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

Socioeconomic, demographic, and cultural determinants of delivery by caesarian section in Ethiopia: Evidence from Ethiopia Mini Demographic and Health Survey 2019

Delivery by cesarean section is a surgical procedure of delivery to a newborn baby, and the process is applied when vaginal delivery is unsafe. This study aims to identify the socioeconomic, demographic, and cultural factors that significantly impact the delivery by caesarean section. The 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS) data were used to conduct this research, and this study considered 2872 ever-married women all over the country who delivered in the clinical setting. Firstly, a frequency distribution table has been constructed to understand the characteristics of the selected explanatory and study variables. Then Chi-square test identifies the association between various socioeconomic and demographic factors and delivery by the caesarian section. Finally, the Binary Logistic Regression was used to determine the factors that substantially impact the caesarian section among women in Ethiopia. The Chi-square test of association showed that mother's age, type of residence, highest education level, religion, socioeconomic status, total children ever born, use of contraception, age of mothers at first birth, and preceding birth interval were significantly associated with the caesarian section. The multivariate binary logistic regression analysis revealed that the mother's current age (Age Group: 31-40; Odds Ratio: 2.487, p<0.05) and religion (Muslim; Odds Ratio: 0.599, p<0.05) substantially influenced the study feature. Moreover, the highest educational level (Secondary and higher; Odds Ratio: 1.581, p<0.05), and the preceding birth interval (>40 months; Odds Ratio: 0.682, p<0.05) were also found to have considerable impacts on the caesarian section. Furthermore, the total number of children ever born (>5; Odds Ratio: 0.498, p<0.05) significantly impacts the delivery by caesarean section in Ethiopia. This study's results would be useful to policymakers to take necessary steps to reduce unnecessary delivery by caesarian section and ensure a safer newborn delivery process.

Cesarean section or normal vaginal delivery: A cross-sectional study of attitude of medical students

INTRODUCTION

Childbirth is regarded as an important life event for women, and growing numbers of them are making the choice to give birth by cesarean delivery. Increasing rate of births by cesarean section is an issue of concern in many countries. In order to reduce the rates of unnecessary cesarean sections, it is essential to acquire information of the reasons that motivate physicians to carry out cesarean sections rather than vaginal deliveries. The objective of present study is to evaluate whether the education process for undergraduate medical students affects their decision-making.

MATERIALS AND METHODS

The present study was cross-sectional and questionnaire based. A total of 292 students participated in the study. Out of which, 150 were first-year students and 142 were doing internship in Maharashtra Institute of Medical Education and Research (MIMER), Talegaon Dabhade, Maharashtra, India. The study was conducted in the months of June and July 2019. Data was collected with the help of person to person interview of all the participants who satisfied the inclusion criteria after obtaining their informed consent. The data was entered by using Microsoft Excel 2007 and was analyzed using Epi Info version 3.3.2. The data was tabulated and analyzed according to responses which were given by the respondents.

RESULTS

A total of 292 students answered the questionnaire. Age of participants varied between 19 and 23 years. 130 males and 162 females were the subjects, out of which 40 students declared fear of labor. Most of the students preferred vaginal delivery over cesarean sections in all the four scenarios. The difference of opinion was significant in case of an uneventful pregnancy and normal pregnancy under their care. For general population as healthcare manager this difference of opinion was not significant. In case of one's own or partner's delivery, internship students preferred cesarean section but this difference was statistically non-significant.

CONCLUSION

Most of the students would recommend vaginal delivery because this form of delivery has fewer risks as compared to cesarean section. Majority of students chose vaginal delivery for the birth of their own child; however, a higher number of interns as compared to first year students preferred cesarean section. Pain associated with vaginal delivery was the most common reason given for choosing cesarean section. The student's preference for childbirth changed in due course of graduation toward cesarean section. This indicates a probable effect of medical education on permissive culture of cesarean section as a mode of delivery.

Caesarean Section in Indonesia: Analysis of Trends and Socio-Demographic Correlates in Three Demographic and Health Surveys (2007–2017)

Objectives

This study determined the prevalence and trends in caesarean section (C-section) deliveries and the factors associated with the utilization of C-section deliveries among Indonesian mothers from 2007 to 2017.

Methods

We used Indonesia Demographic and Health Survey data sets (2007, 2012, and 2017) to assess the prevalence, trends, and factors associated with C-section delivery through univariate, bivariate, and multivariate analyses.

Results

A 10% increase in C-section delivery among Indonesian women was observed between the years 2007 and 2017. Mothers from urban areas tended to receive more C-sections than mothers from rural areas (adjusted odds ratio (aOR) = 1.49). More educated mothers were more likely (aOR = 3.373) to receive C-sections than mothers without formal education. Mothers from wealthy family backgrounds were more (aOR = 1.97) likely to receive C-sections than mothers from low-income families. Antenatal care (ANC) visits were significantly positively associated with receiving C-sections; mothers with more than four ANC visits (aOR = 4.54) tended to receive more C-sections than mothers with no ANC visits. For first births, mothers over 25 years of age were more likely (aOR = 2.07) to receive C-sections than mothers less than 18 years of age.

Conclusion

The percentage of C-sections has alarmingly increased. Thus, authorities in Indonesia should consider these findings and take necessary steps to decrease C-sections. The results of this study should help policymakers formulate appropriate policies that will encourage regular delivery where most appropriate.

Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil

BACKGROUND

There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.

METHODS AND FINDINGS

We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.

CONCLUSIONS

In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.

Household- and community-level determinants of low-risk Caesarean deliveries among women in India

Caesarean section delivery rates in India have doubled from 9% in 2005-06 to 17% in 2015-16, increasing the clinical and economic burden on the health care system. This study applied multilevel models to assess the role of household- and community-level factors in Caesarean section (CS) deliveries among low-risk women in India using data from Round 4 of the National Family Health Survey (NFHS-4) conducted in 2015-16. The sample size was 59,318 low-risk women who had their last birth in an institution during the 5 years preceding the survey. These women were nested in 57,279 households, which were nested in 22,183 communities, which were further nested in 640 districts in India. Around 21% of the low-risk women and 24% of all women who had delivered in an institution had undergone CS. The CS rates among low-risk women were extremely high in private institutions (40%) and in southern India (43%). The explanatory variables age, education of women, household wealth and number of antenatal visits were significantly positively associated, while women's parity was negatively associated, with CS delivery among low-risk women. The multilevel analysis suggested that the likelihood of a low-risk woman opting for CS was influenced by a similar decision of another woman from the same household (37%) and/or community (18%). Furthermore, women with low-risk pregnancies from higher educated communities were less likely (OR 0.92) to undergo CS. There is therefore a need for a community-level awareness programme on the risks and benefits of low-risk CS and vaginal delivery, particularly in the southern region of India.

Socioeconomic and demographic factors associated with caesarean section delivery in Southern Ghana: evidence from INDEPTH Network member site

BACKGROUND

In recent years, caesarean section rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate caesarean section rate and the associated short- and long-term risks. This study sought to identify the rate of caesarean section and associated factors in two districts in rural southern Ghana.

METHODS

Pregnancy, birth, and socio-demographic information of 4948 women who gave birth between 2011 and 2013 were obtained from the database of Dodowa Health and Demographic Surveillance System. The rate of C-section was determined and the associations between independent and dependent variables were explored using logistic regression. The analyses were done in STATA 14.2 at 95% confidence interval.

RESULTS

The overall C-section rate for the study period was 6.59%. Women aged 30-34 years were more than twice likely to have C-section compared to those < 20 year (OR: 2.16, 95% CI: 1.20-3.90). However, women aged 34 years and above were more than thrice likely to undergo C-section compared to those < 20 year (OR: 3.73, 95% CI: 1.45-5.17). The odds of having C-section was 65 and 79% higher for participants with Primary and Junior High level schooling respectively (OR: 1.65, 95% CI: 1.08-2.51, OR:1.79, 95%CI: 1.19-2.70). The likelihood of having C-section delivery reduced by 60, 37, and 35% for women with parities 2, 3 and 3+ respectively (OR:0.60, 95% CI: 0.43-0.83, OR: 0.37, 95% CI: 0.25-0.56, OR:0.35, 95% CI: 0.25-0.54). There were increased odds of 36, 52, 83% for women who belong to poorer, middle, and richer wealth quintiles respectively (OR: 1.36, 95%CI: 0.85-2.18, OR: 1.52, 95% CI: 0.97-2.37, OR: 1.83, 95% CI: 1.20-2.80). Participants who belonged to the richest wealth quintile were more than 2 times more likely to have C-section delivery (OR: 2.14, 95%CI: 1.43-3.20). The odds of having C-section delivery reduced by 76% for women from Ningo-Prampram district (OR: 0.76, 95% CI: 0.59.0.96). Women whose household heads have Junior High level and above of education were 45% more likely to have C-section delivery (OR: 1.45, 95% CI: 1.09-1.93).

CONCLUSION

Age of mother, educational level, parity, household socioeconomic status, district of residence, and level of education of household head are associated with caesarean section delivery.

Opinions of women towards cesarean delivery and priority issues of care in the postpartum period

This study was conducted, in order to determine the opinions of women who had a cesarean delivery and the problems that they faced in the postpartum period. This descriptive study was conducted with 337 women who delivered babies by cesarean section. The data were collected using a semi-structured questionnaire. The results of the study showed that 53.4% of women underwent cesarean delivery for the first time, and 83.1% said that it was the obstetrician's decision to have a cesarean delivery. More than half of the women (61.1%) had a negative experience with cesarean delivery due to postpartum pain (44.7%) and inability to care for their infant (35.9%). The most common problems associated with cesarean delivery were postpartum pain (96.1%), back pain (68.2%), problems passing gas (62.0%), bleeding (56.1%), breastfeeding problems (49.6%) and limitation of movement (43.6%) respectively. Understanding the the opinions and problems of women towards cesarean delivery assists healthcare professionals in identifying better ways to provide appropriate care and support.

Caesarean delivery and its correlates in Northern Region of Bangladesh: application of logistic regression and cox proportional hazard model

BACKGROUND

Caesarean delivery (C-section) rates have been increasing dramatically in the past decades around the world. This increase has been attributed to multiple factors such as maternal, socio-demographic and institutional factors and is a burning issue of global aspect like in many developed and developing countries. Therefore, this study examines the relationship between mode of delivery and time to event with provider characteristics (i.e., covariates) respectively.

METHODS

The study is based on a total of 1142 delivery cases from four private and four public hospitals maternity wards. Logistic regression and Cox proportional hazard models were the statistical tools of the present study.

RESULTS

The logistic regression of multivariate analysis indicated that the risk of having a previous C-section, prolonged labour, higher educational level, mother age 25 years and above, lower order of birth, length of baby more than 45 cm and irregular intake of balanced diet were significantly predict for C-section. With regard to survival time, using the Cox model, fetal distress, previous C-section, mother's age, age at marriage and order of birth were also the most independent risk factors for C-section. By the forward stepwise selection, the study reveals that the most common factors were previous C-section, mother's age and order of birth in both analysis. As shown in the above results, the study suggests that these factors may influence the health-seeking behaviour of women.

CONCLUSIONS

Findings suggest that program and policies need to address the increase rate of caesarean delivery in Northern region of Bangladesh. Also, for determinant of risk factors, the result of Akaike Information Criterion (AIC) indicated that logistic model is an efficient model.

Determinants of women's satisfaction with maternal health care: a review of literature from developing countries

BACKGROUND

Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women's satisfaction with maternity care in developing countries.

METHODS

The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach.

RESULTS

Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women.

CONCLUSIONS

Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.

Spontaneous vaginal delivery or caesarean section? What do Turkish women think?

The aim of this study was to describe women's feelings, attitudes and beliefs about different modes of childbirth. A descriptive cross-sectional study was conducted at the obstetrics clinics of Ege University and Dr Ekrem Hayri Ustundag Obstetrics and Gynaecology Hospital in Izmir, Turkey. Three-hundred forty-two women who had given birth via spontaneous vaginal delivery (SVD) or caesarean section (C/S) between June and December 2009 voluntarily agreed to participate. Fifty-seven per cent of participants were aged 20-24. Sixty per cent of the women (n = 205) had undergone C/S during their last delivery; among these women, the birth method of 90% (n = 185) was decided by their doctors, whereas the remaining 10% (n = 20) made the decision themselves or with their partners. Sixty-three per cent (n = 250) of women who underwent C/S said that if they gave birth again, they would prefer to deliver via SVD. Eighty-eight per cent (n = 300) of women wanted the legal right to choose their birth method. Although the rate of C/S was high, most women stated that if given the choice, they would prefer a SVD if they had another child.

Women's preference for caesarean section: a systematic review and meta-analysis of observational studies

BACKGROUND

The striking increase in caesarean section rates in middle- and high-income countries has been partly attributed to maternal request. We conducted a systematic review and meta-analysis of women's preferences for caesarean section.

OBJECTIVES

To review the published literature on women's preferences for caesarean section.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE, LILACS and PsychINFO was performed. References of all included articles were examined.

SELECTION CRITERIA

We included studies that quantitatively evaluated women's preferences for caesarean section in any country. We excluded articles assessing health providers' preferences and qualitative studies.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened abstracts of all identified citations, selected potentially eligible studies, and assessed their full-text versions. We conducted a meta-analysis of proportions, and a meta-regression analysis to determine variables significantly associated with caesarean section preference.

MAIN RESULTS

Thirty-eight studies were included (n = 19,403). The overall pooled preference for caesarean section was 15.6% (95% CI 12.5-18.9). Higher preference for caesarean section was reported in women with a previous caesarean section versus women without a previous caesarean section (29.4%; 95% CI 24.4-34.8 versus 10.1%; 95% CI 7.5-13.1), and those living in a middle-income country versus a high-income country (22.1%; 95% CI 17.6-26.9 versus 11.8%; 95% CI 8.9-15.1).

AUTHORS' CONCLUSIONS

Only a minority of women in a wide variety of countries expressed a preference for caesarean delivery. Further research is needed to better estimate the contribution of women's demand to the rising caesarean section rates.

A critique of the literature on women's request for cesarean section

BACKGROUND

The influence of women's birth preferences on the rising cesarean section rates is uncertain and possibly changing. This review of publications relating to women's request for cesarean delivery explores assumptions related to the social, cultural, and political-economic contexts of maternity care and decision making.

METHOD

A search of major databases was undertaken using the following terms: "c(a)esarean section" with "maternal request,""decision-making,""patient participation,""decision-making-patient,""patient satisfaction,""patient preference,""maternal choice,""on demand," and "consumer demand." Seventeen papers examining women's preferred type of birth were retrieved.

RESULTS

No studies systematically examined information provided to women by health professionals to inform their decision. Some studies did not adequately acknowledge the influence of obstetric and psychological factors in relation to women's request for a cesarean section. Other potential influences were poorly addressed, including whether or not the doctor advised a vaginal birth, women's access to midwifery care in pregnancy, information provision, quality of care, and cultural issues.

DISCUSSION

The psychosocial context of obstetric care reveals a power imbalance in favor of physicians. Research into decision making about cesarean section that does not account for the way care is offered, observe interactions between women and practitioners, and analyze the context of care should be interpreted with caution.

Elective cesarean section and decision making: a critical review of the literature

BACKGROUND

The cesarean section rate continues to rise in many countries with routine access to medical services, yet this increase is not associated with improvement in perinatal mortality or morbidity. A large number of commentaries in the medical literature and media suggest that consumer demand contributes significantly to the continued rise of births by cesarean section internationally. The objective of this article was to critically review the research literature concerning women's preference or request for elective cesarean section published since that critiqued by Gamble and Creedy in 2000.

METHODS

A search of key databases using a range of search terms produced over 200 articles, of which 80 were potentially relevant. Of these, 38 were research-based articles and 40 were opinion-based articles. A total of 17 articles fitted the criteria for review. A range of methodologies was used, with varying quality, making meta-analysis of findings inappropriate, and simple summaries of results difficult to produce.

RESULTS

The range and quality of studies had increased since 2001, reflecting continuing concern. Women's preference for cesarean section varied from 0.3 to 14 percent; however, only 3 studies looked directly at this preference in the absence of clinical indications. Women's preference for a cesarean section related to psychological factors, perceptions of safety, or in some countries, was influenced by cultural or social factors.

CONCLUSIONS

Research between 2000 and 2005 shows evidence of very small numbers of women requesting a cesarean section. A range of personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinned these requests.

Systematic review of nulliparous women's views of planned cesarean birth: the missing component in the debate about a term cephalic trial

BACKGROUND

The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women's views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial.

METHODS

A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading "cesarean section" and four free text spellings of "cesarean," or "birth" or "delivery," near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman's preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non-English language papers were all excluded.

RESULTS

Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women's preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women's decision making, and influence of societal norms.

CONCLUSIONS

Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women's views of vaginal and cesarean birth is required.

Rising rates, changing relationships: caesarean section and its correlates in South Korea, 1988-2000

OBJECTIVE

To examine the trends in the relationship between caesarean section rates in South Korea and its correlates.

DESIGN

Five rounds (1988, 1991, 1994, 1997 and 2000) of population-based National Fertility and Family Health Survey of South Korea.

SETTING

South Korea. Sample Mothers (N= 9184) aged 15-44 years.

METHODS

Caesarean rates were calculated according to correlates and then directly adjusted to five-year age and parity groups. Distribution of all samples (9184 mothers) was standard, producing age- and parity-adjusted caesarean rates. Linear trends of correlates with caesarean rates were examined for ordinal variables such as education, income, urbanisation level (area of residence) and level of prenatal visits.

MAIN OUTCOME MEASURE

Age- and parity-adjusted caesarean section rates.

RESULTS

As caesarean rates rose by year, the relationship of caesarean section with education, occupation and area of residence has been reversed. Associations between caesarean rates, income level, place of delivery and level of prenatal visit were found in 1988 but disappeared by 2000. In 2000, relatively low caesarean rates were found in variables that will be more prevalent in the future, such as higher maternal education, higher maternal occupation and residence in big cities.

CONCLUSION

Caesarean rates may have reached a plateau in South Korea. No maternal or health service factors were detected to further increase the proportion of caesarean deliveries.

An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience

BACKGROUND

Caesarean section (CS) rates have been increasing dramatically in the past decades around the world. The objective of our study was to investigate the factors increasing the likelihood of undergoing CS in two public hospitals and one private hospital in Athens, Greece. Specifically, the purpose was primarily to assess the impact of non-medical factors such as private health insurance, potential for making informal payments, physician convenience and socio-economic status on the rate of CS deliveries.

METHODS

All available demographic, socio-economic and medical information from the medical records of all deliveries in the three hospitals in January 2002 were analysed. The relative importance of the variables in predicting delivery with CS rather than normal vaginal delivery was calculated in multiple logistic regression models to generate odds ratios (OR).

RESULTS

The CS rate in the public hospitals was 41.6% (52.5% for Greeks and 26% for immigrants), while the CS rate in the private hospital was 53% (65.2% for women with private insurance and 23.9% for women who paid directly). In the public hospitals, after controlling for demographic and medical factors, Greek ethnic background, delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, and on Monday, Wednesday and Friday were found to increase the likelihood of CS delivery. In the private hospital, having private health insurance is the strongest predictor of CS delivery, followed by delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, delivery on a Saturday and being a housewife.

CONCLUSION

The results of this study lend support to the hypothesis that physicians are motivated to perform CS for financial and convenience incentives. The recent commercialization of gynaecology services in Greece is discussed, along with its implications on physicians' decisions to perform CS.

Birth and social class: Northern Thai women's lived experiences of caesarean and vaginal birth

This paper, based on in-depth interviews with Thai women in Northern Thailand, contributes to a sociological understanding of women's childbirth discourses. The findings indicate that the lived experiences of birth differ between individual women. It clearly shows that social resources such as financial resources and education play a salient role in shaping the embodied experience of birth among women in Northern Thailand. Because of their 'everyday lifestyle', middle class women have more control over the experience of childbirth than that of the rural poor women. Middle class women are able to choose where to give birth, have access to private care and actively seek medical technology as a way to have control over their birth. Their material resources enable their choices. These choices seem to be denied to the rural poor women. But not all rural poor women are passive victims of their material resources. No matter how limited the resources women have, they use them. Hence, there are some poor women who actively seek birthing care that enables them to have more control. But regardless of their social positions (urban middle class or rural poor), obstetric interventions are commonly experienced, and most women perceive caesarean birth in a positive light. Several discourses are employed to explain these findings including women's interpretations of their lived world including risk and the medicalisation of childbirth in Thailand. Taking a feminist standpoint, I argue that differences between women need to be taken into account in providing care to women in childbirth so that sensitive and appropriate birthing care can be achieved.

Fatores associados à cesariana entre mulheres de baixa renda em Pelotas, Rio Grande do Sul, Brasil

O objetivo do estudo foi investigar a associação entre as características das mulheres e do cuidado pré-natal na rede de Atenção Primária à Saúde de Pelotas com o tipo de parto. Realizou-se um estudo transversal, incluindo a estrutura dos serviços e o processo de atendimento. Foram estudados todos os centros de saúde da cidade e entrevistadas 712 mães. A taxa de cesarianas foi de 30,0%. Na análise ajustada, o risco de cesariana associou-se com características maternas (menor altura, menor número de gestações, gestação planejada, internações hospitalares e hipertensão arterial na gravidez). Entre as características dos serviços encontrou-se influência protetora do maior tempo de formado do médico pré-natalista e o cumprimento às normas do Programa de Pré-natal. As maiores taxas foram verificadas entre os hospitais universitários. Além da educação da mulher no pré-natal, o reconhecimento precoce e o manejo adequado da hipertensão arterial e das causas de hospitalização sugerem a possibilidade de abordagem pelo setor primário a fim de reduzir a taxa de cesarianas.

The place of birth: Childbearing and kinship in Calcutta middle-class families

Hospital births were introduced to India during the colonial period but became a popular option during the 1960s. Today they have replaced "traditional" home birth among the urban middle classes, and a significant proportion of hospital births are elective Caesarean sections. In this article I examine this mode of birth in the context of specific marital and residential patterns and cross-generational accounts of birth among middle-class women in Calcutta. By paying close attention to affinal relations and the meaning of kinship for birthing women, I challenge assumptions regarding the positive aspects of previous, less medicalized, modes of birth and explore how the shift towards Caesarean sections does not merely signify an unquestioning acceptance of an alienating allopathic regime. The ethnographic accounts of different experiences of childbirth show that the medicalization of childbirth should be situated within the context of wider kin and class relations that affect women's choice and their sense of agency.

Postpartum depression: prevalence and determinants in Lebanon

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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