Pregnant women's preference for cesarean section and subsequent mode of birth - a six-country cohort study

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

FINDINGS

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

KEY CONCLUSIONS

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

CLINICAL TRIAL REGISTRY

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

Preferences for childbirth delivery and pain relief methods among pregnant women in Vietnam

Background

Understanding childbirth delivery and pain relief method preferences is important as a part of the shared decision-making process between pregnant women and health professionals. This study aimed to examine the preferences for childbirth delivery modes and pain relief methods and factors related to these preferences among pregnant women in Vietnam.

Methods

A cross-sectional survey on pregnant women was conducted in two obstetrics hospitals in Vietnam. Face-to-face interviews using a structured questionnaire were performed to collect information about sociodemographic characteristics, pregnancy characteristics, preferences for different childbirth delivery modes, and pain relief methods. Multivariate logistic regression was employed for determining associated factors with the preferences.

Results

Of 576 pregnant women, 34% of participants preferred cesarean section. Most of the sample did not have any preferences for specific pharmacological pain relief methods (70.1%), while support from partner/relatives was the most preferable non-pharmacological method (61.3%), following by water birth (11.1%) and acupuncture (9.9%). Desire to have another baby, relatives' experience, selection date of birth, and instrumental social support were major drivers of the cesarean section selection. This preference was an important factor in the preference for pharmacological pain relief. Meanwhile, high levels of informational and emotional support were associated with non-pharmacological method preference.

Conclusion

This study highlighted a high preference rate for cesarean section in urban pregnant women in Vietnam. Holistic approaches from family, health facility, and policy should be performed to diminish the cesarean rate preference and promote the use of non-pharmacological pain relief methods during birth.

The prevalence and associated factors of fear of childbirth among Turkish pregnant women

OBJECTIVE

This study was conducted to determine the prevalence of fear of childbirth and affecting factors in pregnant women in Turkey.

MATERIALS AND METHODS

This was a cross-sectional study and included a total of 2025.    Pregnant Women Assessment, some variables related to previous and current perinatal processes and Wijma Delivery Expectancy/Experience Questionnaire (version A) were used for data collection.

FINDINGS

In this sample, 42.4% of the women reported fear of childbirth. What the women were afraid of most was the development of unwanted conditions at childbirth, obscurity/uncertainty, and negative attitudes of health professionals. The factors causing fear of childbirth were the low education level, unemployment status, low financial status, stillbirth, unplanned pregnancy, indecisiveness about the type of delivery, not attending prenatal education programs, negative effects of other people, insufficient social support, confiding in the healthcare centre and health professional, negative, and indecisive birth perceptions, prior negative birth experiences and not feeling ready for childbirth (p < 0.001).

CONCLUSIONS

The prevalence of fear of childbirth in this Turkish sample, especially in the multipara is higher than in Western countries. Causes of fear of childbirth can vary with countries and even with each region of a country.

"Because it eases my Childbirth Plan": a qualitative study on factors contributing to preferences for caesarean section in Thailand

BACKGROUND

Although caesarean section (CS) rates have increased rapidly in Thailand, the upward trend is not supported by significant maternal or perinatal health benefits. The appropriate use of CS through QUALIty DECision-making by women and providers (QUALI-DEC project) aims to design and implement a strategy to optimize the use of CS through non-clinical interventions. This study aimed to explore the factors influencing women's and health professionals' preferences for CS delivery in Thailand.

METHODS

We conducted a formative qualitative study by using semi-structured in-depth interviews with pregnant and postpartum women, and healthcare staff. Purposive sampling was used to recruit participants from eight hospitals across four regions of Thailand. Content analysis was used to develop the main themes.

RESULTS

There were 78 participants, including 27 pregnant and 25 postpartum women, 8 administrators, 13 obstetricians, and 5 interns. We identified three main themes and seven sub-themes of women and healthcare providers' perceptions on CS: (1) avoiding the negative experiences from vaginal birth (the pain of labor and childbirth, uncertainty during the labor period); (2) CS is a safer mode of birth (guarantees the baby's safety, a protective shield for doctors); and (3) CS facilitates time management (baby's destiny at an auspicious time, family's management, manage my work/time).

CONCLUSIONS

Women mentioned negative experiences and beliefs about vaginal delivery, labor pain, and uncertain delivery outcomes as important factors influencing CS preferences. On the other hand, CS is safer for babies and facilitates multiple tasks in women's lives. From health professionals' perspectives, CS is the easier and safer method for patients and them. Interventions to reduce unnecessary CS, including QUALI-DEC, should be designed and implemented, taking into consideration the perceptions of both women and healthcare providers.

Intrapartum pudendal nerve block analgesia and childbirth experience in primiparous women with vaginal birth: A cohort study

BACKGROUND

A negative childbirth experience has short- and long-term consequences for both mother and child. This study aimed to investigate the association between intrapartum pudendal nerve block (PNB) analgesia and childbirth experience.

METHODS

Primiparous women with a singleton cephalic vaginal live births at term at Oslo University Hospital from January 1, 2017, to June 1, 2019, were eligible for inclusion. The main outcome was total score on a childbirth experience questionnaire (range 1.0-4.0, higher score indicates better childbirth experience). An absolute risk difference of 0.10 was considered clinically relevant. Propensity score matching was used to adjust for differences in baseline characteristics between women with and without PNB. The analyses were stratified by spontaneous vs instrumental birth. Subanalyses of the questionnaire's domains (own capacity, professional support, perceived safety, and participation) were performed.

RESULTS

Of 979 participating women, mean age was 32 years. Childbirth experience did not differ between women with and without PNB, either in spontaneous (absolute risk difference of the mean: -0.05, P value 0.36) or in instrumental birth (absolute risk difference of the mean: 0.03, P value 0.61). There were no statistically significant differences between PNB group scores for the separate domains.

CONCLUSIONS

Women's childbirth experiences did not differ between birthing people with or without PNB, either in spontaneous or in instrumental births. The clinical implications of our study should be interpreted in light of the pain-relieving effects of PNB.PNB should be provided on clinical indication, including for individuals with severe labor pain.

Predictors of successful vaginal birth after a cesarean section in Ethiopia: a systematic review and meta-analysis

BACKGROUND

The rates of successful vaginal birth after previous cesarean section (VBAC) have been increasing with minimal complication. Successful vaginal birth after cesarean section improves maternal and fetal outcomes by shortening the length of hospital stay, avoiding abdominal surgery, decreasing the risk of infections and hemorrhage, and decreasing injury of the bladder and bowel. Despite a few single studies stating different predictors of successful VBAC, there is a lack of nationwide data to show the determinants of successful VBAC. Thus, this meta-analysis aimed to determine the predictors of successful VBAC in Ethiopia.

METHODS

A systematic literature search was performed from PubMed, Web of Sciences, EMBASE, CINAHL, and Google scholar until July 25, 2022. The quality of included studies was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist. The analysis was executed using Stata 14 statistical software. Heterogeneity was evaluated statistically using Cochran's Q-statistic and quantified by the I² value. A random-effects model was used to estimate the determinants of successful vaginal birth after a cesarean section if substantial heterogeneity was detected across included studies; otherwise, a fixed-effects model was used.

RESULTS

Women living in rural residence (AOR: 2.14; 95% CI: 1.01, 4.52), history of previous spontaneous vaginal delivery (AOR: 2.92; 95% CI: 2.02, 4.23), previous successful vaginal birth after previous cesarean section (AOR: 5.29; 95% CI: 2.20, 12.69), history of stillbirth (AOR: 1.57; 95% CI: 1.20, 2.04), cervical dilation of ≥ 4 cm at admission (AOR: 2.14; 95% CI: 1.27, 3.61), spontaneous ruptured membranes at admission (AOR: 1.32; 95% CI: 1.17, 1.48) were independent determinants of successful vaginal birth after previous cesarean section.

CONCLUSION

The results of this meta-analysis showed that successful VBAC was influenced by past and present obstetric conditions and other predictors. Thus, it is recommended that obstetric care providers should emphasize those factors that lead to successful vaginal birth during counseling and optimal selection of women for the trial of labour after cesarean section.

SYSTEMATIC REVIEW AND META-ANALYSIS REGISTRATION

PROSPERO CRD42022329567.

Factors that Promote a Positive Childbearing Experience: A Qualitative Study

INTRODUCTION

Experiences of pregnancy and birth are important and have long-term impacts on the well-being of women and their families. Perinatal services should aim for care that promotes a positive childbearing experience, as well as optimizing health outcomes for the woman and newborn. This study aimed to understand the health system factors that promote a positive childbearing experience.

METHODS

Women who had a positive experience and had given birth in Australia in the previous 12 months were recruited for individual semistructured interviews. The interview guide focused on health system factors that participants credited with contributing to their positive experience of perinatal care. Interviews were conducted until data saturation was reached. Qualitative data were transcribed verbatim and analyzed using inductive thematic analysis.

RESULTS

Data from 36 interviews were thematically analyzed, and 4 major themes were generated: health care provider attributes, health system attributes, communication and decision-making, and experience of care. The salient factors that promoted positive experiences included care that was respectful and individualized with effective communication, access to midwifery continuity of care models, and good integration between services. Competent and professional health care providers who facilitated shared decision-making were also essential.

DISCUSSION

Although women often sought out care that promoted physiologic birth, they emphasized that the way they were cared for was more important than fulfilling specific birth aspirations. Quality maternity care has the capacity to support a woman's confidence in her own abilities and promote a positive, and sometimes transformative, childbearing experience.

Fear of childbirth and mental health among lesbian, bisexual, transgender and queer people: a cross-sectional study

Background: Most studies of fear of childbirth (FOC) are conducted on heterosexual cisgender pregnant populations of birth-giving parents. Among lesbian and bisexual women, as well as transgender and queer people (LBTQ), minority stress can add an extra layer to FOC. Gender binary and cisnormative assumptions leave it to the patient to educate and navigate healthcare providers, which can increase mental health problems.Objective: The aim of this study is to compare FOC and mental illness among expecting birth-giving parents and their partners in an LBTQ population.Materials and methods: This cross-sectional study recruited 80 self-identified pregnant LBTQ persons and their 54 non-pregnant partners at a LBTQ specialized antenatal clinic in a large Swedish city of over one million inhabitants. The survey included socio-demographic characteristics, sexual and gender orientation, obstetric history, previous mental health, previous trauma exposure and measures of FOC and mental health.Results: Levels of FOC were significantly higher for the pregnant participants (median W-DEQ 67.5) than for partners (median W-DEQ 60.0). The proportion of severe FOC was higher for pregnant participants (20.3%) than for partners (9.4%), although this difference was not statistically significant. Mental illness was significantly associated with FOC.Conclusion: The results add valuable information to our understanding of the specific needs of pregnant LBTQ people and their partners and may help us to develop healthcare in the future.

Maternal childbirth experience and time in labor: a population-based cohort study

A negative childbirth experience may have long term negative effects on maternal health. New international guidelines allow a slower progress of labor in the early active phase. However, a longer time in labor may influence the childbirth experience. In this population-based cohort study including 26,429 women, who gave birth from January 2016 to March 2020, the association between duration of different phases of active labor and childbirth experience was studied. The women assessed their childbirth experience by visual analogue scale (VAS) score. Data was obtained from electronic medical records. The prevalence of negative childbirth experience (VAS 1–3) was 4.9%. A significant association between longer duration of all labor phases and a negative childbirth experience was found for primi- and multipara. The adjusted odds ratio (aOR (95%CI)) of negative childbirth experience and longer time in active labor (above the 90th percentile) in primipara was 2.39 (1.98–2.90) and in multipara 2.23 (1.78–2.79). In primi-and multipara with duration of labor ≥ 12 h or ≥ 6 h the aOR (95%CI) of negative childbirth experience were 2.22 (1.91–2.58) and 1.91 (1.59–2.26) respectively. It is of great importance to identify and optimize the clinical care of women with longer time in labor to reduce the risk of negative childbirth experience and associated adverse long-term effects.

Fear of Childbirth in Nulliparous Women

Purpose

The relation between fear of childbirth (FoC) and gestational age is inconclusive, and self-reported need for help regarding this fear has never been investigated. This study aimed to determine the prevalence and course of FoC according to gestational age, to identify risk factors for the development of FoC, the influence of this fear on preferred mode of delivery, and self-reported need for help.

Methods

Nulliparous pregnant women of all gestational ages completed an online survey. The study consisted of a cross-sectional and a longitudinal analysis. Women who completed the survey in the first or second trimester (T₀) were approached again in their third trimester (T₁). The Wijma Delivery Expectancy Questionnaire Version A (W-DEQ A) was used with a cut-off score ≥ 85 to define presence of fear of childbirth. Questionnaires indexing social support, anxiety, symptoms of depression, preferred mode of delivery, and self-reported need for help were included.

Results

In total, 364 women were enrolled at T₀, and 118 out of 184 eligible women were included in the longitudinal analysis. Point prevalence of FoC at T₀ was 18.4% with no significant difference between trimesters. In the longitudinal sample, the prevalence of FoC decreased from 18.6% (T₀) to 11.0% (T₁), p = 0.004. Although mean scores for FoC decreased significantly, p < 0.001, scores increased in 41 (34.7%) women. The presence of FoC was associated with elevated anxiety, less family support, prenatal care of the obstetrician by choice, preference for a cesarean section, and for pain relief. Women with FoC were more likely to actively seek for help compared to women without FoC.

Conclusion

While FoC is common in each trimester, prevalence decreases over the course of pregnancy. Women with FoC are often actively seeking for help, suggesting that this fear should be addressed better, and help should be offered accordingly.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

Background

Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency.

Methods

We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode.

Results

The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ² = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery.

Conclusions

The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.

Fear of childbirth during pregnancy: associations with observed mother-infant interactions and perceived bonding

Fear of childbirth (FOC) is a common phenomenon that can impair functioning in pregnancy but potential longer term implications for the mother-infant relationship are little understood. This study was aimed at investigating postpartum implications of FOC on the mother-infant relationship. A UK sample of 341 women in a community setting provided data on anxiety, mood and FOC in mid-pregnancy and subsequently completed self-report measures of postnatal bonding in a longitudinal cohort study. Postnatal observations of mother-infant interactions were collected and rated for a subset of 141 women. FOC was associated with maternal perception of impaired bonding, even after controlling for sociodemographic factors, concurrent depression and the presence of anxiety disorders (Coef = 0.10, 95% CI 0.07-0.14, p < 0.001). Observed mother-infant interactions were not associated with FOC (Coef = -0.01-0.03 CI - 0.02 to 0.02, p = 0.46), weakly with concurrent depression (Coef = - 0.10, CI - 0.19 to 0.00, p = 0.06) and not associated with anxiety disorders. The self-efficacy component of FOC was most strongly associated with lower reported bonding (Coef 0.37, 95% CI 0.25-0.49, p < 0.001) FOC makes a distinct contribution to perceived postpartum bonding difficulties but observed mother-infant interaction quality was not affected. This may be due to low self-efficacy impacting psychological adjustment during pregnancy. Targeted interventions during pregnancy focusing both on treatment of key childbirth fears and bonding could help women adjust earlier.

Delivery Mode Preference and Associated Factors among Pregnant Mothers in Harar Regional State, Eastern Ethiopia: A Cross-Sectional Study

Background

The right to prefer mode of delivery is a crucial component of compassionate and respectful care that fosters both maternal and neonatal well-being as the failure to respect the mother's interest increases to the risk of maternal depression and posttraumatic stress. Thus, the aim of the study was to assess delivery mode preference and associated factors among pregnant women.

Methods and Materials

The study was conducted in two hospitals and two health centers. We used a cross-sectional study design incorporating 398 pregnant mothers attending an antenatal care follow-up from February to May 2018. The study excluded pregnant mothers with any previous uterine surgery including caesarean delivery from participation due to their restricted chance to prefer their mode of delivery. Data were collected by using a pretested questionnaire. Data were entered to EpiData Manager version 3.1 and exported to Statistical Package for the Social Sciences version 22 for analysis. Besides, the analysis included both the bivariate and multivariable analyses to check the association between dependent and independent variables. Finally, level of statistical significance was declared at P value < 0.05.

Result

The participant's level of response was 100% (398). The age of the mothers ranges from 15 to 45 years old. The delivery mode preference of the caesarean section (C/S) and spontaneous vertex delivery (SVD) was 115 (28.9%) and 283 (71.1%), respectively. The study revealed that planned 47 pregnancy [AOR, 1.76; CI: 0.89-3.47], young age [AOR, 12.9; CI: 0.23-7.1], and primigravida [AOR, 1.24; CI: 0.29-5.2] were among the variables associated with maternal preference of caesarean section. Conclusion and Recommendation. Nearly one-third of the mothers preferred caesarean delivery as their mode of delivery due to fear of labor pain and repeated vaginal examination by the care providers. This is particularly seen in women who had received higher education level, claim their pregnancy as planned, their choice of delivery at hospital, young aged, pregnant for the first time, and those who had visited antenatal care repeatedly. This implies that policy makers and stakeholders should exert due emphasis to ongoing desire of caesarean delivery as the procedure is not without risk, if it is done without indication. For researchers, we recommend to investigate the preference of mode of delivery in a much broader aspect.

When Fear Surrounding Childbirth Leads Women to Request a Planned Cesarean Birth

Fear surrounding childbirth requires a more in-depth understanding from women’s perspectives, especially those who request a planned cesarean due to that fear. Therefore, we explored primiparous and multiparous women’s lived experiences of fear surrounding childbirth in relation to their decision to request a planned cesarean birth. We used Colaizzi’s (1978) phenomenological method to interview 16 women from 4 provinces and to analyze the data. Women expressed numerous fears and most experienced more than one fear. Most feared their baby/babies being injured or dying during childbirth or developing complications themselves. Others feared experiencing a traumatic birth. Women described numerous emotional and physical manifestations of fear, and all believed that a planned cesarean birth would provide more control over the birth process. For some, the birth of their healthy baby/babies began a healing process, whereas others noted that their fear subsided or resolved upon confirmation that they would have a planned cesarean.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

MEASUREMENT

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

FINDINGS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Why do pregnant women prefer cesarean birth? A qualitative study in a tertiary care center in Southern Thailand

Background

Increasing worldwide rates of cesarean section are of global concern. In recent years, cesarean births upon maternal request have become a hotly debated issue. Hence, this study aimed to explore maternal reasons for cesarean preference without medical indications.

Methods

A descriptive qualitative study was conducted, using in-depth interviews with 27 pregnant women who preferred cesarean birth, attending antenatal care in Songklanagarind Hospital from September 2018 to June 2019. Data were analyzed using content analysis.

Results

Maternal reasons for cesarean preference were classified into six main categories: fear of childbirth, safety concerns related to health risk perceptions, negative previous birth experiences, positive attitudes toward cesarean birth, access to biased information and superstitious beliefs in auspicious birth dates. Most women had more than one reason for opting cesarean birth.

Conclusion

Several reasons for cesarean birth preference have been elucidated. One striking reason was superstitious beliefs in auspicious birth dates, which are challengable for obstetricians to deal with. Obstetricians should explore the exact reasons why women request cesarean birth in order to prevent or diminish unnecessary cesarean births.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03525-3.

Preferred and actual mode of delivery in relation to fear of childbirth

PURPOSE

This prospective cohort study aimed to investigate the interrelation between preferred/actual mode of delivery and pre- and postpartum fear of childbirth (FOC).

MATERIAL AND METHODS

Participants from 13 midwifery practices and four hospitals in Southwest Netherlands filled out questionnaires at 30 weeks' gestation (n = 561) and two months postpartum (n = 463), including questions on preferred mode of delivery, the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and Hospital Anxiety Depression Scale (HADS). Results were related to obstetric data.

RESULTS

Both severe FOC (OR 7.0, p < .001) and previous Cesarean section (CS) (OR 16.6, p < .001) predicted preference for CS. Severe prepartum FOC also predicted actual CS. Preferring a vaginal delivery (VD) and actually having a CS predicted higher postpartum W-DEQ scores (partial r = 0.107, p < .05). Other significant predictors for high postpartum W-DEQ scores were high prepartum W-DEQ (partial r = 0.357) and HADS anxiety scores (partial r = 0.143) and the newborn in need of medical assistance (partial r = -0.169).

CONCLUSIONS

Women preferring a VD but ending up with a CS are at risk for severe FOC postpartum, while the same risk was not demonstrated for women who preferred a CS but had a VD. Prepartum FOC is strongly associated with postpartum FOC, regardless of congruence between preferred and actual mode of delivery.

How to reach trustworthy decisions for caesarean sections on maternal request: a call for beneficial power

Caesarean delivery is a common and life-saving intervention. However, it involves an overall increased risk for short-term and long-term complications for both mother and child compared with vaginal delivery. From a medical point of view, healthcare professionals should, therefore, not recommend caesarean sections without any anticipated medical benefit. Consequently, caesarean sections requested by women for maternal reasons can cause conflict between professional recommendations and maternal autonomy. How can we assure ethically justified decisions in the case of caesarean sections on maternal request in healthcare systems that also respect patients' autonomy and aspire for shared decisions? In the maternal-professional relationship, which can be characterised in terms of reciprocal obligations and rights, women may not be entitled to demand a C-section. Nevertheless, women have a right to respect for their deliberative capacity in the decision-making process. How should we deal with a situation of non-agreement between a woman and healthcare professional when the woman requests a caesarean section in the absence of obvious medical indications? In this paper, we illustrate how the maternal-professional relationship is embedded in a nexus of power, trust and risk that reinforces a structural inferiority for women. To accommodate for beneficial use of power, these decision processes need to be trustworthy. We propose a framework, inspired by Lukes' three-dimensional notion of power, which serves to facilitate trust and allows for beneficial power in shared processes of decision-making about the delivery mode for women requesting planned C-sections.

Does prolonged labor affect the birth experience and subsequent wish for cesarean section among first-time mothers? A quantitative and qualitative analysis of a survey from Norway

Background

Prolonged labor might contribute to a negative birth experience and influence first-time mothers’ attitudes towards future pregnancies. Previous studies have not adjusted for possible confounding factors, such as operative delivery, induction and postpartum hemorrhage. We aimed to determine the impact of prolonged labor on birth experience and a wish for cesarean section in subsequent pregnancies.

Methods

A survey including the validated “Childbirth Experience Questionnaire”. First-time mothers giving birth between 2012 and 2014 at a Norwegian university hospital participated. Data from deliveries were collected. Regression analysis and thematic content analysis were performed.

Results

459 (71%) women responded. Women with labor duration > 12 h had significantly lower scores on two out of four sub-items of the questionnaire: own capacity (p = 0.040) and perceived safety (p = 0.023).

Other factors contributing to a negative experience were:

Cesarean section vs vaginal birth: own capacity (p = 0.001) and perceived safety (p = 0.007). Operative vaginal vs spontaneous birth: own capacity (p = 0.001), perceived safety (p < 0.001) and participation (p = 0.047).

Induced vs spontaneous start: own capacity (p = 0.039) and participation (p = 0.050). Postpartum hemorrhage ≥500 ml vs < 500 ml: perceived safety (p = 0.002) and participation (p = 0.031).

In the unadjusted analysis, prolonged labor more than doubled the risk (odds ratio (OR) 2.66, 95%CI 1.42–4.99) of a subsequent wish for cesarean delivery. However, when adjustments were made for mode of delivery and induction, emergency cesarean section (OR 8.86,95%CI 3.85–20.41) and operative vaginal delivery (OR 3.05, 95%CI 1.46–6.38) remained the only factors significantly increasing the probability of wanting a cesarean section in subsequent pregnancies.

The written comments on prolonged labor (n = 46) indicated four main themes:

Difficulties gaining access to the labor ward.

Being left alone during the unexpectedly long, painful early stage of labor.

Stressful operative deliveries and worse pain than imagined.

Lack of support and too little or contradictory information from the staff.

Conclusions

Women with prolonged labors are at risk of a negative birth experience. Prolonged labor per se did not predict a wish for a cesarean section in a subsequent pregnancy. However, women with long labors more often experience operative delivery, which is a risk factor of a later wish for a cesarean section.

Tensions and interplay: A qualitative study of access to patient-centered birth counseling of maternal cesarean requests in Norway

OBJECTIVE

This study aimed to explore women's access to patient-centered counseling for concerns initiating cesarean requests in absence of obstetric indications in pregnancy, and to identify tensions, barriers and facilitators affecting such care.

DESIGN, SETTING AND INFORMANTS

This qualitative study (June 2016 to August 2017) obtained data through semi-structured in-depth interviews with 17 women requesting planned C-section during birth counseling at a university hospital in Norway and focus group discussions with 20 caregivers (9 midwives and 11 obstetricians) employed at the same hospital. Analysis was carried out by systematic text condensation, a method for thematic analysis in medical research, presented within the frames of Levesque and colleagues' conceptual framework of access to patient-centered care.

FINDINGS

The analysis revealed that there were considerable tensions in care seeking and provision of counseling for maternal requests for C-section. There was a prominent culture of vaginal delivery among caregivers and women. The appropriateness of CS on maternal request was debated and caregivers revealed diverging attitudes and practices when agreement with women was not reached. Women's views on their entitlement to choose were divided, but the majority of women did not support complete maternal choice. Midwife-led counseling were highly appreciated among woman as well as obstetricians.

IMPLICATIONS FOR PRACTICE

Tensions and barriers in care seeking and provision of counseling for women requesting C-section for non-obstetric reasons, call for standardized counseling in order for equal and adequate care to be provided across health care institutions and providers. Dialogue-based decision-making and midwife-led care may improve satisfaction of care, enhance spontaneous vaginal deliveries and avoid future conflicts.

Influence of women's request and preference on the rising rate of caesarean section - a comparison of reviews

The rising caesarean section (CS) rates have been, in part, attributed to women's requests. Several individual studies and literature reviews have attempted to determine the degree of influence of women's requests on overall CS rates, and the common reasons behind these requests, from women's, midwives' and obstetricians' viewpoints. Despite many similarities in their findings, there is both a lack of clarity and disparity on the degree of influence women's requests actually has on the decision to perform a CS. This paper presents a critique of a key finding from a recently published systematic review of clinicians' (midwives' and obstetricians') views of factors that influenced their decision to perform a CS, which identified their belief in 'women's request' as a key factor. This finding is contrasted with findings from three other published reviews, which concluded that women's request contributed minimally to the overall rising rates of CS indicating a disparity in evidence around influence and contribution of women's request. Some of the possible reasons for this disparity can be explained by differences in views of women and clinicians, women's decision being guided by clinicians' beliefs of what is 'safe' and unsafe', and women's concerns being interpreted as their request and preferences to birth by CS. An insight into the possible reasons for the disparity in findings can help explain whether maternal request has any influence on the rising rates of CSs.

A modified caseload midwifery model for women with fear of birth, women's and midwives' experiences: A qualitative study

OBJECTIVE

Although fear of birth is common during pregnancy and childbirth, the best treatment for fear of birth in clinical care remain unclear. Strong evidence suggests that continuity models of midwifery care can benefit women and birth outcomes, though such models are rare in Sweden. Because women with fear of birth could benefit from such models, the aim of this qualitative study was to examine how women with fear of birth and their midwives experienced care in a modified caseload midwifery model.

METHODS

A qualitative interview study using thematic analysis. Participants were recruited from a pilot study in which women assessed to have fear of birth received antenatal and intrapartum care, from a midwife whom they knew. Eight women and four midwives were interviewed.

RESULTS

An overarching theme-"A mutual relationship instilled a sense of peace and security"-and three themes-"Closeness, continuity, and trust," "Preparation and counselling," and "Security, confidence, and reduced fear"-reflect the views and experiences of women with fear of birth and their midwives after participating in a modified caseload midwifery model.

CONCLUSIONS

For both women with fear of birth and their midwives, the caseload midwifery model generated trustful woman-midwife relationships, which increased women's confidence, reduced their fear, and contributed to their positive birth experiences. Moreover, the midwives felt better equipped to address women's needs, and their way of working with the women became more holistic. Altogether, offering a continuity model of midwifery care could be an option to support women with fear of birth.

Preference of birth mode and postnatal health related quality of life after one previous caesarean section in three European countries

OBJECTIVES

Women who have had a caesarean section may have a preference for birth mode during their subsequent pregnancy, either 'vaginal birth after caesarean' (VBAC) or 'elective repeat caesarean section' (ERCS). A mismatch between the preferred and actual birth mode may result in an impaired postnatal Health Related Quality of Life (HRQoL). This study examined the associations between antenatal birth mode preferences, the actual birth mode and postnatal HRQoL in women with one previous caesarean section in three European countries.

DESIGN

Prospective longitudinal survey, as a part of a cluster randomised trial (OptiBIRTH) SETTING: Fifteen maternity units in three European countries: Germany (5), Ireland (5) and Italy (5).

PARTICIPANTS

Women (≥ aged 18 years) living in Germany, Ireland and Italy with one previous caesarean section. The sample consisted of 862 women with complete antenatal and postpartum data.

MEASUREMENTS

Women's preference for birth mode after one previous caesarean section was assessed at inclusion to the trial, and HRQoL was assessed antenatally and at three months postpartum using the Short-Form Six-Dimension health survey. Based on women's preferences and actual birth mode six groups were determined: "match VBAC-VBAC" (preference for vaginal birth, actual mode of birth vaginal birth), "match ERCS-ERCS" (preference for caesarean section, actual mode of birth elective repeat caesarean section), "match ERCS-EMCS" (preference for caesarean section, actual mode of birth emergency repeat caesarean section), "mismatch VBAC-ERCS" (preference for vaginal birth, actual mode of birth elective repeat caesarean section), "mismatch VBAC-EMCS" (preference for vaginal birth, actual mode of birth emergency repeat caesarean section) and "no preference". Associations between the preferred and actual birth mode were examined using univariate and multivariate analyses.

FINDINGS

Women with preference for vaginal birth but who gave birth by elective repeat caesarean section (mismatch VBAC-ERCS) had a lower postnatal HRQoL compared to women with a preference for vaginal birth who actually had a birth vaginally (match VBAC-VBAC, p = 0.02). Poor antenatal HRQoL scores (p < 0.01) and maternal readmission postpartum (p = 0.03) are cofounding factors for poorer postnatal HRQoL scores.

KEY CONCLUSIONS

The results show that women with a preference for a vaginal birth who gave birth by an elective repeat caesarean section had a significantly lower HRQoL at three months postnatal. The long-term consequences and psychological health of women who do not achieve a vaginal birth after caesarean require further consideration and research.

IMPLICATIONS FOR PRACTICE

Attention should be given to the long-term impact of a mismatch in preferred and actual mode on the psychological health of women.

Is the place of birth related to the mother's satisfaction with childbirth? A cross-sectional study in a rural district of the Lao People's Democratic Republic (Lao PDR)

Background

The place of birth has been rapidly changing from home to health facility in Lao People’s Democratic Republic (Lao PDR) following the strategy to improve the maternal and neonatal mortality. This change in the place of birth might affect the mother’s satisfaction with childbirth. The objective of this study was to assess whether the place of birth is related to the mother’s satisfaction with childbirth in a rural district of the Lao PDR.

Methods

A community-based survey was implemented in 21 randomly selected hamlets in Xepon district, Savannakhet province, between February and March, 2016. Questionnaire-based interviews were conducted with mothers who experienced a normal vaginal birth in the past 2 years. Satisfaction with childbirth was measured by the Satisfaction with Childbirth Experience Questionnaire. Using the median, the outcome variable was dichotomized into “high satisfaction group” and “low satisfaction group”. Logistic regression was performed to assess the association between place of birth and satisfaction with childbirth. Three models were examined: In Model 1, only the predictor of interest (i.e., place of birth) was included. In Model 2, the predictor of interest and the obstetrical predictors were included. In Model 3, in addition to these predictors, socio-demographic and economic predictors were included. A mixed-effects model was used to account for the hierarchical structure.

Results

Among the 226 mothers who were included in data analysis, 60.2% gave birth at the health facility and the remaining 39.8% gave birth at home. Logistic regression analysis showed that the mothers who gave birth at the health facility were significantly more likely to have a higher level of satisfaction compared to the mothers who gave birth at home (crude odds ratio: 5.44, 95% confidence interval: 3.03 to 9.75). This association remained even after adjusting for other predictors (adjusted odds ratio: 6.05, 95% confidence interval: 2.81 to 13.03).

Conclusion

Facility-based birth was significantly associated with a higher level of satisfaction with childbirth among the mothers in the study district where maternal and neonatal mortalities are relatively high. The findings of the present study support the promotion of facility-based birth in a rural district of the Lao PDR.

Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers

Background

There is global concern for the overuse of obstetric interventions during labour and birth. Of particular concern is the increasing amount of mothers and babies experiencing morbidity and mortality associated with caesarean section compared to vaginal birth. In high-income settings, emerging evidence suggests that overuse of obstetric intervention is more prevalent among wealthier mothers with no medical need of it. In Australia, the rates of caesarean section and other obstetric interventions are rising. These rising rates of intervention have been mirrored by a decreasing rate of unassisted non-instrumental vaginal deliveries. In the context of rising global concern about rising caesarean section rates and the known health effects of caesarean section on mothers and children, we aim to better characterise the use of obstetric intervention in the state of Queensland, Australia by examining the characteristics of mothers receiving obstetric intervention. Identifying whether there is overuse of obstetric interventions within a population is critical to improving the quality, value and appropriateness of maternity care.

Methods

The association between demographic characteristics (at birth) and birth delivery type were compared with chi-square. The percentage of mothers based on their socioeconomic characteristics were reported and differences in percentages of obstetric interventions were compared. Multivariate analysis was undertaken using multiple logistic regression to assess the likelihood of receiving obstetric intervention and having a vaginal (non-instrumental) delivery after accounting for key clinical characteristics.

Results

Indigenous mothers, mothers in major cities and mothers in the wealthiest quintile all had higher percentages of all obstetric interventions and had the lowest percentages of unassisted (non-instrumental) vaginal births. These differences remained even after adjusting for other key sociodemographic and clinical characteristics.

Conclusions

Differences in obstetric practice exist between economic, ethnic and geographical groups of mothers that are not attributable to medical or lifestyle risk factors. These differences may reflect health system, organisational and structural conditions and therefore, a better understanding of the non-clinical factors that influence the supply and demand of obstetric interventions is required.

Women's experiences of internet-delivered Cognitive Behaviour Therapy (iCBT) for Fear of Birth

BACKGROUND

Fear of Birth is common in pregnant women and associated with negative physical and mental health. There is a clear comorbidity with anxiety and depression. Internet-delivered Cognitive Behaviour Therapy has been suggested as a treatment option for Fear of Birth and a randomized controlled trial comparing internet-delivered Cognitive Behaviour Therapy with midwifery led counselling as standard care has been conducted.

OBJECTIVE

The aim of this study was to describe women's experiences of guided internet-delivered Cognitive Behaviour Therapy for Fear of Birth and to describe the content of their fear.

METHODS

The present study is a qualitative, follow-up interview study following the randomized controlled trial, the U-CARE Pregnancy Trial. In total 19 women allocated to internet-delivered Cognitive Behaviour Therapy for Fear of Birth were interviewed by telephone. A semi-structured interview guide was used and the transcripts were analyzed with thematic analysis.

RESULTS

The women's descriptions of Fear of Birth differed, however their fear was most often associated with fear of losing control, fear for the baby's life or health or own life threatening events. The experiences of internet-delivered Cognitive Behaviour Therapy for Fear of Birth varied, some women were positive to its flexibility although most women preferred a face-to face meeting. The treatment did not pin-point their fears, it was challenging to maintain motivation and to work with the treatment in solitude.

CONCLUSIONS

Women's descriptions of Fear of Birth varied. Most women undergoing internet-delivered Cognitive Behaviour Therapy would have preferred a face-to-face meeting which they imagined would have soothed their fear. Internet-delivered Cognitive Behaviour Therapy for Fear of Birth may be an alternative for some women.

Length of residence and caesarean section in migrant women in Sweden: a population-based study

Background

Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden.

Methods

Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence.

Results

Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32-1.50); OR>1-<6=1.49 (1.42-1.57); OR6-<10=1.61 (1.50-1.72); OR≥10=1.71 (1.64-1.79) and planned caesarean section [OR≤1=1.14 (0.95-1.36); OR>1-<6=1.30 (1.13-1.51); OR6-<10=1.97 (1.64-2.37]; OR≥10=1.82 (1.67-1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings.

Conclusions

The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.

Nurses and midwives' experiences of using non-pharmacological interventions for labour pain management: a qualitative study in Ghana

BACKGROUND

Non-pharmacological interventions hold promise in reducing labour pain, with minimal or no harm to the mother, foetus and the progress of labour and are simple and cost-effective. Yet their use has not been adequately explored in clinical settings, especially in sub-Saharan Africa.

METHODS

This was a descriptive phenomenological study. Fifteen (15) nurses and midwives working in labour wards of two hospitals in Ghana were interviewed. Data analysis was guided by the principles of coding by Bailey and the constant comparative approach to generate themes. Ethics approval was obtained from the 37 Military Teaching Hospital Institutional Review Board in Ghana.

RESULTS

Three major themes were identified that described the experiences of nurses and midwives regarding their use of non-pharmacological interventions in managing labour pain. These were familiarity with non-pharmacological interventions, perceived benefits of non-pharmacological interventions, and barriers to the use of non-pharmacological interventions in the management of labour pain.

CONCLUSIONS

While some non-pharmacological pain management interventions were known and used by the nurses and midwives, they were not familiar with a good number of these interventions. Nurses and midwives perceived these interventions to be beneficial yet a number of barriers prevented easy utilisation.

Maternal reasons for requesting planned cesarean section in Norway: a qualitative study

Background

Pregnant women who request a cesarean section in the absence of obstetric indication have become a highly debated issue in academic as well as popular literature. In order to find adequate, targeted treatment and preventive strategies, we need a better understanding of this phenomenon. The aim of this study is to provide a qualitative exploration of maternal requests for a planned cesarean section in Norway, in the absence of obstetric indications.

Methods

A descriptive qualitative study was conducted consisting of 17 semi-structured, in-depth interviews with women requesting cesarean section and six focus group discussions with 20 caregivers (nine midwives, 11 obstetricians) working at a university hospital in Norway. Data were analyzed with Systematic Text Condensation, a method for thematic cross-case analysis.

Results

Fear of birth emerged most commonly as a result of a previous traumatic birth experience that prompted a preference for a planned cesarean to avoid a repetition of the trauma. For some women in our study, postnatal care and the puerperal period were their crucial past experiences, and giving birth by planned cesarean was seen as a way to ensure mental rather than physical capability to care for the expected child after birth. Others were under the impression of being at high risk for an emergency C-section, and requesting a planned one was based on their perceived risk. Such perceptions included having a narrow pelvis, hereditary factors or previous birth outcomes. Some primiparas requested a planned cesarean based on a deep-seated fear since their early teens, accompanied by alienation towards the idea of giving birth. Some obstetricians participating in our study also experienced requests that lacked what they regarded as any well-grounded reason or significant fear.

Conclusions

Behind a maternal request for a planned cesarean section are various rationales and life experiences needing carefully targeted attention and health care. Previous births are an important driver; thus, maternally requested cesareans should be regarded partly as an iatrogenic problem.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2250-6) contains supplementary material, which is available to authorized users.

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

Background

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

Question

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

Methods

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

Findings

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

Discussion

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

Conclusion

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

Screening for trauma and anxiety recognition: knowledge, management and attitudes amongst gynecologists regarding women with fear of childbirth and postpartum posttraumatic stress disorder

Objective: Fear of childbirth (FoC) and postpartum posttraumatic stress disorder (PP-PTSD) are often less well recognized by healthcare professionals than other peripartum mental health disorders. This study aims to evaluate knowledge, management and attitudes of gynecologists and gynecology residents regarding women with FoC and PP-PTSD.Study design: A cross-sectional study was conducted among gynecologists and gynecology residents using an online questionnaire. An invitation was sent to all 1401 members of the Dutch Society of Obstetrics and Gynecology.Results: Two hundred forty-four respondents completed the online multiple-choice and open question survey. More respondents were able to answer the questions about risk factors, signs/symptoms and consequences of FoC in comparison with similar questions about PP-PTSD. When asked about performing a cesarean section on maternal request, 74% of respondents would grant this request if fear would persist despite adequate psychological treatment. During labor, providing good explanations and obtaining informed consent were most frequently named to reduce fear or the likelihood of a traumatic birth experience. Caregivers' attitudes towards women with FoC or suspected PP-PTSD were mainly positive.Conclusions: Further knowledge, in particular about PP-PTSD, is desirable for appropriate recognition of women with FoC and PP-PTSD. Gynecologists should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves. For optimizing the organization of care, we would recommend the use of a clear (inter)national policy regarding maternal requests for cesarean section (CS).Brief rationaleThe objective of this study was to evaluate knowledge and awareness regarding fear of childbirth (FOC) and postpartum posttraumatic stress disorder (PP-PTSD) among gynecologists and gynecology residents, assessing their attitudes towards women suffering from these conditions, and evaluating organization of care.The main findings and recommendations of the study include that gynecologists should be better trained to appropriately recognize fear of childbirth and postpartum posttraumatic stress disorder, and they should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves.

Socioeconomic differences in access to care in Australia for women fearful of birth

Objective Fear of childbirth is known to increase a woman's likelihood of having a Caesarean section. Continuity of midwifery care is known to reduce this risk, but less than 8% of women have access to this relationship-based, primary care model. The aims of this study were to determine whether healthcare use and access to continuity models are equal across different indicators of socioeconomic status for women who are fearful of birth. Methods A secondary analysis was conducted of data obtained during a randomised controlled trial of a psychoeducation intervention by trained midwives to minimise childbirth fear (the Birth Emotions and Looking to Improve Expectant Fear (BELIEF) study). In all, 1410 women were screened, with 339 women reporting high levels of fear (Wijma-Delivery Expectancy/Experience Questionnaire ≥66). Demographic, obstetric information, birth preference and psychosocial measures were collected at recruitment and at 36 weeks gestation for the 339 fearful women, with the birth method and health service use returned by 183 women at 6 weeks after the birth. Results Univariate analysis revealed no significant difference in the number of general practitioner and midwife visits between women of high and low income and high and low education. However, women with higher levels of education had 2.51-fold greater odds of seeing the same midwife throughout their pregnancy than women with lower education (95% confidence interval 1.25-5.04), after adjusting for age, parity and hospital site. Conclusions Given the known positive outcomes of continuity of midwifery care for women fearful of birth, health policy makers need to provide equity in access to evidence-based models of midwifery care. What is known about this topic? Caseload midwifery care is considered the gold standard care due to the known positive outcomes it has for the mother and baby during the perinatal period. Pregnant women who receive caseload midwifery care are more likely to experience a normal vaginal birth. What does this paper add? There is unequal access to midwifery caseload care for women fearful of birth across socioeconomic boundaries. Midwifery caseload care is not used for all fearful mothers during the perinatal period. What are the implications for practitioners? Health policy makers seeking to provide equity in access to maternity care should be aware of these inequalities in use to target delivery of care at this specific cohort of mothers.

Childbirth preferences and related fears - comparison between Norway and Israel

Background

Fear of childbirth (FOC) could have significant impact on women’s childbearing choices and experience. Culture affects the way women conceptualize childbirth, influencing the fears and expectations they may hold in relation to it. In the current study, we examined differences in childbirth preferences of cesarean section and use of epidural analgesia between Norwegian and Israeli pregnant women. Later, we used the Norwegian six-factor solution of the widely-used Wijma Delivery Expectancy Questionnaire (W-DEQ-A) to compare levels of the different FOC factors. Finally, we investigated differences in the associations between FOC and childbirth preferences between the two countries.

Methods

Secondary analysis of two large surveys. Women from Israel (n = 490) and Norway (n = 2918) were recruited during prenatal check-ups in community clinics and a university hospital. At around 32 weeks of gestation, all participants filled out questionnaires, including the W-DEQ-A. Statistical analysis included exploratory factor analysis, confirmatory factor analysis, M/ANOVA, Spearman’s Rho and Fisher’s Z tests for the significance of the difference between independent correlations.

Results

The Norwegian six-factor solution of the W-DEQ fit well with the Israeli data. Norwegian women were more concerned about loneliness, feeling less self-efficacy, negatively appraising birth, and lacking positive anticipation. Israeli women were more concerned about negative outcomes for the child and experienced greater general fear and fear of pain. Norwegian women preferred more cesarean sections compared to Israeli women, who preferred more epidural use than Norwegians. FOC factors were more strongly related to childbirth preferences among Norwegians.

Conclusions

Cultural differences between Israel and Norway are reflected by the differences seen in the levels of fear reported across the six factors. In Israel, birth culture is very medicalized, motherhood is highly revered, and there is an emphasis on having “perfect babies”. In contrast, Norwegian women have fewer children, and birth is considered more natural. This could explain why Israeli women were more concerned that their child might be harmed during birth, while Norwegian women were more concerned with the physical and emotional expectations of birth.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1997-5) contains supplementary material, which is available to authorized users.

Systematic review and meta-analysis of studies on delivery preferences in Brazil

BACKGROUND

Cesarean delivery rates in Brazil are among the highest in the world. User preference is often mentioned as an important factor driving this.

OBJECTIVES

To identify, appraise, and synthesize the results of studies into delivery preferences in Brazil.

SEARCH STRATEGY

MEDLINE, LILACS, and PsycINFO databases were searched, without language restrictions, using "delivery" and "preference" from inception to November 4, 2017.

SELECTION CRITERIA

Cross-sectional or cohort studies with quantitative data on delivery preferences of lay persons in Brazil.

DATA COLLECTION AND ANALYSIS

Two reviewers performed study selection, quality assessment, and data extraction. A meta-analysis of proportions with a preference for cesarean delivery was performed, including subgroups analyses.

MAIN RESULTS

There were 28 studies with 31 071 participants included. The overall prevalence of preference for cesarean delivery was 27.2% (95% confidence interval [CI] 26.7%-27.7%; 28 studies, n=31 071). Cesarean delivery preference was higher among multiparas with previous cesarean deliveries (58.0%, 95% CI 56.6%-59.3%; nine studies, n=5542) than among multiparas without prior cesarean deliveries (17.3%, 95% CI 16.4%-18.2%; eight studies, n=7903), and among women with private health insurance (44.3%, 95% CI 43.0%-45.6%; nine studies, n=6048) than among those who depended on the public healthcare system (22.7%, 95% CI 22.2%-23.3%; 20 studies, n=24 314).

CONCLUSIONS

Overall, most lay persons in Brazil did not prefer to deliver by cesarean.

Women's experience of midwife-led counselling and its influence on childbirth fear: A qualitative study

BACKGROUND

Women with childbirth fear have been offered counseling by experienced midwives in Sweden for decades without evidence for its effectiveness, in terms of decrease in childbirth fear. Women are usually satisfied with the counselling. However, there is a lack of qualitative data regarding women's views about counselling for childbirth fear.

AIM

To explore women's experiences of midwife-led counselling for childbirth fear.

METHOD

A qualitative interview study using thematic analysis. Twenty-seven women assessed for childbirth fear who had received counselling during pregnancy at three different hospitals in Sweden were interviewed by telephone one to two years after birth.

FINDINGS

The overarching theme 'Midwife-led counselling brought positive feelings and improved confidence in birth' was identified. This consisted of four themes describing 'the importance of the midwife' and 'a mutual and strengthening dialogue' during pregnancy. 'Coping strategies and support enabled a positive birth' represent women's experiences during birth and 'being prepared for a future birth' were the women's thoughts of a future birth.

CONCLUSIONS

In this qualitative study, women reported that midwife-led counselling improved their confidence for birth through information and knowledge. The women experienced a greater sense of calm and preparedness, which increased the tolerance for the uncertainty related to the birthing process. This, in turn, positively affected the birth experience. Combined with a feeling of safety, which was linked to the professional support during birth, the women felt empowered. The positive birth experience strengthened the self-confidence for a future birth and the childbirth fear was described as reduced or manageable.

Changes in birth-related pain perception impact of neurobiological and psycho-social factors

PURPOSE

To analyse post-partum short- and long-term pain sensitivity and the influence of endogenous pain inhibition as well as distinct psycho-social factors on birth-related pain.

METHODS

Pain sensitivity was assessed in 91 primiparous women at three times: 2-6 weeks before, one to 3 days as well as ten to 14 weeks after childbirth. Application of a pressure algometer in combination with a cold pressor test was utilised for measurement of pain sensitivity and assessment of conditioned pain modulation (CPM). Selected psycho-social factors (anxiety, social support, history of abuse, chronic pain and fear of childbirth) were evaluated with standardised questionnaires and their effect on pain processing then analysed.

RESULTS

Pressure pain threshold, cold pain threshold and cold pain tolerance increased significantly directly after birth (all p < 0.001). While cold pain parameters partly recovered on follow-up, pressure pain threshold remained increased above baseline (p < 0.001). These pain-modulating effects were not found for women with history of abuse. While CPM was not affected by birth, its extent correlated significantly (r = 0.367) with the drop in pain sensitivity following birth. Moreover, high trait anxiety predicted an attenuated reduction in pain sensitivity (r = 0.357), while there was no correlation with fear of childbirth, chronic pain and social support.

CONCLUSION

Pain sensitivity showed a decrease when comparing post-partum with prepartum values. The extent and direction of CPM appear to be a trait variable that predicted post-partum hypalgesia without being changed itself. Post-partum hypalgesia was reduced in women with a history of abuse and high trait anxiety, which suggests that individual differences in CPM affect childbirth experience.

Caesarean Birth is Associated with Both Maternal and Paternal Origin in Immigrants in Sweden: a Population-Based Study

BACKGROUND

To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden.

METHODS

Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity.

RESULTS

Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10-2.19; multiparous OR 1.13-2.02) and planned caesarean (primiparous OR 1.18-2.25; multiparous OR 1.13-2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76-0.86; multiparous OR 0.74-0.86. Planned; primiparous OR 0.75-0.82; multiparous OR 0.60-0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women.

CONCLUSIONS

Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors.

The Elevated Rate of Cesarean Section and Its Contribution to Non-Communicable Chronic Diseases in Latin America: The Growing Involvement of the Microbiota

The current recommendation of the World Health Organization (WHO) regarding cesarean section (C-section) is that this clinical practice should be carried out only under specific conditions, when the health or life of the mother/newborn dyad is threatened, and that its use should not exceed 10-15% of the total deliveries. However, over the last few decades, the frequency of C-section delivery in medium- and high-income countries has rapidly increased worldwide. This review describes the evolution of this procedure in Latin American countries, showing that today more than half of newborns in the region are delivered by C-section. Given that C-section delivery is more expensive than vaginal delivery, its use has increased more rapidly in the private than the public sector; nevertheless, the prevalence of C-section deliveries in the public sector is higher than the WHO's recommendations and continues to increase, representing a growing challenge for Latin America. Although the medium- and long-term consequences of C-section delivery, as opposed to vaginal delivery, on the infant health are unclear, epidemiological studies suggest that it is associated with higher risk of developing asthma, food allergy, type 1 diabetes, and obesity during infancy. These findings are important, as the incidence of these diseases in the Latin American pediatric population is also increasing, particularly obesity. Although the link between these diseases and delivery mode remains controversial, recent studies indicate that the establishment of the gut microbiota is delayed in infants born by C-section during the postnatal period, i.e., during a critical developmental window for the maturation of the newborn's immune system. This delay may favor the subsequent development of inflammatory and metabolic disorders during infancy. Accordingly, from a public health perspective, it is important to slow down and eventually reverse the pattern of increased C-section use in the affected populations.

The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review

BACKGROUND

Obstetricians are often reluctant to grant requests for an elective cesarean section (ECS) due to childbirth fear. To date, it is unknown if an ECS on request improves mental well-being in the mother in the peripartum period and if possible beneficial effects on anxiety and depression could outweigh the increased risk of complications associated with a surgical delivery. A systematic review was conducted to explore the effect of ECS on request on peripartum anxiety and depression.

METHODS

We searched on PubMed, PsychoInfo and Embase. Studies were included with primary data on anxiety and/or depression postpartum in women with childbirth fear who had requested an ECS. After full-text evaluation of 65 papers and quality analysis of four papers, three papers were included. Of one paper additional and yet unpublished data were provided. Studies varied in outcome measures, hence no meta-analysis was performed.

RESULTS

Women who requested an ECS had higher antepartum depression and anxiety levels but no different postpartum depression levels than women who delivered vaginally. One study of good quality examined the effect of vaginal delivery in women preferring ECS: These women had significantly higher symptom levels of post-traumatic stress disorder (PTSD) and depression than women with normal vaginal delivery.

CONCLUSIONS

The prospect of an ECS does not lower antepartum anxiety and/or depression levels in women requesting an ECS. If women resolutely persist in wishing an ECS despite adequate counselling and/or psychiatric treatment, the risk of developing depressive and PTSD symptoms in case of vaginal delivery should be taken into account, and an ECS may be considered as a valid alternative.

The meaning of labour pain: how the social environment and other contextual factors shape women's experiences

Background

The majority of women experience pain during labour and childbirth, however not all women experience it in the same way. In order to develop a more complete understanding of labour pain, this study aimed to examine women’s experiences within the perspective of modern pain science. A more complete understanding of this phenomenon can then guide the development of interventions to enhance women’s experiences and potentially reduce their need for pharmacological intervention.

Methods

A qualitative study was conducted using phenomenology as the theoretical framework. Data were collected from 21 nulliparous women, birthing at one of two large maternity services, through face-to-face interviews and written questionnaires. Data were analysed using an Interpretative Phenomenological Analysis approach.

Results

The data from this study suggest that a determining factor of a woman’s experience of pain during labour is the meaning she ascribes to it. When women interpret the pain as productive and purposeful, it is associated with positive cognitions and emotions, and they are more likely to feel they can cope. Alternatively, when women interpret the pain as threatening, it is associated with negative cognitions and emotions and they tend to feel they need help from external methods of pain control. The social environment seems particularly important in shaping a woman’s pain experience by influencing her interpretation of the context of the pain, and in doing so can change its meaning. The context and social environment are dynamic and can also change throughout labour.

Conclusion

A determining factor in a woman’s experience of pain during labour is its perceived meaning which can then influence how the woman responds to the pain. The meaning of the pain is shaped by the social environment and other contextual factors within which it is experienced. Focussed promotion of labour pain as a productive and purposeful pain and efforts to empower women to utilise their inner capacity to cope, as well as careful attention to women’s cognitions and the social environment around them may improve women’s experiences of labour pain and decrease their need for pain interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1343-3) contains supplementary material, which is available to authorized users.

The birth beliefs scale - a new measure to assess basic beliefs about birth

INTRODUCTION

Basic beliefs about birth as a natural and safe or a medical and risky process are central in the decisions on where and how to birth. Despite their importance, they have not been studied separately from other childbirth-related constructs. Our aim was to develop a measure to assess these beliefs.

METHOD

Pregnant Israeli women (N = 850, gestational week ≥14) were recruited in women's health centers, in online natural birth forums, and through home midwives. Participants filled in questionnaires including sociodemographic and obstetric background, the Birth Beliefs Scale (BBS), dispositional desire for control (DC) and planned mode of delivery.

RESULTS

Factor analyses revealed that the BBS is composed of two factors: beliefs about birth as a natural process and beliefs about birth as a medical process. Both subscales showed good internal and test-retest reliability. They had good construct validity, predicted birth choices, and were weakly correlated with DC. Women's medical obstetric history was associated with the BBS, further supporting the validity of the scale.

DISCUSSION

Beliefs about birth may be the building blocks that make up perceptions of birth and drive women's preferences. The new scale provides an easy way to distinctly assess them so they can be used to further understand planned birth behaviors. Additional studies are needed to comprehend how these beliefs form in different cultural contexts and how they evolve over time.