Maternal preference for cesarean delivery: do women get what they want?

Staff Resources in Public and Private Hospitals and Their Implication for Medical Practice: A French Study of Caesareans

This study aimed to investigate the effect of hospital staffing resources on medical practice in public versus private hospitals. We used exhaustive delivery data from a French district of 11 hospitals over an 11-year period, from 2008 to 2018, including 168,120 observations. We performed multilevel logistic regression models with hospital fixed or random effects, while controlling for factors known to influence obstetric practice. We found that hospital staff ratios of obstetricians and that of midwives affected caesarean rates, but with different effects depending on the hospital sector. In public hospitals, the higher the ratio of obstetricians and that of midwives, the lower the probability of planned caesareans. In private hospitals, the higher the ratio of obstetricians, the greater the probability of planned caesareans. Indeed, in public hospitals, obstetricians and midwives, both salaried employees, do not have financial or organizational incentives to perform more caesareans. In private hospitals, obstetricians, who are independent doctors, may have such incentives. Our results underline the importance of having an adequate supply of health professionals in healthcare facilities to ensure appropriate care, with specific regard to the different characteristics of the public and private sectors.

Pregnancy and Childbirth After Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Little data exist on pregnancy and childbirth for adolescent idiopathic scoliosis (AIS) patients treated with a spinal fusion. The current literature relies on data from patients treated with spinal fusion techniques and instrumentation, such as Harrington rods, that are no longer in use. The objective of our study is to understand the effects of spinal fusion in adolescence on pregnancy and childbirth.

METHODS

Prospectively collected data of AIS patients undergoing posterior spinal fusion that were enrolled in a multicenter study who have had a pregnancy and childbirth were reviewed. Results were summarized using descriptive statistics and compared with national averages using χ 2 test of independence.

RESULTS

A total of 78 babies were born to 53 AIS patients. As part of their pre-natal care, 24% of patients surveyed reported meeting with an anesthesiologist before delivery. The most common types of delivery were spontaneous vaginal delivery (46%, n=36/78) and planned cesarean section (20%, n=16/78). Compared with the national average, study patients had a higher rate of cesarean delivery ( P =0.021). Of the women who had a spontaneous vaginal birth, 53% had no anesthesia (n=19/36), 19% received intravenous intermittent opioids (n=7/36), and 31% had regional spinal or epidural anesthesia (n=11/36). spontaneous vaginal delivery patients in our study cohort received epidural or spinal anesthesia less frequently than the national average ( P <0.001). Of those (n=26 pregnancies) who did not have regional anesthesia (patients who had no anesthesia or utilized IV intermittent opioids), 19% (n=5 pregnancies) were told by their perinatal providers that it was precluded by previous spine surgery.

CONCLUSION

The majority of AIS patients reported not meeting with an anesthesiologist before giving birth and those who had a planned C-section did so under obstetrician recommendation. The presence of instrumentation after spinal fusion should be avoided with attempted access to the spinal canal but should not dictate a delivery plan. A multidisciplinary team consisting of obstetrician, anesthesiologist, and orthopaedic surgeon can provide the most comprehensive information to empower a patient to make her decisions regarding birth experience anesthesia based on maternal rather than provider preference.

LEVEL OF EVIDENCE

IV.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

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

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

Severe recalled labor pain and elective cesarean section in a subsequent delivery: a cohort study of Norwegian parous women

INTRODUCTION

Some women keep on recalling intense labor pain experienced at childbirth to a degree that may negatively affect their life during the postpartum period or lead them to request a cesarean section (CS) in the subsequent delivery. This longitudinal study aimed to assess the impact of severe recalled labor pain from the previous birth on the preference for and delivery by an elective CS in the subsequent delivery. Furthermore, we investigated whether co-occurring maternal demographic, somatic and mental health factors related to the previous and subsequent delivery, explain parts of a potential association.

MATERIAL AND METHODS

The study sample comprised 1135 parous women from the Akershus Birth Cohort. Severe recalled labor pain was assessed on a numeric rating scale at pregnancy week 17, and at pregnancy week 32, the preference for an elective CS for the subsequent delivery was assessed. Information on actual delivery by elective CS in the subsequent delivery was retrieved from the electronic birth record. Logistic regression analyses were conducted to examine the impact of severe recalled labor pain on elective CS.

RESULTS

Severe recalled labor pain at the previous birth was associated with a preference for an elective CS (odds ratio [OR] 3.57, 95% confidence interval [CI] 2.25-5.67) and actual delivery by elective CS (OR 4.71, 95% CI 2.32-9.59). This association remained statistically significant for the preference for an elective CS (adjusted OR [aOR] 2.12, 95% CI 1.24-3.62) but diminished for delivery by elective CS (aOR 2.30, 95% CI 0.99-5.35) when adjusting for a variety of covariates. Factors related to previous childbirth such as number of years since previous birth, assisted vaginal delivery, anal sphincter lesions, overall birth experience and fear of childbirth were also linked to preference for and delivery by an elective CS.

CONCLUSIONS

Women with severe recalled labor pain were about twice as likely to prefer an elective CS compared with women without severe recalled pain. For actual delivery, the significant association with severe recalled pain diminished after adjustment for covariates. However, sample size was small and, irrespective of severe recalled labor pain, preference for an elective CS was statistically significantly associated with actual delivery by elective CS.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

MEASUREMENT

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

FINDINGS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

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.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

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

BACKGROUND

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

AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study

BACKGROUND

The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China.

METHODS AND FINDINGS

This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010-September 2014 and October 2014-December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period. A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: -0.09 [95% CI -0.16 to -0.02] between Stage 1 and baseline, p = 0.014; -0.11 [95% CI -0.20 to -0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = -4.368, p < 0.001) and PMR (Z = -13.142, p < 0.001) declined by stage over the intervention period. One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed.

CONCLUSIONS

Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was most evident among nulliparous women who delivered term singletons. Despite some limitations for causal inference, Guangzhou's experience in controlling the CS rate by implementing composite interventions with public health education and perinatal healthcare service improvement could have implications for other similar areas with high rates of CS.

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.

Skin-to-skin contact and what women want in the first hours after a caesarean section

OBJECTIVE

To explore women's experience of skin-to-skin contact and what women want in the first two hours after a caesarean.

DESIGN

Audio recorded interviews were conducted with women as a part of a larger video ethnographic research study where video recordings, observations, field notes, focus groups and further in-depth interviews were conducted.

SETTING

A metropolitan hospital in Sydney, Australia.

PARTICIPANTS

Twenty-one women who had a caesarean section were involved in interviews around six weeks postpartum.

ANALYSIS

The transcribed interviews were thematically analysed.

FINDINGS

Women wanted their baby to stay with them and have skin-to-skin contact, even if they felt apprehensive about providing this care. An overarching theme was, 'I want our baby'. Several subthemes also emerged: 'I felt disconnected when I was separated from my baby', 'I want to explore my naked baby', 'I want my partner involved', and 'It felt right'.

KEY CONCLUSIONS

Despite the challenges of providing skin-to-skin contact in the operating theatre and recovery, health professionals and institutions should recognise the importance of advocating for what women want including keeping women, their partners and babies together and encouraging continuous maternal and infant contact and skin-to-skin contact.

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.

Mode of Delivery Preference Among Pregnant Nulliparous Women

Background: Nearly a third of women in the United States deliver by cesarean at first childbirth. The extent to which women's prenatal mode of delivery preference contributes to the cesarean decision is not clear. Little research has measured pregnant nulliparous women's prelabor mode of delivery preference in relation to actual mode of delivery in the United States. Materials and Methods: A total of 3006 pregnant nulliparous women were asked about mode of delivery preference during pregnancy as part of the First Baby Study, a prospective study of women delivering in Pennsylvania hospitals, 2009-2011. Multivariable regression models were used to assess the association between women's preference for cesarean delivery and two decision stages: (1) the decision to have planned prelabor cesarean and (2) the intrapartum decision to have unplanned cesarean among those attempting vaginal delivery, adjusting for confounders. Results: Overall, 3.1% preferred cesarean delivery, 3.0% had no preference, and 93.9% preferred vaginal. Among those who preferred vaginal delivery, 4% had a planned cesarean; among those with no preference, 13.3% did; and among those who preferred cesarean, 33.7% did. In adjusted models, preference for cesarean was strongly associated with having planned prelabor cesarean (adjusted odds ratio [aOR] = 6.02; 95% confidence interval [CI] = 3.26-11.12), but was not significantly associated with unplanned cesarean among those who attempted vaginal delivery (aOR = 1.35; 95% CI = 0.77-2.38). Conclusions: Although preference for cesarean delivery among nulliparous women was uncommon, women who preferred cesarean were more likely to have planned prelabor cesarean delivery than those who preferred vaginal delivery.

Women's preference for caesarean section and the actual mode of delivery - Comparing five sites in Norway

OBJECTIVES

The caesarean (CS) section rate varies among hospitals in Norway, and little is known about whether this is influenced by women's preferences. The aim of this study was to investigate the differences in women's preferred mode of delivery during pregnancy between five hospitals in Norway, and to relate this to the actual mode of delivery.

STUDY DESIGN

A prospective cohort study of 2,177 unselected pregnant women in five hospitals in Norway. Women were recruited at their standard ultrasound examinations, and data was collected through questionnaires and electronic patient charts. The exposure was a CS preference and the main outcome measure was the actual mode of delivery.

RESULTS

In total, 3.5% of the primiparous women and 9.6% of the multiparous women reported a preference for CS. This was associated with fear of childbirth and education between 10 and 13 years in both groups, symptoms of depression and an age over 35 years old among the primiparous women, and a previous CS and/or negative birth experience among the multiparous. The multiparous women in Drammen and Tromsø were less likely to prefer a CS, and none of the primiparous women in Tromsø preferred a CS. A total of 67.8% of those who preferred a CS gave birth with this mode of delivery.

CONCLUSION

There were significant differences between the hospitals according to the CS preference. This preference was associated with the previous obstetric history and psychological factors. Therefore, creating good birth experiences and offering women counselling may reduce the CS preference rate.

Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective study

OBJECTIVE

To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes.

DESIGN

Population-based pregnancy cohort study.

SETTING

The Norwegian Mother and Child Cohort Study.

SAMPLE

A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous.

METHODS

Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway.

MAIN OUTCOME MEASURES

Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery.

RESULTS

Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4-10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8-6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1-6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3-5.0) compared with women with previous live birth and 3.7 (1.8-7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS.

CONCLUSIONS

Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth.

TWEETABLE ABSTRACT

Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.

Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery

BACKGROUND

To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan.

METHODS

This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed.

RESULTS

In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls.

CONCLUSION

Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates.

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

INTRODUCTION

The rate of cesarean section (CS) for non-medical reasons has risen and it is a concern for health care. Women's preferences may vary across countries for psychosocial or obstetric reasons.

METHODS

A prospective cohort study of 6549 women in routine antenatal care giving birth in Belgium, Iceland, Denmark, Estonia, Norway or Sweden. Preference for mode of birth was self-reported in mid-pregnancy. Birth outcome data were collected from hospital records.

RESULTS

A CS was preferred by 3.5% of primiparous women and 8.7% of the multiparous women. Preference for CS was associated with severe fear of childbirth (FOC), with a negative birth experience in multiparous women and with depressive symptoms in the primiparous. Women were somewhat more prone to prefer a cesarean in Iceland, odd ratio (OR) 1.70 (1.02-2.83), adjusted for age, education, depression, FOC, history of abuse, previous cesarean and negative birth experience. Out of the 404 women who preferred CS during pregnancy, 286 (70.8%) delivered by CS, mostly for a medical indication. A total of 9% of the cesareans in the cohort had a non-medical indication only.

CONCLUSIONS

Women's preference for CS often seems to be due to health concerns. Both medical and psychological factors need to be addressed in antenatal counseling. Obstetricians need to convey accurately to women the risks and benefits of CS in her specific case. Maternity professionals should identify and explore psychosocial reasons for women's preferences.

Cesarean wound scar characteristics for the prediction of pelvic adhesions: a meta-analysis of observational studies

OBJECTIVE

The pathophysiologic processes that result in wound healing are the same regardless of the tissue involved. The purpose of the present meta-analysis is to evaluate whether cesarean scar characteristics may predict the presence of pelvic adhesions.

MATERIALS AND METHODS

We conducted a systematic review searching the Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016), Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) and Google Scholar (2004-2016) databases together with reference lists from included studies. All prospective and retrospective observational cohort studies were included. Statistical meta-analysis was performed using the RevMan 5.1 software.

RESULTS

Current evidence suggests that depressed scars are positively associated with intra-abdominal adhesions (ΟR 2.79, 95%CI 1.74-4.46). Elevated scars might also correlate with the presence of adhesions, however, this association did not reach statistical significance (OR 1.61, 95%CI 0.91-2.85, p = 0.10). The same was reported in the case of scar pigmentation (REM, OR 1.68, 95%CI 0.86-3.26, p = 0.13). Flat scars were predictive of the absence of adhesions (899 patients, REM, OR 0.33, 95%CI 0.23-0.54, p < 0.00001).

CONCLUSION

According to our meta-analysis, abdominal wound characteristics following cesarean section can predict the presence of adhesions. However, given the small number of published studies, further research is needed to corroborate our findings.

A case-control study of caesarean delivery on maternal request: who and why?

OBJECTIVE

The current study aimed to evaluate the profile of women who are most likely to undergo caesarean delivery on maternal request (CDMR) and clarify their reasons for this decision.

METHODS

For this multicentre case-control study, data were collected from 429 women who underwent CDMR and 429 matched controls who delivered vaginally from June, 2008 through February, 2009. Participants were interviewed by telephone regarding sociodemographic variables, health and lifestyle.

RESULTS

CDMR predictors were as follows: increasing age (OR = 1.09/year; 95%CI: 1.05-1.14), family status (unmarried without a steady partner versus married - OR = 3.60; 95%CI: 1.08-11.97), decreasing level of religiosity (secular versus ultra-orthodox - OR = 11.82; 95%CI: 3.75-37.21), and never having engaged, or ceasing sports activity during pregnancy (OR = 1.79; 95%CI: 1.09-2.91 and 2.38; 95%CI: 1.28-4.43, respectively). Above average income reduced the probability of CDMR (OR = 0.56; 95%CI: 0.33-0.94). The most frequent reasons for choosing CDMR were concern for pain (21.9%), concern for their own or baby's health (20.4% and 16.5%, respectively) and emotional aspects (10.0%).

CONCLUSIONS

Older, unmarried and/or secular women had increased probability of CDMR. Addressing specific concerns regarding vaginal delivery may provide the basis for a patient-oriented intervention for preventing unnecessary surgery.

Fear of childbirth and elective caesarean section: a population-based study

BACKGROUND

This population-based cohort study aimed to investigate the demographic and psychosocial characteristics associated with fear of childbirth and the relative importance of such fear as a predictor of elective caesarean section.

METHODS

A sample of 1789 women from the Akershus Birth Cohort in Norway provided data collected by three self-administered questionnaires at 17 and 32 weeks of pregnancy and 8 weeks postpartum. Information about the participants' childbirths was obtained from the hospital records.

RESULTS

Eight percent of the women reported fear of delivery, defined as a score of ≥85 on the Wijma Delivery Expectancy Questionnaire. Using multivariable logistic regression models, a previous negative overall birth experience exerted the strongest impact on fear of childbirth, followed by impaired mental health and poor social support. Fear of childbirth was strongly associated with a preference for elective caesarean section (aOR 4.6, 95% CI 2.9-7.3) whereas the association of fear with performance of caesarean delivery was weaker (aOR 2.4, 95% CI 1.2-4.9). The vast majority (87%) of women with fear of childbirth did not, however, receive a caesarean section. By contrast, a previous negative overall birth experience was highly predictive of elective caesarean section (aOR 8.1, 95% CI 3.9-16.7) and few women without such experiences did request caesarean section.

CONCLUSIONS

Results suggest that women with fear of childbirth may have identifiable vulnerability characteristics, such as poor mental health and poor social support. Results also emphasize the need to focus on the subjective experience of the birth to prevent fear of childbirth and elective caesarean sections on maternal request. Regarding the relationship with social support, causality has to be interpreted cautiously, as social support was measured at 8 weeks postpartum only.

Previous prelabor or intrapartum cesarean delivery and risk of placenta previa

OBJECTIVE

The purpose of this study was to examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery before the onset of labor from intrapartum cesarean delivery.

STUDY DESIGN

We conducted a retrospective cohort study of electronic medical records from 20 Utah hospitals (2002-2010) with restriction to the first 2 singleton deliveries of nulliparous women at study entry (n=26,987). First pregnancy delivery mode was classified as (1) vaginal (reference), (2) cesarean delivery before labor onset (prelabor), or (3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by previous delivery mode with the use of logistic regression and was adjusted for maternal age, insurance, smoking, comorbidities, previous pregnancy loss, and history of previa.

RESULTS

Most first deliveries were vaginal (82%; n=22,142), followed by intrapartum cesarean delivery (14.6%; n=3931), or prelabor cesarean delivery (3.4%; n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by previous delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<.001). Relative to vaginal delivery, previous prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62; 95% confidence interval, 1.24-5.56). There was no significant association between previous intrapartum cesarean delivery and previa (adjusted odds ratio, 1.22; 95% confidence interval, 0.68-2.19).

CONCLUSION

Previous prelabor cesarean delivery was associated with a >2-fold significantly increased risk of previa in the second delivery, although the approximately 20% increased risk of previa that was associated with previous intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after previous prelabor cesarean delivery may be important when considering nonmedically indicated prelabor cesarean delivery.

Mode of delivery preferences in a diverse population of pregnant women

OBJECTIVE

The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean.

STUDY DESIGN

This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches.

RESULTS

Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity.

CONCLUSION

Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach.

Strength of preference for vaginal birth as a predictor of delivery mode among women who attempt a vaginal delivery

OBJECTIVE

We sought to assess the relationship between strength of preference for vaginal birth and likelihood of vaginal delivery among women attempting this delivery mode.

STUDY DESIGN

We conducted a longitudinal study of mode of delivery preferences among women who were <36 weeks' pregnant. Participants completed a sociodemographic and clinical questionnaire and were asked if they preferred vaginal or cesarean delivery. Participants who preferred vaginal delivery completed a standard gamble exercise to assess the strength of this preference on a 0-to-1 scale (higher scores indicate stronger preference for vaginal delivery); those preferring cesarean delivery were assigned a value of 0. Data on clinical characteristics and delivery mode were obtained via telephone interview or chart review. Logistic regression was used to identify predictors of delivery mode among women who attempted a vaginal delivery.

RESULTS

Of 210 participants, 156 attempted a vaginal delivery. Their mean and median vaginal delivery preference scores were 0.70 (SD 0.31) and 0.75 (interquartile range, 0.50-0.99), respectively. In multivariate analyses, women with a prior cesarean delivery (adjusted odds ratio [aOR], 0.08; 95% confidence interval [CI], 0.02-0.39) or who delivered an infant ≥4000 g (aOR, 0.04; 95% CI, 0.01-0.28) had significantly lower odds of having a vaginal delivery. After controlling for potential confounders, participants with a stronger preference for vaginal delivery were at significantly higher odds of having a vaginal delivery (aOR, 1.54; 95% CI, 1.01-2.34 for every 0.2 increase on the 0-to-1 scale).

CONCLUSION

Among women who attempt a vaginal delivery, the strength of preference for vaginal birth is predictive of the delivery mode ultimately undergone.

Adverse maternal outcomes associated with fetal macrosomia: what are the risk factors beyond birthweight?

Background

To identify risk factors, beyond fetal weight, associated with adverse maternal outcomes in delivering infants with a birthweight of 4000 g or greater, and to quantify their role in maternal complications.

Methods

All women (n = 1564) with singleton pregnancies who attempted vaginal delivery and delivered infants weighing at least 4000 g, in two French tertiary care centers from 2005 to 2008, were included in our study. The studied outcome was maternal complications defined as composite item including the occurrence of a third- or fourth-degree perineal laceration, or the occurrence of severe postpartum hemorrhage requiring the use of prostaglandins, uterine artery embolization, internal iliac artery ligation or haemostatic hysterectomy, or the occurrence of blood transfusion. Univariate analysis, multivariable logistic regression and estimation of attributable risk were used.

Results

Maternal complications were increased in Asian women (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 1.1–9.3, Attributable risk (AR): 3%), in prolonged labor (aOR = 1.9 [95% CI; 1.1–3.4], AR = 12%) and in cesarean delivery during labor (aOR = 2.2 [95% CI; 1.3–3.9], AR = 17%). Delivering infants with a birthweight > 4500 g also increased the occurrence of maternal complications (aOR = 2.7 [95% CI; 1.4–5.1]) but with an attributable risk of only 10%. Multiparous women with a previous delivery of a macrosomic infant were at lower risk of maternal complications (aOR = 0.5 [95% CI; 0.2–0.9]).

Conclusion

In women delivering infants with a birthweight of 4000 g or greater, some maternal characteristics as well as labor parameters may worsen maternal outcome beyond the influence of increased fetal weight.