An investigation of women's involvement in the decision to deliver by caesarean section

[Legal Compliance of Medical Information in the Case of a Relatively Indicated Secondary Caesarean Section in Obstetric Clinics in Germany - Part I: Status Quo-Survey]

INTRODUCTION

In order to guarantee the patient's right to self-determination, in the case of a relative indication for a secondary caesarean section the Supreme Court expects early information about this real treatment alternative and the patient's option to choose the delivery method. The aim of this study throughout Germany was to survey the status quo of legal compliance of the practice of providing information at all German obstetric clinics and a further comparison based on the clinic format.

METHODS

All obstetric clinics in Germany were emailed within the context of an anonymous online study using a questionnaire developed on the basis of the BGH judgment of August 28, 2018 (AZ: VI ZR 509/17). Three questions had to be answered cumulatively with "yes" to affirm legal compliance. The responding clinics were divided into six groups based on their format (status as university hospital / other hospitals stratified by number of births per year).

RESULTS

93 questionnaires were analyzed. 14 clinics (15.05%) met the requirements. Clinics with an annual number of births of 1,000-1,499 perform best in comparison.

CONCLUSION

There is an urgent need for a secure, legally compliant information concept for everyday birth practice in German clinics.

Women's psychosocial outcomes following an emergency caesarean section: A systematic literature review

Background

Given the sudden and unexpected nature of an emergency caesarean section (EmCS) coupled with an increased risk of psychological distress, it is particularly important to understand the psychosocial outcomes for women. The aim of this systematic literature review was to identify, collate and examine the evidence surrounding women’s psychosocial outcomes of EmCS worldwide.

Methods

The electronic databases of EMBASE, PubMed, Scopus, and PsycINFO were searched between November 2017 and March 2018. To ensure articles were reflective of original and recently published research, the search criteria included peer-reviewed research articles published within the last 20 years (1998 to 2018). All study designs were included if they incorporated an examination of women’s psychosocial outcomes after EmCS. Due to inherent heterogeneity of study data, extraction and synthesis of both qualitative and quantitative data pertaining to key psychosocial outcomes were organised into coherent themes and analysis was attempted.

Results

In total 17,189 articles were identified. Of these, 208 full text articles were assessed for eligibility. One hundred forty-nine articles were further excluded, resulting in the inclusion of 66 articles in the current systematic literature review. While meta-analyses were not possible due to the nature of the heterogeneity, key psychosocial outcomes identified that were negatively impacted by EmCS included post-traumatic stress, health-related quality of life, experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the most commonly examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptoms and diagnosis.

Conclusions

EmCS was found to negatively impact several psychosocial outcomes for women in particular post-traumatic stress. While investment in technologies and clinical practice to minimise the number of EmCSs is crucial, further investigations are needed to develop effective strategies to prepare and support women who experience this type of birth.

Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia?

BACKGROUND

In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions.

METHODS

Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean.

RESULTS

Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0).

CONCLUSION

Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.

Perspectives, Decision Making, and Final Mode of Delivery in Pregnant Women With a Previous C-Section in a General Hospital in Peru: Prospective Analysis

Objective: Explore the perspectives, decision-making process, and final mode of delivery among pregnant women with a previous C-section (Cesarean section) in a general public sector hospital in Lima, Peru. Methods: A qualitative prospective study using semistructured interviews at two time points in the outpatient obstetrics and gynecology clinic of a public sector, university-affiliated reference hospital in Lima, Peru. Seventeen adult pregnant women with a prior C-section who were deemed by their attending obstetrician to be candidates for a trial of labor were interviewed. The first interview was between 37 and 38 weeks of pregnancy, and the second interview was 24 to 48 hours after delivery.

MAIN OUTCOME MEASURES

Predelivery decision-making process and final mode of delivery. Results: Among the 17 participants, about half (9) of the participants stated that the physician explained that they had two approaches for delivery, a trial of labor after C-section (TOLAC) or elective repeated C-section (ERCD). Two women stated that their respective providers explained only one option, either an ERCD or TOLAC. However, 6 women did not receive any information from their providers about their delivery options. Of the 10 participants that decided TOLAC, 8 ended up having a C-section, and of the 7 patients that had planned an ERCD, 1 ended up having a vaginal delivery. Conclusion: Many participants affirmed that they made the decision about their approach of delivery. However, most of the participants that decided a TOLAC ended up having a C-section because of complications during the final weeks of pregnancy or during labor.

Vaginal birth after caesarean: Views of women from countries with low VBAC rates

PROBLEM AND BACKGROUND

Vaginal birth after caesarean section is a safe option for the majority of women. Seeking women's views can be of help in understanding factors of importance for achieving vaginal birth in countries where the vaginal birth rates after caesarean is low.

AIM

To investigate women's views on important factors to improve the rate of vaginal birth after caesareanin countries where vaginal birth rates after previous caesarean are low.

METHODS

A qualitative study using content analysis. Data were gathered through focus groups and individual interviews with 51 women, in their native languages, in Germany, Ireland and Italy. The women were asked five questions about vaginal birth after caesarean. Data were translated to English, analysed together and finally validated in each country.

FINDINGS

Important factors for the women were that all involved in caring for them were of the same opinion about vaginal birth after caesarean, that they experience shared decision-making with clinicians supportive of vaginal birth, receive correct information, are sufficiently prepared for a vaginal birth, and experience a culture that supports vaginal birth after caesarean.

DISCUSSION AND CONCLUSION

Women's decision-making about vaginal birth after caesarean in these countries involves a complex, multidimensional interplay of medical, psychosocial, cultural, personal and practical considerations. Further research is needed to explore if the information deficit women report negatively affects their ability to make informed choices, and to understand what matters most to women when making decisions about vaginal birth after a previous caesarean as a mode of birth.

Possible relationship between general and pregnancy-related anxiety during the first half of pregnancy and the birth process: a prospective cohort study

OBJECTIVES

The rate of interventions during childbirth has increased dramatically during the last decades. Maternal anxiety might play a role in the progress of the labour process and interventions during labour. This study aimed to identify associations between anxiety in the first half of pregnancy and the birth process, including any interventions required during labour. In addition, differences in the associations by parity and ethnicity were explored.

DESIGN

Prospective cohort study.

SETTING

Primary care midwifery practices and secondary/tertiary care obstetric practices in Amsterdam, participating in the multiethnic ABCD (Amsterdam Born Children and their Development) study (participation rate 96%; response 8266/12 373 (67%)).

PARTICIPANTS

Included were women with singletons, alive at labour start, with a gestational age ≥24 weeks (n=6443).

INDEPENDENT VARIABLE

General anxiety (State-Trait Anxiety Inventory state) and pregnancy-related anxiety (Pregnancy-Related Anxieties Questionnaire (PRAQ)) were self-reported in the first half of pregnancy.

OUTCOMES

Associations between both forms of anxiety and several indicators of the birth process were analysed. Subgroup analyses were performed for parity and ethnicity.

RESULTS

The prevalence of high general anxiety (State-Trait Anxiety Inventory score ≥43) and pregnancy-related anxiety (PRAQ score ≥P90) were 30.9% and 11.0%, respectively. After adjustment, in nulliparae, both general anxiety and pregnancy-related anxiety were associated with pain relief and/or sedation (OR for general anxiety 1.23; 95% CI 1.02 to 1.48; OR for pregnancy-related anxiety 1.45; 95% CI 1.14 to 1.85). In multiparae, general anxiety was associated with induction of labour (OR 1.53; 95% CI 1.16 to 2.03) and pregnancy-related anxiety was associated with primary caesarean section (OR 1.66; 95% CI 1.02 to 2.70). Associations were largely similar for all ethnicities.

CONCLUSIONS

High levels of general and pregnancy-related anxiety in early pregnancy contribute modestly to more interventions during the birth process with similar associations between ethnic groups, but with some differences between nulliparae and multiparae.

Influencing factors in choosing delivery method: Iranian primiparous women's perspective

Background

Studies on the primiparous mothers’ decision on delivery method are limited.

Aim

The aim of his study was to determine the factors that influence the choice of delivery method by Iranian primiparous women.

Methods

This cross-sectional study was conducted in April through September 2014. Participants were 460 primiparous women in 8 hospitals of 4 cities in Iran. Finally, 230 cesarean section and 230 vaginal delivery women were selected. Inclusion criteria were being primiparous, and having no contraindication for vaginal delivery. Study tool was a researcher-developed questionnaire that its validity and reliability were proved. Data were gathered by direct interview and analyzed by SPSS version 16.

Results

Average age of the participants was 23 years. Factors that correlated with the choice of Cesarean section were upper education, high socioeconomic level, tendency of husband, living with the husband’s family, insistence of the physician, receiving maternal care in personal offices, fear of delivery pain, low knowledge of the mother, high age of marriage and pregnancy, history of abortion, and lack of family support. More than 60% of the participants had little knowledge about the delivery methods. Satisfaction with cesarean section was 70% and with the vaginal delivery was 77%. Half of the cesareans were performed on the insistence of the physician.

Conclusion

Considering the factors identified in this study, can enforce the intention of mothers to have vaginal delivery by improving their knowledge and perception about this delivery method.

The Impact of Patient Participation in Health Decisions Within Medical Encounters

Background: Although there are compelling moral arguments for patient participation in medical decisions, the link to health outcomes has not been systematically explored. Objective: Assess the extent to which patient participation in decision making within medical encounters is associated with measured patient outcomes. Methods: We conducted a primary search in PubMed—excluding non-English and animal studies—for articles on decision making in the context of the physician–patient relationship published through the end of February 2015, using the MeSH headings (Physician-Patient Relations [MeSH] OR Patient Participation [MeSH]) and the terms (decision OR decisions OR option OR options OR choice OR choices OR alternative OR alternatives) in the title or abstract. We also conducted a secondary search of references in all articles that met the inclusion criteria. Results: A thorough search process yielded 116 articles for final analysis. There was wide variation in study design, as well as measurement of patient participation and outcomes, among the studies. Eleven of the 116 studies were randomized controlled trials (RCTs). Interventions increased patient involvement in 10 (91%) of the 11 RCTs. At least one positive outcome was detected in 5 (50%) of the 10 RCTs reporting increased participation; the ratio of positive results among all outcome variables measured in these studies was much smaller. Although proportions differed, similar patterns were found across the 105 nonrandomized studies. Conclusions: Very few RCTs in the field have measures of participation in decision making and at least one health outcome. Moreover, extant studies exhibit little consistency in measurement of these variables, and results are mixed. There is a great need for well-designed, reproducible research on clinically relevant outcomes of patient participation in medical decisions.

Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women

OBJECTIVE

To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures.

DATA SOURCES/STUDY SETTING

Listening to Mothers III, a nationally representative survey of women 18-45 years who delivered a singleton infant in a U.S. hospital July 2011-June 2012 (N = 2,400).

STUDY DESIGN

Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure.

PRINCIPAL FINDINGS

Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5-5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3-3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2-8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4-11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0-11.3).

CONCLUSIONS

Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider-patient miscommunication and minimize potentially unnecessary procedures may be warranted.

Socioeconomic position early in adolescence and mode of delivery later in life: findings from a Portuguese birth cohort

Objective

This study assessed the influence of socioeconomic position at 12 years of age (SEP-12) on the variability in cesarean rates later in life.

Methods

As part of the Portuguese Generation XXI birth cohort we evaluated 7358 women with a singleton pregnancy who delivered at five Portuguese public hospitals serving the region of Porto (April/2005–September/2006). Based on the twelve items that described socioeconomic circumstances at age 12, a latent class analysis was used to classify women’s SEP-12 as high, intermediate and low. Multiple Poisson regression was used to estimate adjusted risk ratio (RR) and respective 95% confidence interval (95% CI).

Results

The cesarean rates in high, intermediate and low SEP-12 were, respectively, 40.9%, 37.5% and 40.5% (p = 0.100) among primiparous women; 14.2%, 11.6% and 15.5% (p = 0.04) among multiparous women with no previous cesarean and 78.6%, 72.2% and 70.0% (p = 0.08) among women with a previous cesarean. A low to moderate association between SEP-12 and cesarean rates was observed among multiparous women with a previous cesarean, illustrating that women from higher SEP-12 were more likely to have a surgical delivery (RR = 1.12;95%CI:1.01–1.24 comparing high with low SEP-12 and RR = 1.03:95%CI:0.94–1.14 comparing intermediate with low SEP-12) not explained by potential mediating factors. No such association was found either in primiparous or in multiparous women without a previous cesarean.

Conclusions

The association between SEP-12 and cesarean rates suggests the effect of past socioeconomic context on the decision concerning the mode of delivery, but only among women who experienced a previous cesarean. Accordingly, it appears that early-life socioeconomic circumstances drive cesarean rates but the effect can be modified by lived experiences concerning childbirth.

Birth control: to what extent do women report being informed and involved in decisions about pregnancy and birth procedures?

Background

Health policy, guidelines, and standards advocate giving patients comprehensive information and facilitating their involvement in health-related decision-making. Routine assessment of patient reports of these processes is needed. Our objective was to examine decision-making processes, specifically information provision and consumer involvement in decision-making, for nine pregnancy, labour, and birth procedures, as reported by maternity care consumers in Queensland, Australia.

Methods

Participants were women who had a live birth in Queensland in a specified time period and were not found to have had a baby that died since birth, who completed the extended Having a Baby in Queensland Survey, 2010 about their maternity care experiences, and who reported at least one of the nine procedures of interest. For each procedure, women answered two questions that measured perceived (i) receipt of information about the benefits and risks of the procedure and (ii) role in decision-making about the procedure.

Results

In all, 3,542 eligible women (34.2%) completed the survey. Between 4% (for pre-labour caesarean section) and 60% (for vaginal examination) of women reported not being informed of the benefits and risks of the procedure they experienced. Between 2% (epidural) and 34% (episiotomy) of women reported being unconsulted in decision-making. Over one quarter (26%) of the women who experienced episiotomy reported being neither informed nor consulted.

Conclusions

There is an urgent need for interventions that facilitate information provision and consumer involvement in decision-making about several perinatal procedures, especially those performed within the time-limited intrapartum care episode.

Cesarean delivery on maternal request: survey among obstetricians/gynecologists in south-east Hungary

Introduction: increased frequency of maternal request for cesarean delivery may be a contributing factor to the rising cesarean section rate in Hungary, although there is no formal indication that would allow Hungarian obstetricians to perform this procedure legally. Thus, it is difficult to estimate the role of maternal request in the rising cesarean rate. Aim: The aim of the authors was to assess the attitudes of obstetricians toward this procedure. Method: In early 2010 anonymous questionnaires were distributed to each of the 137 obstetricians working in the maternity wards of counties Bács-Kiskun, Békés and Csongrád, with a response rate of 74.5% (n = 102). Results: More than half of the respondents refused the possibility of a legalized indication for this procedure in Hungary; however, in case it was legalized, 81 (79.4%) obstetricians would feel ready to perform it. Conclusions: The resistance of more than half of the obstetricians to an explicit indication for the procedure is in conflict with the theoretical willingness of the majority of them to perform it. Orv. Hetil., 2013, 154, 1303–1311.

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.

The patient observer: eye-movement desensitization and reprocessing for the treatment of posttraumatic stress following childbirth

BACKGROUND

No standard intervention with proved effectiveness is available for women with posttraumatic stress following childbirth because of insufficient research. The objective of this paper was to evaluate the possibility of using eye-movement desensitization and reprocessing treatment for women with symptoms of posttraumatic stress disorder following childbirth. The treatment is internationally recognized as one of the interventions of choice for the condition, but little is known about its effects in women who experienced the delivery as traumatic.

METHODS

Three women suffering from posttraumatic stress symptoms following the birth of their first child were treated with eye-movement desensitization and reprocessing during their next pregnancy. Patient A developed posttraumatic stress symptoms following the lengthy labor of her first child that ended in an emergency cesarean section after unsuccessful vacuum extraction. Patient B suffered a second degree vaginal rupture, resulting in pain and inability to engage in sexual intercourse for years. Patient C developed severe preeclampsia postpartum requiring intravenous treatment.

RESULTS

Patients received eye-movement desensitization and reprocessing treatment during their second pregnancy, using the standard protocol. The treatment resulted in fewer posttraumatic stress symptoms and more confidence about their pregnancy and upcoming delivery compared with before the treatment. Despite delivery complications in Patient A (secondary cesarean section due to insufficient engaging of the fetal head); Patient B (second degree vaginal rupture, this time without subsequent dyspareunia); and Patient C (postpartum hemorrhage, postpartum hypertension requiring intravenous treatment), all three women looked back positively at the second delivery experience.

CONCLUSIONS

Treatment with eye-movement desensitization and reprocessing reduced posttraumatic stress symptoms in these three women. They were all sufficiently confident to attempt vaginal birth rather than demanding an elective cesarean section. We advocate a large-scale, randomized controlled trial involving women with postpartum posttraumatic stress disorder to evaluate the effect of eye-movement desensitization and reprocessing in this patient group.

On the cutting edge: ethical responsiveness to cesarean rates

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is at stake since a technological imperative undermines patients' ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates.

Effect of repeated public releases on cesarean section rates

OBJECTIVES

Public release of and feedback (here after public release) on institutional (clinics and hospitals) cesarean section rates has had the effect of reducing cesarean section rates. However, compared to the isolated intervention, there was scant evidence of the effect of repeated public releases (RPR) on cesarean section rates. The objectives of this study were to evaluate the effect of RPR for reducing cesarean section rates.

METHODS

From January 2003 to July 2007, the nationwide monthly institutional cesarean section rates data (1,951,303 deliveries at 1194 institutions) were analyzed. We used autoregressive integrated moving average (ARIMA) time-series intervention models to assess the effect of the RPR on cesarean section rates and ordinal logistic regression model to determine the characteristics of the change in cesarean section rates.

RESULTS

Among four RPR, we found that only the first one (August 29, 2005) decreased the cesarean section rate (by 0.81 percent) and continued to have an impact period through the last observation in May 2007. Baseline cesarean section rates (OR, 4.7; 95% CI, 3.1 to 7.1) and annual number of deliveries (OR, 2.8; 95% CI, 1.6 to 4.7) of institutions in the upper third of each category at before first intervention had a significant contribution to the decrease of cesarean section rates.

CONCLUSIONS

We could not found the evidence that RPR has had the significant effect of reducing cesarean section rates. Institutions with upper baseline cesarean section rates and annual number of deliveries were more responsive to RPR.

'Safe passage': pregnant Iranian Kurdish women's choice of childbirth method

AIM

This article is a report of a grounded theory study of the influence of emotions on women's selection of a method of childbirth.

BACKGROUND

There is substantial evidence to indicate that a pregnant woman's emotions play an important role in the decision-making process of selecting a child delivery method. Despite this, however, there is a notable lack of research about the relationship between pregnant women's emotions and their choice of a childbirth method in developing countries.

METHODS

A qualitative study using the grounded theory approach was conducted. The data were collected from 22 Iranian Kurdish pregnant women in their third trimester using semi-structured interviews. Concurrent data collection and analysis took place between 2008 and 2009. A cumulative process of theoretical sampling and constant comparison was used to identify concepts and then expand, validate, and clarify them.

FINDINGS

The substantive grounded theory that was identified from data analysis was 'safe passage'. 'Safe passage' involved five phases that were not mutually exclusive in their occurrence. The five phases of the 'safe passage' theory that were identified from the data analysis were: 'safety of baby', 'fear', 'previous experience', 'social support' and 'faith'. The goal of 'safe passage' was to achieve a healthy delivery and to ensure the health of the newborn.

CONCLUSION

'Safe passage' was a process used to determine how the emotions of pregnant Iranian Kurdish women influenced their choice of the mode of child delivery. More research is needed in this field to develop a body of knowledge beneficial to midwifery education and practice.

Influences on decision making among primiparous women choosing elective caesarean section in the absence of medical indications: findings from a qualitative investigation

OBJECTIVE

Patient-initiated elective Caesarean section (PIECS) is increasingly prevalent and is emerging as an urgent issue for individual maternity practitioners, hospitals, and policy makers, as well as for maternity patients. This qualitative study sought to explore women's experiences of the decision-making process leading to elective operative delivery without medical indication.

METHODS

We conducted 17 exploratory qualitative in-depth interviews with primiparous women who had undergone a patient-initiated elective Caesarean section in the absence of any medical indication. The study took place in five hospitals (three urban, two semi-rural) in British Columbia.

RESULTS

The findings revealed three themes within the process of women deciding to have a Caesarean section: the reasons for their decision, the qualities of the decision-making process, and the social context in which the decision was made. The factors that influenced a patient-initiated request for delivery by Caesarean section in participants in this study were diverse, culturally dependent, and reflective of varying degrees of emotional and evidence-based influences.

CONCLUSION

PIECS is a rare but socially significant phenomenon. The a priori decision making of some women choosing PIECS does not follow the usual diagnosis-intervention trajectory, and the care provider may have to work in reverse to ensure that the patient fully understands the risks and benefits of her decision subsequent to the decision having been made, while still ensuring patient autonomy. Results from this study provide a context for a woman's request for an elective Caesarean section without medical indication, which may contribute to a more efficacious informed consent process.

Institutional processes and individual responses: women's experiences of care in relation to cesarean birth

BACKGROUND

Cesarean section is an increasingly common mode of birth, and although clinical care has improved and the risks reduced, less attention has been paid to the effect of the procedure and the care received. The aim of this study was to gain a better understanding by investigating individual women's recent experiences and reflections on their care.

METHODS

Views of women who had recently undergone cesarean birth were obtained in a study in which a random sample of women was selected by means of birth registrations in England and invited to complete a questionnaire 3 months after the birth. Text responses to open-ended questions about care during labor and birth, the postnatal period in hospital, and anything else women wished to say about their maternity care were analyzed using qualitative methods.

RESULTS

A response rate of 63 percent was achieved; 23 percent of women (n = 682) had a cesarean section birth, 53 percent of which were because of unforeseen problems in labor. A total of 66 percent of women who had a cesarean section responded to one or more open questions. Anticipated themes that were confirmed related to expectations, uncertainty, emotional reactions, pain and discomfort, explanations, support, and adjustment. Emerging themes included "being heard,""how it might have been different,""wasted effort,""just another mother,""wounds and hurt feelings," and "needing to talk."

CONCLUSIONS

Women responded as individuals and despite different clinical circumstances, the role of the staff and the institutions in which care was provided were key factors in the way most women constructed their cesarean section experience. The themes described present a powerful argument and reminder about why health professionals working in maternity care need to continue to listen to women.

Decision making in patient-initiated elective cesarean delivery: the influence of birth stories

Patient-initiated elective cesarean delivery is emerging as an urgent issue for practitioners, hospitals, and policy makers and for pregnant women. This exploratory qualitative study looks at the birth stories and cultural knowledge that women use to inform the decision about an elective cesarean without medical indication. Data collection consisted of exploratory qualitative in-depth interviews with 17 primiparous women in British Columbia, Canada. Interviews revealed the influence of socially circulated birth stories and cultural narratives on their attitudes towards mode of delivery. Participants included in their decision making process both medical information and informal birth stories that were technologically inclined and confirmed their preference for cesarean delivery. Results indicate that women who participated in this study drew heavily from social and cultural knowledge in forming their decision to give birth by patient-initiated elective cesarean delivery. Although the numbers of women who request a cesarean delivery for social reasons is still small, the persuasive influence on parturient women of positive cesarean stories and negative vaginal stories must be considered. Care providers and childbirth educators need to become familiar with the social influences impacting women's decisions for mode of delivery so that truly informed choice discussions can be undertaken.

An exploratory study of women's experiences and key stakeholders views of moxibustion for cephalic version in breech presentation

A phenomenological research approach was taken to explore women's feelings and experiences of using moxibustion for cephalic version in breech presentation. Eight women with an uncomplicated breech presentation at term were offered moxibustion. Qualitative interviews were carried out before and after the treatment and women completed daily logs of their experiences. Women experienced anxieties about the implications of breech presentation and the options offered to them. All women carried out the treatment successfully and overall experiences were positive. Compliance was excellent and women reported few negative effects. The partner's co-operation was important to ensure that the procedure was carried out effectively and safely. Key stakeholders were also interviewed to determine their views on the requirements of implementing moxibustion into the maternity services. The need for research evidence of effectiveness was a priority. In addition, a number of practical issues are suggested for consideration in the implementation of a service or in future research designs.

Decision support for women choosing mode of delivery after a previous caesarean section: a developmental study

OBJECTIVE

To examine the impact of a decision support intervention designed for women choosing mode of delivery after one previous caesarean section.

METHODS

A decision support intervention was developed comprising of an informational DVD/video and a home visit by a midwife. 16 women received standard clinical care and 16 women additionally received the intervention. Pilot questionnaire data was collected at 12, 28 and 37 weeks gestation from all participants. 18 of the 32 participants also participated in semi-structured interviews after they had decided mode of delivery at 37 weeks gestation.

RESULTS

Four themes were identified in the qualitative data relating to decision-making: informational support, emotional support, participation and involvement in decision-making, and the way in which decision support was used.

CONCLUSION

The difficulties experienced by women in this decision-making scenario were confirmed. The intervention was welcomed by the participants and both qualitative and quantitative findings suggest the intervention improved decision-making experiences.

PRACTICE IMPLICATIONS

This intervention offers an accessible method of decision support which effectively targets the needs of women choosing mode of delivery after a previous caesarean delivery. Using easily reproducible informational materials, and the pre-existing skills of midwives, it would be relatively straightforward to introduce this intervention into current clinical practice.

How much influence do women in Sweden have on caesarean section? A follow-up study of women's preferences in early pregnancy

OBJECTIVE

to investigate factors associated with having a caesarean section, with special emphasis on women's preferences in early pregnancy.

DESIGN

a cohort study using data from questionnaires in early pregnancy and 2 months after childbirth, and data from the Swedish Medical Birth Register.

SETTING

women were recruited from 97% of all antenatal clinics in Sweden at their booking visit during 3 weeks between 1999 and 2000, and followed up 2 months after birth.

PARTICIPANTS

a total of 2878 Swedish-speaking women were included in the study (87% of those who consented to participate and 63% of all women eligible for the study).

FINDINGS

Of 236 women who wished to have their babies delivered by caesarean section when asked in early pregnancy, 30.5% subsequently had an elective caesarean section and 14.8% an emergency caesarean section. The logistic regression analyses showed that, a preference for caesarean section in early pregnancy (odds ratio [OR] 9.63, 95% confidence interval [CI] 5.94-15.59), a medical diagnosis (OR 9.03, 95% CI 5.68-14.34), age (OR 1.08, 95% CI 1.03-1.13), parity (OR 0.58, 95% CI 0.37-0.91), a previous elective caesarean section (OR 15.11, 95% CI 6.83-33.41) and a previous emergency caesarean section (OR 18.29, 95% CI 10.00-33.44) was associated with having an elective caesarean section. Having an emergency caesarean section was associated with a preference for a caesarean section (OR 2.59, 95% 1.61 to 4.18), a medical diagnosis (OR 4.12, 95% CI 2.91-5.88), age (OR 1.08, 95% CI 1.05-1.12), primiparity (OR 3.34, 95% CI 1.78-6.27), a previous emergency caesarean section (OR 10.69, 95% CI 6.03-18.94), and a previous elective caesarean section (OR 7.21, 95% CI 2.90-17.92).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

a woman's own preference about caesarean section was associated with the subsequent mode of delivery. Asking women about their preference regarding mode of delivery in early pregnancy may increase the opportunity to provide adequate support and possibly also to reduce the caesarean section rate.

Is preparation for emergency obstetric anaesthesia adequate? A maternal questionnaire survey

BACKGROUND

Women are often unprepared for emergency obstetric procedures and need to receive information about anaesthesia quickly and succinctly. In the absence of previous studies, we sought feedback from women to find out how information was given, and particular areas of concern in order to define practice and improve women's experiences.

METHODS

After Ethics Committee approval this prospective structured questionnaire study was conducted in a teaching and a district general hospital. Women were recruited up to 48 h after anaesthesia.

RESULTS

Of 102 women studied, 55 had no prior knowledge of obstetric anaesthetic interventions and risks until told, usually by the obstetrician (n=47), just before the procedure. The most frightening aspect was anticipating the efficacy of regional anaesthesia (n=18), but 28 women were reassured by the explanation provided by the anaesthetist. All but two women expressed satisfaction with the content of information and the described attendant risks. Nevertheless, in contrast to our observed practice, 51 (50%) would have preferred having verbal information before labour preferably from an anaesthetist or midwife.

CONCLUSIONS

Most women were unprepared for emergency obstetric anaesthesia. Many received information just before the event. After delivery they expressed a clear preference for earlier information.

Minding the shop: The case of obstetrics conferences

We estimate the impact of annual obstetricians and gynecologists' conferences on births in Australia and the United States. In both countries, the number of births drops by 2-4 percent during the days on which these conferences are held. Since it is unlikely that parents take these conferences into account when conceiving their child, this suggests that medical professions are timing births to suit their conference schedule. We argue that for this reason professional obstetrics societies should reconsider the timing of their annual conferences to accommodate the lowest natural birth rate in the year.

Why are the rates of cesarean section in Brazil higher in more developed cities than in less developed ones?

The objective of the present study was to investigate factors associated with cesarean sections in two cities located in different regions of Brazil and to determine factors that explain the higher cesarean section rate in the more developed city, Ribeirão Preto, compared to the less developed one, São Luís. Data from two cohort studies comprising 2846 women in Ribeirão Preto in 1994, and 2443 women in São Luís in 1997/1998 were used. Adjusted and non-adjusted risk estimates were calculated using a Poisson regression model. The cesarean section rate was 33.7% in São Luís and 50.8% in Ribeirão Preto. Adjusted analysis in a joint sequential model revealed a 51% higher risk of cesarean section in Ribeirão Preto compared to São Luís (prevalence rate ratio (PRR) = 1.51). Adjustment for category of hospital admission reduced the PRR to 1.09, i.e., this variable explained 82% of the difference in the cesarean section rate between the two cities. Adjustment for the variable "the same physician for prenatal care and delivery" reduced the PRR to 1.07, with the "physician" factor explaining 86% of the difference between rates. When simultaneously adjusted for the two variables, the PRR decreased to 1.05, with these two variables explaining 90% of the difference in the cesarean section rate between the two cities, and the difference was no longer significant. The difference in the cesarean section rate between the two Brazilian cities, one more and one less developed, was mainly explained by the physician factor and, to a lesser extent, by the category of hospital admission.

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

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

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study

OBJECTIVE

To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section.

MAIN OUTCOME MEASURES

The evolution of decision making, women's participation in decision making, and factors affecting decision making.

DESIGN AND METHODS

A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.

SETTING

An antenatal unit in a large teaching hospital in Scotland and participants' homes.

SAMPLE

Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.

RESULTS

Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section.

CONCLUSION

Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.

The policy environment encouraging C-section in Lebanon

OBJECTIVE

This study aims to analyse the environment encouraging C-section in Lebanon and to reveal approaches that could be adopted for the reduction of this practice, by considering the attitudes, opinions and actions of different stakeholders.

METHODS

Semi-structured interviews were conducted with 20 selected key players, including hospital directors, midwives, insurance bodies, syndicates and scientific societies, ministries, international agencies, medical schools, media representatives and women's groups. In addition, a group discussion was conducted with 10 obstetricians. Semi-structured interviews were conducted with a convenience sample of 36 women who had a C-section within 4 months preceding the study. Data was analysed using the Policy Maker software version 2.3.

RESULTS

Findings of the study point to the role of multiple factors in shaping the current practices related to C-section deliveries, among which are the organisation of the health care system, the dominance of the private sector, the lack of physician accountability, the minimisation of midwives' roles in the process and women's misconceptions about C-sections.

CONCLUSIONS

Involvement of the diversity of players is important to change practices in maternity care in Lebanon, after considering their position and power. Different strategies making use of available opportunities to improve the current situation are discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Factors associated with preference for cesarean delivery]

OBJECTIVE

To study factors related to preference for cesarean delivery, among pregnant women without medical complications.

METHODS

A cross-sectional study was carried out among 156 pregnant women, in a private clinic in the city of Osasco, State of São Paulo, from October 2000 to December 2001. The pregnant women were at 28 weeks of pregnancy or more, with no formal contraindication for vaginal delivery at the time of the interview. Sociodemographic data and past and present obstetric history were assessed by applying a questionnaire. The pregnant women were specifically asked what their current preference for delivery was. Pearson's Chi-square test and logistic regression for multivariate analysis were performed with a 5% significance level.

RESULTS

Sixty-seven pregnant women (42.9%) said they had little motivation to undergo vaginal delivery. In the multivariate analysis, the following variables were statistically significant: previous vaginal birth (p=0.001; ORadj=0.04; 95% CI=0.01-0.12); husband's monthly income greater than 750 reais (p=0.006, ORadj=3.44; 95% CI=1.38-8.33). The women with a previous vaginal delivery presented 25-fold lower chance of choosing cesarean delivery. The opinion that the previous delivery experience was unsatisfactory was marginally associated with the main outcome (p=0.06; ORadj=0.42; 95% CI=0.16-1.05).

CONCLUSIONS

Motivation for cesarean delivery is associated with influences such as the type and degree of satisfaction with previous delivery and income.

The development and process evaluation of an information-based intervention for pregnant women aimed at addressing rates of caesarean section

OBJECTIVE

Few strategies aimed at addressing rising rates of caesarean section have explicitly involved information-based approaches for pregnant women. This study describes the development and evaluation of such an intervention for pregnant women, encompassing pamphlets and a peer support network (PSN).

DESIGN

Process evaluation.

SETTING

The study was undertaken at a metropolitan teaching hospital in Adelaide, South Australia.

POPULATION

A consecutive sample of pregnant women attending the ultrasound clinic over a two-month period, recruited at 18 weeks of gestation.

METHODS

Participants received two pamphlets at 18 weeks of gestation and information on a PSN at around 28 weeks of gestation. A questionnaire was sent to women at seven weeks postnatal, asking them to evaluate the intervention.

MAIN OUTCOME MEASURES

The extent to which the intervention resources were used and participants were satisfied with the resources they received.

RESULTS

Ninety-two women returned questionnaires (response rate of 62%). Women generally resisted engaging with the informational resources, citing irrelevance to their situation, for example, 53% (49/92) read all of the pamphlets. None of the women used the PSN. Women who had experienced childbirth previously and those of higher education were significantly more likely to read the pamphlets. While generally satisfied with pamphlet content, one in five women reported feeling distressed by some of the information.

CONCLUSIONS

This exploratory study casts doubt on the notion of information provision for pregnant women as a panacea for addressing rising rates of caesarean section.

Are league tables controlling epidemic of caesarean sections in South Korea?

OBJECTIVE

To assess the impact of the publication of hospital caesarean section rates on the reduction of these rates in South Korea, and explore associated factors contributing to the decrease.

DESIGN

Observational study.

SETTING

South Korea.

SAMPLE

Two hundred and sixty-three hospitals in South Korea.

METHODS

The caesarean section rates of 263 hospitals, before and after the release of caesarean section rates to the public, were obtained. The factors influencing the reduction in hospital caesarean section rates were also explored using multiple logistic regression.

MAIN OUTCOME MEASURE

Hospital caesarean section rates.

RESULTS

After the release of information in 2000, the total (clinic and hospital) caesarean section rates in 2000 and 2001 decreased to 38.6% and 39.6%, respectively, from 43.0% in 1999. Caesarean section rates for hospitals were 45.9%, 42.7% and 44.6% in 1999, 2000 and 2001, respectively. Hospitals with the highest baseline caesarean section rates (OR 9.4, 95% CI 4.2-21.0) and highest number of deliveries (OR 8.1, 95% CI 2.1-31.1) were significant factors contributing independently to a decrease in caesarean section rates. Market share, competition, characteristics of revenue generation and ownership did not significantly influence the change of rates.

CONCLUSION

The public release of information on caesarean section rates in Korea has reversed the ever-increasing trend in these rates. Hospitals with pre-existing high caesarean section rates or a larger number of deliveries were influenced by the information release and could be the main targets for interventions to decrease these rates.

Essences and imperatives: an investigation of technology in childbirth

This paper explores the connection between our cultural inclination towards technology, the nature of technology itself, and birthing women's attitudes towards obstetrical technology using an analytical framework that includes literature on the philosophy of technology, as well as the sociology of childbirth. Data were gathered using a survey instrument and semi-structured interviews to contrast women's attitudes towards technology and experiences of childbirth in a large Canadian city: 25 women who planned a home birth assisted by a midwife and 25 low-risk women who planned a hospital birth. The results reveal that the total number of interventions the women experienced correlates in part to their attitudes towards technology: resistance to it on the part of home birthers and flexibility on the part of hospital birthers. Home birthers' resistance to technology stemmed from a consciousness of its overuse which blocks awareness of a sacred and authoritative "birthing force". Rather than rejecting technology, however, home birthers made conscious decisions about its appropriate use and relied upon access to a range of secondary technologies.

Study of subjectivity in the perception of cesarean birth

This study defined the structural patterns of subjectivity in the perception of cesarean birth. Q methodology was used on 71 statements collected through interviews with seven persons and a literature review followed. Twenty-nine Q samples were selected and administered to 22 persons, and four types of subjectivity were revealed by the QUANL PC Program. Type 1, or the 'naturalist', is characterized by a passive tendency and dislikes artificial methods, feeling that they are performed for hospital income and the trend for social preference. Type 2, 'logical thinker', thinks that cesarean birth should be selected if there are obstetric complications and severe anxiety about labor, even though it results in low intimacy with the baby. Type 3, 'maternal instinctivism', values the maternal-baby relationship and the sense of accomplishment from childbirth. Type 4, 'egocentric', thinks that cesarean section should be chosen when the woman has severe anxiety about labor or when the obstetric condition becomes dangerous. Before commencement of the patient's labor pains, the nurses and medical personnel who are participating in the delivery should assess the structural pattern on parturient woman's subjectivity in the perception of cesarean section. As a further step, they should encourage the woman and her family to participate in the decision-making process for considering the type of delivery the mother wants.

Association of Acculturation with Cesarean Section among Latinas

OBJECTIVES

Examine the association of acculturation and cesarean section after adjusting for clinical and non-clinical factors that could influence clinical discretion in performing the surgery.

METHODS

A sample of 2102 low-risk, low-income primarily Mexican Latinas in San Diego County was divided into two groups: primiparas and multiparas. For each parity group, logistic regression was used to assess the association of acculturation and cesarean section.

RESULTS

Among multiparous Latinas, the risk of cesarean section for highly acculturated women exceeded the risk for the less-acculturated women, but the result was reverse for primiparous women. The adjusted relative odds of cesarean section were twice as high [OR 2.1, 95%CI 1.1-4.1] for multiparous US-born Latinas relative to multiparous Spanish-speaking women born in Mexico. While for primiparous women this same comparison showed US-born Latinas to be approximately half as likely to have a cesarean delivery [OR 0.4, 95%CI 0.2-0.7].

CONCLUSIONS

In order to reduce the chances of unnecessary cesarean sections among Latinas, the role of acculturation in women who have and have not already given birth needs to be investigated further.

The DiAMOND trial protocol: a randomised controlled trial of two decision aids for mode of delivery among women with a previous caesarean section [ISRCTN84367722]

Background

Caesarean section (CS) has become an increasingly common method of delivery worldwide, rising in the UK from 9% of deliveries in 1980 to over 21% 2001. This increase, and the question of whether CS should be available to women on request, has been the subject of considerable debate, and national reports and guidelines have specifically highlighted the importance of patient choice in the decision making process. For women who have already experienced CS, the UK National Institute of Clinical Excellence recommends that the decision should consider maternal preferences and priorities in addition to general discussion of the overall risks and benefits of CS. Decision aids for many different medical treatment and screening decisions have been developed and evaluated, but there is relatively little evidence for the use of decision aids for choice of mode of delivery among women with a previous CS. The aim of the study is to evaluate two interventions to assist decision making about mode of delivery among pregnant women with one previous CS.

Methods/design

Women with one previous CS are recruited to the trial during their booking visit at approximately 12–20 weeks' gestation in participating maternity units in Bristol, Weston and Dundee. Using central randomisation, women are allocated to one of three arms: information programme and website; decision analysis; usual care. Both interventions are computer-based, and are designed to provide women with detailed information about the potential outcomes for both mother and baby of planned vaginal delivery, planned CS and emergency CS. The decision analysis intervention additionally provides a recommended 'preferred option' based on maximised expected utility. There are two primary outcomes (decisional conflict and actual mode of delivery), and five secondary outcomes (anxiety, knowledge, perceptions of shared decision making; satisfaction with decision making process, proportion of women attempting vaginal delivery). Primary follow up for the questionnaire measures is at 36–37 weeks' gestation, and a total of 660 women will be recruited to the study. The primary intention-to-treat analyses will comprise three pair-wise comparisons between decision analysis, information and usual care groups, for each of the two primary outcomes. A qualitative study will investigate women's experiences of the decision making in more depth, and an economic evaluation from the perspective of the NHS will be conducted.

Discussion

Provision of information to women facing this decision appears variable. The DiAMOND study aims to inform best practice in this area by evaluating the effectiveness of two interventions designed to aid decision making.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.

Pregnant women's preferences and knowledge of term breech management, in an Australian setting

OBJECTIVE

To assess women's familiarity with breech presentation and external cephalic version (ECV), and to identify women's preferences and attitudes regarding breech management.

DESIGN

Cross-sectional survey.

SETTING

King George V (KGV) Memorial Hospital for Mothers and Babies, Sydney, Australia, a major metropolitan teaching hospital.

POPULATION

174 pregnant women (20-38 weeks gestation) attending KGV for antenatal care in 2001.

METHODS

Data were obtained from a self-administered questionnaire that was distributed through the antenatal clinics.

MAIN OUTCOME MEASURES

Women's familiarity of breech presentation and ECV, women's attitude towards ECV, decision to attempt ECV, and with whom participants would like to make a decision regarding ECV.

FINDINGS

Of the 174 respondents, 85% could correctly identify breech presentation, and 66% had heard of ECV. For 87% this information was from books, and family/friends, and not their midwife/doctor. Equal numbers of women responded that they would or would not choose ECV (39%), and the remaining 22% were uncertain. Factors influencing their decision included concerns about the safety for the baby, ECV not guaranteeing vaginal birth despite successful version, and ECV not being effective enough. Seventy-two per cent wanted to make the decision to attempt ECV together with their doctor.

CONCLUSION

Although the majority of the women had a preference for vaginal birth, their knowledge of ECV appeared insufficient to enable them to make informed decisions about attempting ECV. These findings suggest that care-providers should offer women information on ECV, in a shared-decision-making environment.

Women's attitudes toward mode of delivery in South Korea--a society with high cesarean section rates

BACKGROUND

In South Korea, cesarean section rates (i.e., the proportion of all live births delivered by cesarean section) approached 40 percent in 2000. The relative contribution of physicians and women to this high rate has been a source of debate. This study explored attitudes toward mode of delivery among South Korean women.

METHODS

A nationwide cross-sectional telephone survey of 505 Korean women aged 20 to 49 years was conducted using a proportionate quota and systematic random sampling method. The response rate was 57.3 percent. Data were collected using a structured questionnaire consisting of 7 questions about vaginal and cesarean delivery.

RESULTS

Over 95 percent of women preferred vaginal delivery during pregnancy and were willing to recommend this method to others. Of the women who delivered by cesarean section, 10.6 percent stated that they had requested a cesarean birth. Attitudes toward vaginal or cesarean delivery differed significantly according to a woman's education level.

CONCLUSIONS

Most study participants showed more favorable attitudes toward vaginal delivery than cesarean delivery. This result does not support the assumption that the upsurge of cesarean section rates in South Korea is associated with women's positive attitudes toward cesarean section. The main cause of the rapid rise of cesarean section rates in South Korea during the past two decades have its origins in health care practitioners and the health care system in which they work.

Women’s Views Regarding Participation in a Proposed Randomized Controlled Trial of Twin Delivery

OBJECTIVE

To determine the views of women regarding participation in a proposed multicentre randomized controlled trial comparing planned vaginal birth to planned Caesarean delivery for twins at 32 or more weeks' gestation, in which the first twin (twin A) is presenting as a vertex.

METHODS

Pregnant women with a known twin gestation were recruited from 2 hospital centres. Written information was provided about the proposed Twin Birth Study, and the women were then requested to complete a questionnaire to determine their views regarding participation in the proposed trial.

RESULTS

Of the 64 women recruited for the study, 31 (48%) indicated they would be willing to consider participating in the proposed trial (95% CI, 37-60%), 14 (22%) were unsure about trial participation (95% CI, 13-33%), and 19 (30%) indicated they would not be willing to participate in the proposed study (95% CI, 20-42%). The most common reason for agreement to participation was altruism (n = 28). Those who responded "not sure" wished to speak with their partner (n = 5) or their doctor (n = 8) before deciding on participation. Of those who indicated they would not participate in the proposed trial, 12 (63%) indicated they preferred to have a vaginal birth, and 7 (37%) preferred to have a Caesarean section.

CONCLUSIONS

Almost half the women in our sample were agreeable to considering their participation in a randomized trial that will compare planned vaginal birth to planned Caesarean section for twins at 32 or more weeks' gestation with twin A presenting as a vertex. Altruism was the most common reason for agreeing to participate, whereas preference for a specific mode of delivery was the most common reason for declining participation.