Women's Psychological Adjustment Following Emergency Cesarean Versus Vaginal Delivery

The relationship between birth satisfaction, posttraumatic stress disorder and postnatal depression symptoms in Croatian women

Studies show that a woman's dissatisfaction with her birth experience may affect her well-being. This study aimed to examine: (1) the birth satisfaction in Croatian women and compare it with UK normative data; (2) the association of different dimensions of birth satisfaction with posttraumatic stress disorder (PTSD) and depressive symptoms. In a cross-sectional online study, 603 postnatal Croatian women completed the Birth Satisfaction Scale-Revised (subscales: Stress experienced during labour (SL), Women's personal attributes (WA), and Quality of care provision (QC)); City Birth Trauma Scale (subscales: Birth-related symptoms and General symptoms); and Edinburgh Postnatal Depression Scale. Subscale and total scale scores were calculated. Path analysis tested the model of three aspects of birth satisfaction effect on PTSD dimensions and depressive symptoms. The average birth satisfaction score was significantly lower compared to the UK data on the total scale and all three subscale scores. Path analysis revealed that all three dimensions of birth satisfaction (SL, WA, and QC) had an effect on Birth-related symptoms. However, only Women's personal attributes (i.e., feeling anxiety or being in control during childbirth) had an effect on General symptoms and depressive symptoms, as well. Different aspects of birth satisfaction are important for maternal mental health following childbirth.

Measuring women's childbirth experiences: a systematic review for identification and analysis of validated instruments

BACKGROUND

Women's childbirth experience can have immediate as well as long-term positive or negative effects on their life, well-being and health. When evaluating and drawing conclusions from research results, women's experiences of childbirth should be one aspect to consider. Researchers and clinicians need help in finding and selecting the most suitable instrument for their purpose. The aim of this study was therefore to systematically identify and present validated instruments measuring women's childbirth experience.

METHODS

A systematic review was conducted in January 2016 with a comprehensive search in the bibliographic databases PubMed, CINAHL, Scopus, The Cochrane Library and PsycINFO. Included instruments measured women's childbirth experiences. Papers were assessed independently by two reviewers for inclusion, and quality assessment of included instruments was made by two reviewers independently and in pairs using Terwee et al's criteria for evaluation of psychometric properties.

RESULTS

In total 5189 citations were screened, of which 5106 were excluded by title and abstract. Eighty-three full-text papers were reviewed, and 37 papers were excluded, resulting in 46 included papers representing 36 instruments. These instruments demonstrated a wide range in purpose and content as well as in the quality of psychometric properties.

CONCLUSIONS

This systematic review provides an overview of existing instruments measuring women's childbirth experiences and can support researchers to identify appropriate instruments to be used, and maybe adapted, in their specific contexts and research purpose.

Anger After Childbirth: An Overlooked Reaction to Postpartum Stressors

Other than postpartum depression, little is known about women's emotional responses to childbirth and subsequent stressors. Anger was explored on the basis of theory and evidence that it is a likely emotional response in this context. During their third trimester of pregnancy and approximately six weeks after delivery, 163 participants completed the Beck Depression Inventory and the anger subset of the Affect Balance Scale. A number of childbirth-relevant variables were examined as predictors of postpartum emotional response, controlling for prepartum levels and for the association between anger and depressed mood. As expected, a substantial group of women reported high levels of anger irrespective of depressed mood. Although the majority of variables predicted depressed mood, childcare stress, age, and religious self-identification were independently predictive of postpartum anger (all p values > .05). Implications for research and clinical intervention are discussed.

A Rasch-based dimension of delivery experience: spontaneous vs. medically assisted conception

AIMS AND OBJECTIVES

To devise a set of indices representative of a latent dimension of delivery perception, aimed at the assessment of birth experience after both spontaneous and medically assisted conception.

BACKGROUND

Birth experience is of great importance for its prognostic value for the woman and newborn's psychophysical well-being, especially after the experience of assisted reproduction technology. Up to date, a delivery perception assessment measure targeted to both spontaneously and medically assisted conceiving women does not exist yet.

DESIGN

Measure development and psychometric analysis; quantitative and qualitative analysis of women's delivery experience measures.

METHODS

Thirty-one indices characterising seven relevant aspects of birth perception were devised from the literature and evaluated on a 4-point Likert-type scale by 98 childbearing women (54 spontaneously and 44 medically assisted conceiving) in the 24-48 hours postpartum time frame. Women's obstetric history information was also collected. The dimension psychometric definition was pursued within a latent trait perspective, by applying the many-facet Rasch measurement model.

RESULTS

A latent delivery perception dimension composed of 18 valid and reliable indices, qualifying six labour and delivery perception clinical aspects, was identified. Medically assisted conceiving women evidenced a more positive birth perception, but when analysing each index, they showed peculiar intense worries about themselves and their baby's health, even if they felt more satisfied, safer and stronger in almost every labour and birth aspect.

CONCLUSIONS

The delivery perception dimension integrates all relevant birth experience aspects in 18 easy-to-administer indices and provides a valid, reliable and feasible assessment tool for both the clinical practice and research purposes.

RELEVANCE TO CLINICAL PRACTICE

The delivery perception dimension clearly discriminates between women's types of conception and identifies relevant differences in their birth experience, which are interesting for their clinical implications within a prognostic and intervention perspective of support provision in the early postpartum period.

The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study

The aim of this prospective study was to examine the etiology of post-traumatic stress symptoms following childbirth within a transactional framework of stress. Participants were women (N = 1,499) from the Akershus Birth Cohort. These women were followed from pregnancy to 8 weeks postpartum. We modeled predisposing factors (e.g., fear of childbirth) and precipitating factors (subjective and objective birth experiences) as predictors of post-traumatic stress symptoms. Post-traumatic stress symptoms were measured by means of the Impact of Event Scale, objective birth experiences by means of birth journals, and subjective birth experiences by means of three questions. A structural equation model showed that subjective birth experiences had the highest association with post-traumatic stress symptoms. Moreover, they mediated the effect of predisposing factors and objective birth experiences. The results suggest that women's subjective birth experiences are the most important factor in the development of post-traumatic stress symptoms following childbirth.

Cesarean section and postpartum depression: a review of the evidence examining the link

OBJECTIVE

The objective of this study was to examine the evidence for an association between cesarean section and postpartum depression.

METHODS

Medline and PsychInfo databases were searched. All studies on cesarean section that evaluated maternal mood between 10 days and 1 year after delivery were reviewed. Nine methodologically superior studies, including the only randomized, controlled trial (RCT), were analyzed separately. The nine studies that provided adequate summary statistics were combined in a meta-analysis.

RESULTS

Of the 24 studies that have examined the association between cesarean section and postpartum depression, five found a significant adverse association, 15 found no significant association, and four found mixed results. With only one exception, methodologically superior studies found either no significant association or mixed evidence for an association between cesarean section and postpartum depression. Meta-analyses of suitable studies failed to find evidence for a significant association between cesarean section and postpartum depression. Possible reasons why different studies have obtained different results are critically evaluated.

CONCLUSION

A link between cesarean section and postpartum depression has not been established.

Cesarean section on demand

The safety of cesarean section has improved dramatically over the past 50 years. During the past 20 years a greater awareness of and discussion about the symptomatic morbidity that can result for women following vaginal delivery has occurred and women's expectations for the outcome of pregnancy for them and their babies has increased. A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by cesarean section rather than the reverse. With the balance in favor of benefit for the baby from delivery by cesarean section, it is now difficult to sustain the argument favoring vaginal delivery rather than planned cesarean section, using maternal morbidity and mortality statistics. A critical evaluation of the costs indicates that there are probably few grounds for denying women their request for cesarean section for economic reasons. It seems likely, therefore, that in the near future those advising women on the options for delivery will need to ensure that the risks of vaginal delivery are explained as well as those for planned cesarean section.

Exploring factors influencing Chinese women's decision to have elective caesarean surgery

OBJECTIVES

to identify the factors that influence Hong Kong Chinese women's decision to have an elective caesarean section. To explore Chinese women's perceptions of their autonomous involvement in childbirth decision-making.

DESIGN

a qualitative exploratory design.

SETTING

a postnatal ward of a private hospital in Hong Kong.

PARTICIPANTS

a purposive sample of six postnatal women who had undergone an elective caesarean section.

FINDINGS

four thematic categories were identified including: avoiding fetal and maternal risks, exercising autonomy to make an independent choice, Chinese belief systems, and rejoicing and regretting.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

we propose the provision of a 'named' midwife and continuity of care. Improving the availability of information on caesarean sections, accommodating a Chinese belief system in the planning of midwifery services at the international level and establishing post caesarean section peer support groups are recommended.

Psychological aspects of caesarean section

This chapter gives an overview of research relating to psychological aspects of caesarean section. It focuses on four main questions: *What are the psychological effects of caesarean section on the mother, her partner and her relationship with her infant? *What factors (obstetric, psychological, attitudinal, and health care-related) make women more vulnerable to adverse psychological outcomes after a caesarean section? *What are women distressed about when they have had a caesarean section? *How can post-caesarean psychological distress be prevented or managed?A methodological critique of existing studies on psychological aspects of caesarean section is also given. In conclusion, recommendations for practice and for future research are made.

Sequelae of cesarean and vaginal deliveries: psychosocial outcomes for mothers and infants

Mother-infant dyads grouped according to whether the infants had been delivered vaginally (n = 74) or by planned (n = 37) or unplanned cesarean (n = 56) were compared on psychosocial outcomes at 4 and 12 months postpartum. Hypotheses were that unplanned cesarean delivery would be related to less optimal outcomes and that this relationship would be mediated by mother's appraisal of the delivery and would attenuate over time. No delivery-related differences in mother-infant interactions were found at 4 or 12 months postpartum with one exception: Women low in neuroticism who delivered by unplanned cesarean showed less positive affect toward their infants at 4 months than did women high in neuroticism who delivered by unplanned cesarean or women in any other group. There was some evidence of the mediating role of maternal appraisal of the delivery on these effects. In general, the results indicate little cause for concern about the quality of mother-infant interactions following cesarean deliveries.

Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study

OBJECTIVE

This paper reports the findings of a prospective longitudinal study of 272 nulliparous pregnant women, which investigated as one of its objectives the psychological sequelae of obstetric procedures.

METHOD

Participants completed structured interviews and standardised, published psychometric questionnaires, including the Rosenberg Self-Esteem Scale and the Profile of Mood States late in pregnancy and again early in the postpartum period.

RESULTS

Little evidence was found to support the notion that the total number of obstetric interventions was linked to a deterioration in postpartum mood. Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem.

CONCLUSIONS

The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression.

College students' knowledge and attitudes about cesarean birth

BACKGROUND

Numerous clinicians and researchers have expressed concern about the necessity and potential adverse consequences of many cesarean births in the United States. The purpose of this study was to explore college students' attitudes and beliefs about cesarean section.

METHODS

One hundred two college students (66% women) completed a 20-item questionnaire that asked if they viewed cesarean delivery as a potentially negative experience, as a normal or acceptable method of childbirth, and as medically necessary, and asked about their beliefs concerning risk and prevention of cesarean birth.

RESULTS

The number of "undecided" responses in the study was striking (7.8% to 69.6% across the 20 items). In general, women and men responded similarly, although women were significantly more likely than men to say they would be profoundly disappointed if their babies had to be delivered by cesarean section. Despite expressing cynicism about the cesarean birth rate (40% agreed that many unnecessary cesarean births occurred) and not viewing the procedure as a normal way of giving birth (47%), most respondents (over 70%) disagreed that giving birth by cesarean would be a negative experience or would make a woman feel like a failure.

CONCLUSION

A high level of uncertainty exists about certain aspects of cesarean birth among young women and men, highlighting the need for information for prospective parents. Most college students did not view the cesarean birth experience as either potentially negative or normal. Future research should explore coverage of cesarean birth in childbirth education classes and the roles physicians, nurses, and midwives play in preparing expectant parents for the possibility of cesarean delivery.

Psychosocial impact of cesarean section on the family: a literature review

This paper reviews the literature linking cesarean section with maternal, paternal and infant/child/familial psychosocial impact. Cesarean section is discussed as both major surgery, with concomitant physical and psychosocial ramifications, and as an increasingly and routinely utilized method of birthing. Also considered are factors associated with the current high cesarean birthrate, as well as socio-cultural based factors contributing to varying parental conceptualizations and expectations of birthing. Empirical research published during the past 14 years associates cesarean section with adverse maternal and paternal psychosocial outcome and with possible negative consequences for the infant/child. Weaknesses/flaws of psychosocial impact studies are discussed, including timing and location of data collection, sample bias, and the difficulties of analyzing vast arrays of complex variables. Enumeration of both physical/environmental variables and psychosocial/cultural variables of maternal psychosocial impact are included. A number of these variables form a profile of a woman at relatively high risk of adverse psychosocial outcome. This profile is useful in identification of approaches and strategies for the prevention of adverse psychosocial outcome as well as in the identification of women who might benefit from focused perinatal psychotherapeutic services. The importance of psychotherapeutic services for cesarean families, including local, national and international cesarean support networks, is discussed. Emphasis is given to the importance of increased awareness of psychosocial issues and of current research on the part of medical care providers and health policy experts.

Women's perceptions of cesarean and vaginal delivery: another look

Perception of the birth experience was examined in a sample of 106 women who had unplanned cesarean deliveries, 113 who had planned cesarean deliveries, and 254 who had vaginal deliveries. Vaginally delivered women had more positive perceptions than their unplanned cesarean counterparts (p < .001). There were no differences in perceptions between the unplanned and planned cesarean groups, or between the planned cesarean and vaginal groups. General anesthesia for cesarean delivery was associated with more negative perceptions than regional anesthesia, and regional anesthesia for vaginal delivery was associated with more negative perceptions than no or local anesthesia. Pain intensity and physical distress were negatively correlated with perceptions.