Reframing birth: a consequence of cesarean section

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of midwifery-led counseling on expectant fathers' fear of childbirth: a smartphone- based randomized controlled trial

BACKGROUND

Expectant fathers experience a range of different emotions during their wife's pregnancy; one of these feelings is fear. It has adverse consequences on both the father and his family. The aim of this study was to investigate the effect of midwifery-led counseling on the fear of childbirth among expectant fathers.

METHODS

A two-armed parallel design randomized controlled trial was conducted from July to August 2020. Fifty expectant fathers with severe fear of childbirth at the 24th-27th weeks of gestation, in the Iranian setting, were assigned to intervention and control groups (allocation ratio1:1) using permuted block randomization. Participants assigned to the intervention group were engaged in six 60-90-min midwifery-led counseling sessions (twice a week) in the Skyroom platform. Measures were administered at recruitment, post-intervention, and one-month follow-up. The primary outcome was the change in fear of childbirth score between groups over time. Secondary outcomes were changes in the General Self-Efficacy score as well as changes in the frequency of the preferred type of delivery between groups over time.

RESULTS

The mean age of the participants was 31.64 (3.33) years. In the intention-to-treat analysis, the fear of childbirth score in the intervention group significantly decreased (β = - 11.84; 95% Confidence Interval: - 21.90 to - 1.78; P = 0.021) compared to that of the control group. In terms of secondary outcomes, the intervention group showed a significant increase in General Self-Efficacy compared to the intervention group at one-month follow-up measurement (β = 1.43; 95% Confidence Interval: 0.28 to 2.58; P = 0.014). However, the frequency of preferred delivery type was not significantly different between the intervention and control groups (P = 0.139).

CONCLUSIONS

Midwifery-led counseling can be an effective approach in reducing expectant fathers' childbirth fear with potential clinical significance. Although the inconclusive results imply more research on this issue.

TRIAL REGISTRATION

Registration number: IRCT20150608022609N6 . Registered 12/04/2019.

Women's experiences of VBAC in Cyprus: a qualitative study

BACKGROUND AND AIM

In 21st century, there has been an increasing interest in vaginal birth after previous caesarean section (VBAC) in Cyprus, a country with a very high operative birth rate. Research-based evidence of women's VBAC experiences in Cyprus is non-existent, despite its significance for the well-being of mothers and families. The aim of this study is to gain insight into the women's lived experience of VBAC in Cyprus. In this study women's experiences of VBAC are explored for the first time in Cyprus.

METHOD

The study is qualitative and exploratory in nature. Data were collected through semi-structured interviews with 10 women, who experienced vaginal birth after a previous caesarean section (VBAC) in Cyprus. A descriptive phenomenological approach was employed for the analysis of data.

RESULTS

Analysis of data yielded four major themes: (a) medicalization of childbirth, (b) preparing for a VBAC, (c) birth environment, and (d) healing through VBAC. On the whole, the women interviewed described their previous experience of CS as traumatic, in contrast to vaginal childbirth. VBAC was considered an utterly positive experience that made the women feel empowered and proud of themselves.

CONCLUSION

This study offers valuable insight into a newly researched subject in Cyprus, which is necessary for advancing perinatal care in Cyprus. The findings indicate that women need evidence-based information, guidelines on birthing options, good preparation with tailored information and personalized care for a successful vaginal birth after a previous caesarean section. Proper, non-biased, consultations are a main factor that affects women's choice of mode of birth. The introduction of new, women-friendly perinatal strategies that respect and promote childbirth rights is imperative in the case of Cyprus. All women have the right to exercise informed choice and the choice to alternative birthing options.

Women's views of birth after cesarean section

BACKGROUND

Vaginal birth is a safe mode of childbirth for the majority of women after cesarean section (CS). However, data show that women who have undergone a CS are more likely to have an elective CS (ECS) than a vaginal birth after CS (VBAC) in many areas of the world.

AIM

This study aimed to review the literature about women's mode of birth preferences and attitudes and the underlying reasons for, and factors associated with, their preferences.

METHODS

This is narrative literature review. PubMed/MEDLINE and Scopus databases were searched, limiting the results to non-interventional studies published between 1990 and 2020. Twenty-one articles were included in the analysis.

RESULTS

The review found 34 different factors that influence women's preferences. Five factors influenced both VBAC and ECS preference, depending on the study. The most common factors having a dualistic effect on preference were: medical staff recommendation, doctor's opinion, and fear of pain. The most common factors were: desire to experience natural childbirth, faster/easier recovery, support from doctor's, and midwife's opinion. Among the factors influencing the preference for ECS, two were particularly prominent: predictability, controllability and comfortability of CS and the belief that CS is safer for the baby and/or mother.

CONCLUSIONS

Our review showed that there are a variety of factors that influence women's preference for the mode of delivery after CS. Some of these have a dualistic effect according to the study. The key to making an informed decision regarding the mode of delivery is communication with medical professionals.

Design and psychometric evaluation of the fathers' fear of childbirth scale: a mixed method study

Background

Fear of childbirth is reported in 13% of fathers, and it may have adverse consequences for the fathers’ health as well as their families. To reduce the fear of childbirth in the expectant fathers, an appropriate screening tool is needed. Due to the lack of a valid and reliable questionnaire to measure fathers’ fear of childbirth, this study was conducted to develop the Fathers’ Fear of Childbirth Scale and evaluate its psychometric properties.

Methods

This mixed method study was conducted in two phases. In the qualitative phase (or item generation), semi-structured interviews were conducted with 20 expectant fathers, and a literature review was performed to generate the Fathers’ Fear of Childbirth Scale items pool. In the quantitative phase (or psychometric evaluation), reliability as well as face, content, and construct validity of this scale were evaluated. To establish construct validity, exploratory and confirmatory factor analyses were performed. Reliability was evaluated through internal consistency and composite reliability measures.

Results

The primary version of Fathers’ Fear of Childbirth Scale contained 32 items, which were reduced to 17 items while establishing construct validity. Exploratory factor analysis extracted two factors, namely fear of childbirth process (12 items) and fear of hospital (5 items). These factors explained 50.82% of the total variance. Goodness of fit indices within the confirmatory factor analysis was acceptable. Internal consistency and composite reliability indices of all the factors were greater than 0.70.

Conclusion

The Fathers’ Fear of Childbirth Scale has a suitable validity and reliability for assessing fear of childbirth in fathers. It is a simple report instrument that can be easily implemented by health care professionals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03696-7.

Antenatal survey of women's birthing choices in Qatar

Objectives Attitudes towards labour care and women's choices for their preferred mode of delivery are documented in studies from the around the world, however less is known about women's birth choices in the Middle East. This study was designed with the aim of exploring beliefs and attitudes in this region. Methods Voluntary participation in an ethics-approved survey was offered to pregnant women attending the antenatal clinic at Sidra Medicine from August 2018 to January 2019 with no exclusion criteria. Results Of the 346 respondents, 58.1% were Arabic and the remainder expatriates. This group composition allowed comparison between women native and non-native to the Gulf region. Arabic and non-Arabic women differed significantly in previous birth experiences: the Arabs had had more doctor-led deliveries (45 vs. 34%), epidurals (56.6 vs. 45%) and episiotomies (65.7 vs. 54%). 70.2% of the respondents chose a normal delivery as their preferred birth mode though a smaller majority of the Arabic subgroup did (63.2 %). 60.4% preferred delivery by doctors and longer hospital stays (47.6), more so Arabic participants (64.7 and 68.6 %). Significantly less Arabs, would choose husbands as birth partners (51.2 vs. 86.2%) and more expressed a gender preference for doctors. Other group choices are presented. Conclusions Though women in this region made comparable choices about mode of delivery as their Western counterparts, they demonstrated an expectation of a culturally distinct and more medicalized approach to care in labour. The findings highlight the need for further studies to inform regional obstetric care and health education interventions as well as tailoring maternity care services.

Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study

BACKGROUND

Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women's decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method.

METHODS

A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis.

RESULTS

Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women's choice … with conditions, their assessment of women's chances of a successful TOLAC, their perception of women's risk tolerance, women's preferred delivery method, and their perception of women's beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers' perspectives on risk of TOLAC.

CONCLUSION

The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Patients at the centre of care: debriefing patients after caesarean section

Empowering patients and working collaboratively to improve healthcare is a focus for current healthcare development strategies. In obstetric practice, working in collaboration with women to discuss mode of delivery after caesarean section has been shown to impact women’s choice. A preliminary survey in our tertiary maternity unit showed 20% of women gained ‘full clarity’ with the information they received after caesarean-section regarding indication, complications and impact on future delivery. Focus groups identified what information patients required about their surgery. General practitioners (GP) highlighted a lack of communication between secondary and primary care. Junior obstetricians surveyed felt uncertain about debriefing. The aim was to improve monthly ‘full clarity’ scores to 30% in 6 months. Our team introduced a debrief form, filled by the operator and kept in maternity notes. The operator verbally debriefed as part of their current standard practice. Junior doctors postoperatively debriefed the patient using the form. The triplicate form ensured both patients and primary care received a copy. It was anticipated that in the long term, this would provide consistent information and aid informed decision making in subsequent pregnancies. Review of the forms’ use was undertaken weekly. Multidisciplinary input identified barriers to uptake. Plan, Do, Study, Act cycles promoted the project, disseminated results, evidenced growing participation and rewarded consistent form use. Patient groups critiqued the form layout. Teaching aimed to improve junior doctor confidence in debriefing discussions. Sustained participation resulted in effective form uptake. Patient ‘full clarity’ scores improved to 60% with minimal impact on workload. Teaching successfully improved junior doctor confidence as evidenced by increased documented debrief discussions. GP focus groups felt empowered to counsel women consistently about their surgery increasing clarity for everyone. This project highlights that patient satisfaction improves when we listen to their views and commit to change.

Women's preference for vaginal birth after a first delivery by cesarean

BACKGROUND

Nearly 90% of United States pregnant women with a prior cesarean give birth by repeat cesarean. Public health goals encourage greater use of vaginal birth after cesarean (VBAC), but there is little prospective data on predictors of women's preference for VBAC. We characterized predictors of women's preferred mode of delivery after a first cesarean and thematically categorized reasons for their preference.

METHODS

Data were from a cohort of 3006 women whose first childbirth was in Pennsylvania in 2009-2011. The analytic sample included women who had their first birth by cesarean and reported mode of delivery preference for their next delivery at 12 months postpartum (n = 616). Associations with future birth mode preference were assessed using multivariate logistic regression, and reasons for preference were categorized using content analysis.

RESULTS

At 12 months postpartum, 45% of women who delivered by cesarean in their first birth wanted to have their next delivery vaginally. Independent predictors of VBAC preference were Black race/ethnicity, nonrecurrent indication for the first cesarean, planning three or more additional children, and difficulty recovering from the first cesarean. The most common reason for preferring a vaginal birth was wanting the experience of vaginal birth; the most common reason for preferring cesarean birth was that the first birth was by cesarean.

CONCLUSION

Nearly half of respondents preferred VBAC in future births, but national estimates indicate that only about 12% of women with prior cesareans have a VBAC. This suggests a need to ensure greater access to VBAC for women who want it.

Fear of childbirth in urban and rural regions of Turkey: Comparison of two resident populations

OBJECTIVE:

Childbirth is a natural physiological event experienced by many women; however, it is frequently also a source of fear in women. Rates of cesarean sections in Turkey are higher in the urban areas than in the rural areas. We hypothesized that lower fear of childbirth (FOC) rates would be observed in the city having the lowest cesarean section rates in Turkey. This study aimed to compare FOC in women in two resident populations: one in a rural area and the other in an urban area.

METHODS:

This study was conducted on 253 pregnant women in Istanbul, a large urban municipality, and Siirt, a city in rural Turkey. A descriptive information form and the A version of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) were used.

RESULTS:

Severe FOC levels were recorded in women in the Istanbul sample; moreover, these levels were higher than those recorded in women in the Siirt sample. In addition, women in the Istanbul sample preferred vaginal birth to cesarean section and had greater FOC, a finding which demonstrates that women prefer vaginal birth even though they have a higher FOC level and live in a city with high cesarean section rates. Where women live (rural versus urban areas) affects their perception of birth and consequently, their FOC levels.

CONCLUSION:

The results of this study suggest that further cross-cultural and regional research is needed for better understanding FOC and factors associated with elevated FOC levels within each cultural setting.

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

OBJECTIVE

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

DESIGN

Systematic review of qualitative literature using meta-ethnography.

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

Frequency of placenta previa in previously scarred and non scarred uterus

Objective:

To determine the frequency of placenta Previa in patients coming to a tertiary care unit with previously scarred and non-scarred uterus.

Methods:

A descriptive cross sectional study was carried on 114 cases who underwent caesarean sections (37 cases out of 645 cases with non scarred uterus and 77 cases from 721 cases with scarred uterus) in the department of obstetrics and gynecology Lady Willingdon Hospital from January 2008– December 2011.

Results:

Most patients (47.36%) were between 26-30 years age group, presented with gestational age between 36-40 weeks (70.17%), were mostly G2-4, while frequency of placenta Previa in non-scarred uterus was 32.45% (37 cases), and frequency in previously scarred uterus was 67.54% (77 cases). Major degree Previa was found in 88 cases (77.19%). There were 5.70% cases of placenta Previa from non-scarred uteruses and 10.67% cases of placenta Previa (10.67%) from already scarred uteruses. Stratification revealed a higher trend of the morbidity with the increase in number of previous caesarean sections.

Conclusion:

A significantly higher frequency of placenta Previa was found among patients coming to a tertiary care hospital with previously scarred uterus.

Providing Information and Support to Postnatal Women Who Have Experienced a Cesarean Section: A Pilot Study

BACKGROUND:Australia has a low uptake of vaginal birth after cesarean despite the evidence that this is best practice. A new midwifery-led service was introduced with the overall goal to improve the quality of care offered to women and their families that have experienced a cesarean section. The postnatal arm of the service targeted women who had experienced their first cesarean section. The service included an early hospital postnatal visit from the next birth after cesarean (NBAC) midwives whereby women were given an opportunity to share their experiences. Women were subsequently given an evidence-based resource on birth after cesarean as well as the midwives’ contact details should they wish to contact them anytime during the first 6 weeks after birth.

AIM:To evaluate the effectiveness the postnatal arm of the service on women’s birth mode intentions in a subsequent pregnancy and their levels of childbirth fear and self-efficacy at 12 weeks postpartum.

METHOD:Comparative descriptive design (pre-/posttest). Fifty-three women receiving standard care (comparison group) and 50 women receiving the NBAC postnatal service completed a childbirth fear measure (Wijma Delivery Expectancy/Experience Questionnaire Version B), a self-efficacy scale (New General Self-Efficacy Scale [NGSE]), and were asked their preferred birth mode for a subsequent pregnancy. Data was collected at 3–5 days and 12 weeks postpartum. Descriptive statistics and chi-square analysis were used to test several formulated hypotheses.

RESULTS:Although women who received a visit from the NBAC midwives were more likely to state they intended to birth vaginally in a next pregnancy, compared to women receiving standard care, the finding was not significant (p= .272). Likewise, there was no difference in childbirth fear with both groups of women having high levels of childbirth fear (comparison [86.27] and NBAC group [84.67]). Comparison of self-efficacy items between groups at 12 weeks were not significant aside from NBAC women feeling more confident with their ability to complete tasks well (p= .005).

CONCLUSION:Although the findings of this small study were not statistically significant, the simple and timely nature of the intervention seems worthy of further consideration and investigation. In addition, research needs to continue to focus on how midwives can better meet women’s emotional needs in the postpartum period helping to ameliorate women’s fear and build confidence for their next pregnancy and birth experience.

A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals

INTRODUCTION

For women with a lower uterine incision without indication for repeat Caesarean section (CS), vaginal birth for their next pregnancy is a safe option. Although these women should be encouraged to consider vaginal birth after a Caesarean section (VBAC) it is not consistently supported in practice. There is relatively little information on the extent to which maternal preference, birthing decisions and outcomes match best available evidence.

AIM

To describe current VBAC rates for women in Queensland, Australia and compare this to safe, achievable VBAC rates reported in national and international studies.

METHOD

Perinatal data from 2004 to 2011 were reviewed to determine current VBAC rates following a primary CS for women birthing in Queensland. These were compared with VBAC rates reported in the literature.

RESULTS

Queensland has a high overall CS rate and high repeat CS rate compared with the national average. In 2010, Queensland VBAC rates for next birth following primary CS were 14% (range 13-21% public sector, 7-11% private hospitals). This is substantially lower than achievable Australian rates of 24% and international rates.

CONCLUSION

Low VBAC rates reflect low numbers of women commencing labour in a pregnancy subsequent to a primary CS. There is unexplained variation in VBAC rates between maternity facilities. Clinical reviews to support evidence-based practice are warranted.

Study protocol for reducing childbirth fear: a midwife-led psycho-education intervention

BACKGROUND

Childbirth fear has received considerable attention in Scandinavian countries, and the United Kingdom, but not in Australia. For first-time mothers, fear is often linked to a perceived lack of control and disbelief in the body's ability to give birth safely, whereas multiparous women may be fearful as a result of previous negative and/or traumatic birth experiences. There have been few well-designed intervention studies that test interventions to address women's childbirth fear, support normal birth, and diminish the possibility of a negative birth experience.

METHODS/DESIGN

Pregnant women in their second trimester of pregnancy will be recruited and screened from antenatal clinics in Queensland, Australia. Women reporting high childbirth fear will be randomly allocated to the intervention or control group. The psycho-educational intervention is offered by midwives over the telephone at 24 and 34 weeks of pregnancy. The intervention aims to review birth expectations, work through distressing elements of childbirth, discuss strategies to develop support networks, affirm that negative childbirth events can be managed and develop a birth plan. Women in the control group will receive standard care offered by the public funded maternity services in Australia. All women will receive an information booklet on childbirth choices. Data will be collected at recruitment during the second trimester, 36 weeks of pregnancy, and 4-6 weeks after birth.

DISCUSSION

This study aims to test the efficacy of a brief, midwife-led psycho-education counselling (known as BELIEF: Birth Emotions - Looking to Improve Expectant Fear) to reduce women's childbirth fear. 1) Relative to controls, women receiving BELIEF will report lower levels of childbirth fear at term; 2) less decisional conflict; 3) less depressive symptoms; 4) better childbirth self-efficacy; and 5) improved health and obstetric outcomes.

TRIAL REGISTRATION

Australian New Zealand Controlled Trials Registry ACTRN12612000526875.

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

BACKGROUND

About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women's preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women.

METHODS

This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women's magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview.

RESULTS

A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives.

CONCLUSION

Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean.

Factors Associated With a Positive Birth Experience: An Exploration of Swedish Women’s Experiences

BACKGROUND: The birth of a baby is a powerful life event that has implications for a woman’s well-being and future health. A positive birth experience promotes a sense of achievement, enhances feeling of self-worth, and facilitates confidence—all of which are important for a healthy adaptation to motherhood and psychological growth. Understanding what constitutes a positive birth experience is critical to providing maternity care that meets childbearing women’s individual needs, preferences, and priorities.

OBJECTIVE: To explore the prevalence of Swedish women reporting a very positive birth experience 2 months and 1 year after childbirth and identify factors associated with this experience. In addition, the study aimed to identify whether women’s assessment of their birth experience changed over time.

METHOD: A prospective, longitudinal study where the main outcome variable was perceptions of a very positive birth experience. The study was undertaken in a Northern region of Sweden in 2007. Women were recruited at their ultrasound examination in midpregnancy. Data was collected via questionnaires. There were 928 women who responded to questions about their birth experience at 2 months postpartum. Nearly 83% of these women (n= 763) also completed the questionnaire package 1 year after birth. Descriptive statistics were used together with Friedman’s test to detect changes over time. Logistic regression analysis was performed to reveal which factors contributed most to a very positive birth experience.

RESULT: More than a third of the women reported a very positive birth experience. Women’s assessment of birth changed over time with 22% of the women becoming more positive and 15% more negative. Important associated factors for a very positive birth experience included positive feelings about the approaching birth as well as feeling in control, using no or only cognitive forms of pain management, and achieving a spontaneous vaginal birth. Furthermore, how women rated their midwifery care was also shown to affect their assessment of their birth experience.

CONCLUSION: This study found that women’s birth experiences changed over time and most becoming more positive after 1 year. Factors associated with a very positive birth experience were related to women’s prenatal attitudes, intrapartum procedures, pain relief used, and care received during labor and birth. Respectful individualized midwifery care that remains focused on the woman and keeping birth normal increases positive perceptions of the birth experience.

Association Between Mode of Birth and Self-Reported Maternal Physical and Psychological Health Problems at 10 Weeks Postpartum

AIM:To determine the association between mode of birth and physical and psychological health problems reported at 10 weeks postpartum.

METHODS:A cross-sectional, self-report survey was completed by 2,699 Western Australian women at 10 weeks postpartum. Information on birth mode and physical and psychological health was sought. Descriptive statistics and frequency distributions were performed to describe the sample. Logistic regression was used to determine the association between mode of birth and the reported number of physical health problems (two or more and three or more) and two psychological health problems.

RESULTS:The occurrence of physical health problems for all women were incontinence (11.5%), no bowel control (2.6%), backache (41%), heavy bleeding (14.1%), and excessive fatigue or tiredness (35.7%). A significant association was found between all cesarean sections (elective and emergency) and the number of physical health problems compared to spontaneous vaginal births. Women who had an emergency cesarean were most likely (OR= 3.15, CI = 2.40–4.13,p< 0.0005) to report two or more physical problems, whereas women who had an elective cesarean were more likely (OR= 2.75, CI = 2.08–3.63,p< 0.0005) to report three or more physical problems.

Nearly 15% of women reported being unhappy for more than a few days. This was highest in women having an emergency cesarean (16.4%) and lowest in women giving birth spontaneously (13.5%). Some 6.4% of women stated they were constantly reliving negative thoughts of birth and/or labor. Women who had an emergency cesarean were more likely (OR= 3.10, CI = 1.96–4.89,p< 0.0005) to choose this item and they were also more likely (OR= 2.04, CI = 1.01–4.13,p< 0.047) to experience both psychological health items.

CONCLUSION:Women’s reports of health problems within the first 10 weeks postpartum are concerning and warrant ongoing attention. The prevalence of health problems was higher in women who had experienced a cesarean. This information on morbidity postbirth is essential for women and their care providers in making informed decisions around available birth options.

Becoming Redundant: Australian Women’s Experiences of Pregnancy After Being Unexpectedly Scheduled for a Medically Necessary Term Elective Cesarean Section

PURPOSE: There is now a comprehensive body of evidence reporting the effects of emergency cesarean section on women’s emotional well-being. How women respond to becoming in need of a medically necessary elective cesarean section, however, has not previously been reported. This article describes and explains how a cohort of Australian women experienced the remainder of the antenatal period following the discovery during pregnancy of a medical reason to book a term elective cesarean section.

DESIGN: Grounded theory methodology was used for this study.

FINDINGS: Seven categories emerged from data analysis to represent the women’s responses to becoming in need of a medically necessary term elective cesarean section. Four categories describe women’s actions and interactions as they dealt with their lost expectations and their perceived “displacement” from their baby’s birth. The other three categories represent the factors that mediated, or caused, women’s responses.

MAIN CONCLUSIONS: This study provides new knowledge about how women experience and respond to an unwanted and unforeseen change in their childbearing journey. The sense of disappointment and loss that is likely to arise for women who must “change track” must be anticipated, recognized, acknowledged, and when possible, forestalled by maternity care professionals.

A qualitative analysis of the content of telephone calls made by women to a dedicated 'Next Birth After Caesarean' antenatal clinic

BACKGROUND

The 'Next Birth After Caesarean' (NBAC) clinic is a dedicated service for women who have had a previous caesarean section. The midwifery-led clinic commenced at a tertiary hospital in Western Australia in 2008. As part of this service, access to a midwife via telephone is available.

AIM

This paper aims to provide maternity health care providers with an increased understanding of, and insight into, the different information needs of this specific group of maternity care consumers.

METHODS

A qualitative descriptive approach was used to analyse the content of 170 telephone calls made by women to the NBAC clinic over a period of 16 months (July 2008-November 2009).

RESULTS

Six distinct categories of calls were elicited from the analysis process with the majority of calls related to women seeking information and support about the option of vaginal birth after caesarean (VBAC). These were labeled: 'Wanting and seeking a VBAC'; 'Is VBAC a possiblility?'; 'Seeking clarification and cross-checking information in the face of opposition'; 'Existing NBAC clients checking in/checking out'; 'Feeling distressed and disappointed; wanting to talk' and 'Professional inquiry about NBAC service'.

DISCUSSION

It is acknowledged that women require access to non-biased information to be able to make informed decisions about birth after caesarean. However there remains limited evidence on the precise informational needs of these women. It appears from our findings that this particular group of maternity service consumers requires opportunities to discuss their particular needs within the context of their individual childbearing experiences.

CONCLUSION

Preliminary evidence is provided that a telephone service led by midwives may be one effective strategy to meet women's informational needs and address decisional conflict in relation to options for birth after a caesarean section.

Elective caesarean section as a transformative technological process: players, power and context

AIM

In this paper we present a critical analysis of the debate surrounding elective caesarean section using the Social Construction of Technology perspective as a framework of analysis.

BACKGROUND

The rate of caesarean section births is increasing worldwide in industrialized countries. Reasons given for the increase include women's characteristics, care providers' attitudes, prevention of pelvic floor disorders and adverse outcomes.

DATA SOURCES

CINAHL, PubMed, Ovid, Academic Search Premier and Cochrane Data bases were searched for the years 2000 to 2007 using search terms elective caesarean section, caesarean section on demand and maternal choice caesarean section.

DISCUSSION

The social constructivist approach explains how caesarean section as a mode of delivery has been transformed from an emergency to an elective procedure. Analysing elective caesarean section as a socially constructed technological process exposes positions taken by obstetricians, midwives, perinatal nurses and women, including the power dynamics and contextual influences.

CONCLUSION

The Social Construction of Technology perspective creates space for perinatal nurses to examine the implications of the use and meaning of elective caesarean section in a broader social context. Examining elective caesarean section from the Social Construction of Technology perspective exposes an emphasis on safety and risk for the foetus, while avoiding the equally important goal of promoting optimal postnatal health for mothers and infants. The Social Construction of Technology perspective highlights how those who define the problem control the solution.

Why do women request caesarean section in a normal, healthy first pregnancy?

BACKGROUND AND CONTEXT

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

OBJECTIVE

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

DESIGN

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

SETTING

two states of Australia: Queensland and Western Australia.

PARTICIPANTS

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

FINDINGS

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a 'safe' and 'responsible' choice. KEY CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.

Caesarean section and tubal infertility: is there an association?

Rising Caesarean section (CS) rates have fuelled concerns about the effect of abdominal delivery on female fertility due to post-surgical complications affecting the Fallopian tubes. The association between exposure to CS and subsequent tubal infertility was explored by means of a case-control study. This study compared 220 women with secondary infertility due to tubal factor with 1244 women with secondary infertility due to non-tubal causes and 18,376 fertile women (women with a previous live birth followed by another live birth during the time period when the infertile cases were trying to conceive) in terms of exposure to CS. Exposure to CS in women with secondary tubal infertility was similar to other infertile women (21.4% versus 21.6%) but lower in fertile controls (14.5%). After adjusting for confounding factors, CS does not appear to be significantly associated with tubal infertility [adjusted odds ratio (95% confidence interval) for previous CS for infertile and fertile controls were 1.06 (0.73-1.52) and 1.2 (0.9-1.7), respectively]. However, other factors that were found to be predictive of secondary tubal infertility include history of intrauterine device use, pelvic inflammatory disease, ectopic pregnancy, endometriosis and previous pelvic surgery.

Believing in birth--choosing VBAC: the childbirth expectations of a self-selected cohort of Australian women

AIM

This study explored the childbirth expectations and knowledge of women who had experienced a caesarean and would prefer a vaginal birth in a subsequent pregnancy.

BACKGROUND

Vaginal birth after caesarean is considered best practice. However, in most western world countries, despite the inherent risks of caesarean for both mother and baby, the number of women labouring after a previous caesarean is declining.

METHODS

Newspaper advertisements were used to recruit Western Australian women who had experienced a caesarean. Thematic analysis was used to analyse the interview data collected from women who attempted a vaginal birth (n=24), or stated they would choose this option, in a subsequent pregnancy (n=11).

FINDINGS

For this cohort of women, their caesarean experience reinforced their previously held expectations about birthing naturally. The women held strong views about the importance of working with their bodies to achieve a vaginal birth, which was considered an integral part of being a woman and mother. Positive support from family and friends and a reluctance to undergo another caesarean was also influential. Women articulated the risks of caesarean and considered vaginal birth enhanced the health and well-being of the mother and baby, promoted maternal infant connection and the eased the transition to motherhood.

CONCLUSION

This study documents how the importance of birth, as a significant life event, remained the focus of these women's childbirth expectations influencing future decisions on birth mode and mediating against the 'pressure' of medical discourse promoting caesarean.

RELEVANCE TO CLINICAL PRACTICE

Knowledge and appreciation of the multiple dimensions that contribute to women's decisions after a caesarean provides valuable information on which service providers and researchers can draw as they investigate interventions that enhance the uptake and success of women birthing vaginally after a caesarean.