considered at high risk by both. Perceived risk improved prediction of adverse birth outcomes, especially lower birth weight, in women considered by providers to be at low risk.

CONCLUSION

Women's perceptions of risk are an important contributor to prediction of birth outcomes, but the combination of information from both a woman and her health care provider is superior. Incorporating women's perceptions into obstetric risk determination may help to reduce the number of women identified as high risk who subsequently have a normal birth outcome (false positives), and more importantly, the number of women considered to be at low risk who ultimately experience an adverse outcome (false negatives).

Ability to pay and impoverishment among women who give birth at a University Hospital in Kathmandu, Nepal

Pregnant women giving birth in Nepal need to use out-of-pocket payment for delivery care services due to a lack of insurance policies. The objective of this study was to examine the ability of pregnant Nepalese women to pay for delivery care services and the effects of the current household health expenditure on impoverishment due to hospital-based delivery services, especially normal delivery (ND) and caesarean section (CS). A cross-sectional study was conducted from May to August 2009 at Tribhuvan University Teaching Hospital. Ability to pay was defined as the current health spending being less than 5% of annual household income. Poverty occurred when a household's per capita income fell to less than US$1 per day. Impoverishment was considered as poverty headcount and normalised poverty gap. On average, the percentage of annual household income spent on current delivery care was 5.9% in the ND group and 9.7% in the CS group. The CS group had a stronger impoverishment effect resulting in a high per cent change of payment-induced poverty headcount by 78.1% and poverty gap by 97.3% compared to 7.7 and 24.1% in the ND group, respectively. There is a strong need to develop a well-prepared financial system to prevent the issue of poverty and impoverishment.

Iranian obstetricians' views about the factors that influence pregnant women's choice of delivery method: a qualitative study

BACKGROUND

Caesarean section is a commonly performed childbirth procedure. While caesarean section is undeniably a lifesaving procedure for some mothers and babies, it can also be an unnecessary procedure for others. Different factors may be involved in the rate of birth by caesarean section.

QUESTION

This qualitative study was conducted in Kashan city, Iran, to explore obstetrician's views of what might influence pregnant women's choice of delivery method.

METHODS

Obstetricians' views and experiences were collected using semi-structured interviews. Interviews were conducted in a clinic or hospital, based on the preference of the 18 physicians who agreed to participate in the study. All interviews were recorded and transcribed. Participants were asked key questions, including: "Why do some women prefer caesarean section?"; "What kind of delivery did you have and why?"; "What kind of delivery would you recommend to pregnant women and why?" Inductive qualitative content analysis was undertaken using the method described by Morreti with 120 initial codes categorized into six categories.

FINDINGS

The six categories developed from the initial codes were: factors relating to women, obstetricians, delivery conditions, complications, society's beliefs and the health system.

CONCLUSION

A qualitative study conducted in Iran showed that most of the factors identified by participants facilitated the choice of caesarean section. Vaginal birth was anticipated as a painful and lengthy process, with low cultural acceptance and resulting in less income for obstetricians.

Caesarean section for non-medical reasons at term

BACKGROUND

Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and a greater risk of stillbirth and neonatal morbidity. The differences in neonatal physiology following vaginal and caesarean births are thought to have implications for the infant, with caesarean section potentially increasing the risk of compromised health in both the short and the long term. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics.

OBJECTIVES

To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and reference lists of relevant studies.

SELECTION CRITERIA

All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section.

DATA COLLECTION AND ANALYSIS

We identified no studies that met the inclusion criteria.

MAIN RESULTS

There were no included trials.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth.

Caesarean section in the absence of need: a pathologising paradox for public health?

Caesarean section in the absence of need: a pathologising paradox for public health? This qualitative study explored the discourses constructing women's choice for a caesarean section, in the absence of clinical indication. The research was informed from the theoretical ideas of poststructuralism that presumes people's reality is shaped discursively through the discourses they encounter. A Foucauldian discourse analysis was undertaken of the transcripts of participant's interviews and the texts of both professional and popular media before inductively discerning the prevailing discourses that influence the choice of caesarean in the absence of need. In shaping women's choice in childbirth the discourses of autonomy, convenience and desire alongside fear and risk were identified in the talk and texts of women, childbirth professionals and popular culture. For the purposes of this article we have confined our focus to the findings related to how caesarean is represented in both professional and popular discourse and include feminist discussions around childbirth as an embodied practice. We contend that the discourses of autonomy, desire and risk unite with broader societal discourses to expose a pathologising paradox in which normal bodily performance emerges as abnormal and the abnormal as normal. The trend has implications for both future healthy populations and the equitable distribution of maternity resources.

Developing criteria for cesarean section using the RAND appropriateness method

Background

Cesarean section rates are increasing worldwide, and a rapid increase has been observed in Iran. Disagreement exists between clinicians about when to use cesarean section. We aimed to identify the appropriateness criteria for the use of cesarean section in Iran.

Method

A consensus development study using a modified version of the RAND Appropriateness Method (RAM). We generated scenarios from valid clinical guidelines and expert opinions. A panel of experts participated in consensus development: first round via mail (12 members), second round face-to-face (9 members). We followed the RAM recommendations for the development of the scenario lists, rating scales, and statistical analyses.

Results

294 scenarios relevant to cesarean section were identified. 191 scenarios were considered appropriate, of which 125 scenarios were agreed upon. The panel found cesarean inappropriate for 21% of scenarios, and 'equivocal' for 14% of scenarios.

Conclusion

RAM is useful for identifying stakeholder views in settings with limited resources. The participants' views on appropriateness of certain indications differed with available evidence. A large number of scenarios without agreement may partly explain why it has been difficult to curb the growth in cesarean section rate.

Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis

BACKGROUND

The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime.

METHODS

We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth.

RESULTS

The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life.

CONCLUSIONS

When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.

What characterizes women who want to give birth as naturally as possible without painkillers or intervention?

OBJECTIVE

To describe the characteristics of pregnant women who wish to have as natural a birth as possible without analgesics and without intervention.

STUDY DESIGN

National cohort study.

SETTING

Norwegian Institute of Public Health.

POPULATION

55,859 pregnant women booked for antenatal care in Norway 1999-2007.

METHODS

Data on women's interest in natural birth and a set of possible predictors were retrieved from a questionnaire completed at the 30th week of pregnancy and linked to the Medical Birth Registry of Norway.

MAIN OUTCOME MEASURE

Natural birth and the characteristics of pregnant women with such preferences.

RESULTS

Interest in natural childbirth was consistently expressed by 72%. Positive experience from previous pregnancies, first birth or third or later birth, no fear of giving birth, and reporting positive intra-psychic phenomena are significantly associated with the wish for natural birth.

CONCLUSIONS

Positive experiences from previous childbirths and no fear of giving birth are the strongest factors associated with a wish for as natural birth as possible and should be taken into consideration in public health.

[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.

Cesarean delivery by maternal request: what neonatal nurses need to know

The rate of cesarean deliveries by maternal request (CDMRs) is rising in the U.S. This article explains why women choose this type of delivery, notes the risks of CDMR for the infant, and suggests ways neonatal nurses can minimize the risks for well infants, as well as for those who must be admitted to the NICU.

Fears associated with childbirth among nulliparous women in Turkey

OBJECTIVE

to describe fears associated with childbirth and reasons for the fears.

DESIGN

a qualitative study. Data were gathered through semi-structured interviews and analysed using content-analysis method.

SETTING

outpatient maternity clinic of a university hospital in Turkey.

PARTICIPANTS

19 nulliparous pregnant women who stated that they had fear related to childbirth.

FINDINGS

women's fears were related to labour pain, birth-related problems and procedures, attitudes of health-care personnel and sexuality. The reasons for their fears included type and quality of childbirth information, personal characteristics and experiences, maternity ward environment and lack of confidence in health-care personnel. Seven of the women were considering an elective caesarean section. The role of husbands in the childbirth experience was not mentioned by any participants. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTISE: women experience considerable fear related to impending childbirth. Considering the potential for negative findings caused by fear, and the likelihood of requesting a caesarean section, it is important for health professionals who provide antenatal care to explore fears related to childbirth. The development and evaluation of formal childbirth education is also recommended.

Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications

A growing number of children around the world are being born by surgical delivery, or cesarean section. Concerns over rising rates of cesareans have focused on the risk of death and medical complications associated with surgical delivery but have largely neglected psychosocial and behavioral factors that affect and are affected by cesarean delivery. We summarize research which indicates that women who deliver by cesarean section have more negative perceptions of their birth experience, their selves, and their infants, exhibit poorer parenting behaviors, and may be at higher risk for postpartum mood disturbance compared to women delivering infants vaginally. We also review evidence that suggests that cesareans adversely influence women's moods and perceptions by restricting the control that they can exercise over birth and by violating expectations about childbirth. Based on these findings, we recommend ways to reduce the aversiveness of cesareans, offer recommendations for future research, and discuss implications of escalating rates of cesareans, including medically non-indicated cesareans by request.

Cesarean section on request in a developing country

OBJECTIVE

To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country.

METHOD

Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed.

RESULTS

The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies.

CONCLUSION

The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice.

Public Health Implications of Cesarean on Demand

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in "cesarean on maternal request" in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health.

Caesarean section for non-medical reasons at term

BACKGROUND

Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics.

OBJECTIVES

To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2005), MEDLINE (1974 to April 2005), EMBASE (1974 to April 2005), CINAHL (1982 to April 2005) and PsycINFO (1887 to April 2005). We also performed a manual search of the references of all retrieved articles, sought unpublished papers and abstracts submitted to international conferences and contacted expert informants.

SELECTION CRITERIA

All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section.

DATA COLLECTION AND ANALYSIS

We identified no studies that met the inclusion criteria.

MAIN RESULTS

There were no included trials.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth.

Maternal request CS--role of hospital teaching status and for-profit ownership

OBJECTIVE

To examine whether hospitals' for-profit (FP) ownership and non-teaching status are associated with greater likelihood of maternal request cesarean (CS) relative to public and not-for-profit (NFP) and teaching status, respectively.

METHOD

Retrospective, cross-sectional, population-based study of Taiwan's National Health Insurance claims data, covering all 739,531 vaginal delivery-eligible singleton deliveries during 1997-2000, using multiple logistic regression analyses.

RESULTS

Adjusted for maternal age and geographic location, FP district hospitals (almost all non-teaching), followed by ob/gyn clinics were significantly more likely to perform request CS (OR=3.5-2.3) than public and NFP teaching hospitals. Among non-teaching and teaching hospitals, FPs were more likely to perform request CS than public and NFP hospitals (OR=2.3 and 2.5, respectively).

CONCLUSIONS

Our findings are consistent with greater propensity of physicians in FP institutions to accommodate patient requests involving revenue-maximizing procedures such as request CS. This effect is moderated by teaching hospitals' preference for complicated cases, consistent with their teaching mission and hi-tech infrastructure.

Brazilian doctors' perspective on the second opinion strategy before a C-section

OBJECTIVE

To describe the opinion of doctors who participated in the Latin American Study on Cesarean section in Brazil regarding the second opinion strategy when faced with the decision of performing a C-section.

METHODS

Seventy-two doctors from the hospitals where the study took place (where the second opinion was routinely sought) and 70 from the control group answered a pre-tested self-administered structured questionnaire. Descriptive tables were prepared based on the frequency of relevant variables on opinion of physicians regarding: effectiveness of the application of the second opinion strategy; on whether they would recommend implementation of this strategy and reasons for not recommending it in private institutions; feasibility of the strategy implementation and reasons for not considering this implementation feasible in private institutions.

RESULTS

Half of the doctors from the intervention hospitals (50%) and about two thirds of those in the control group (65%) evaluated the second opinion as being or having the potential of being effective/very effective in their institutions. The great majority of those interviewed from both intervention and control hospitals considered this strategy feasible in public (87% and 95% respectively) but not in private hospitals (64% and 70% respectively), mainly because in the latter the doctors would not accept interference from a colleague in their decision-making process.

CONCLUSION

Although the second opinion strategy was perceived as effective in reducing C-section rates, doctors did not regard it feasible outside the public health system in Brazil.

Evidence-informed obstetric practice during normal birth in China: trends and influences in four hospitals

Background

A variety of international organizations, professional groups and individuals are promoting evidence-informed obstetric care in China. We measured change in obstetric practice during vaginal delivery that could be attributed to the diffusion of evidence-based messages, and explored influences on practice change.

Methods

Sample surveys of women at postnatal discharge in three government hospitals in Shanghai and one in neighbouring Jiangsu province carried out in 1999, repeated in 2003, and compared. Main outcome measures were changes in obstetric practice and influences on provider behaviour. "Routine practice" was defined as more than 65% of vaginal births. Semi-structured interviews with doctors explored influences on practice.

Results

In 1999, episiotomy was routine at all four hospitals; pubic shaving, rectal examination (to monitor labour) and electronic fetal heart monitoring were routine at three hospitals; and enema on admission was common at one hospital. In 2003, episiotomy rates remained high at all hospitals, and actually significantly increased at one; pubic shaving was less common at one hospital; one hospital stopped rectal examination for monitoring labour, and the one hospital where enemas were common stopped this practice. Mobility during labour increased in three hospitals. Continuous support was variable between hospitals at baseline and showed no change with the 2003 survey.

Provider behaviour was mainly influenced by international best practice standards promoted by hospital directors, and national legislation about clinical practice.

Conclusion

Obstetric practice became more evidence-informed in this selected group of hospitals in China. Change was not directly related to the promotion of evidence-based practice in the region. Hospital directors and national legislation seem to be particularly important influences on provider behaviour at the hospital level.