"Cesarean Delivery on Maternal Request": was the NIH conference based on a faulty premise?

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status

OBJECTIVES

Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status.

METHODS

Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms.

RESULTS

Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured.

CONCLUSIONS

There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.

Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae

Objective:

Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched.

Methods:

A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs.

Results:

Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support.

Conclusions:

The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

An analysis of variations of indications and maternal-fetal prognosis for caesarean section in a tertiary hospital of Beijing: A population-based retrospective cohort study

In recent decades, we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. According to the World Health Organization (WHO) systematic review, if the increase in CS rate was between 10% and 15%, the maternal and neonatal mortality was decreased. However, above this level, increasing the rate of CS is no longer associated with reduced mortality. To date, no consensus has been reached on the main factors driving the cesarean epidemic. To reduce the progressively increasing rate of CS, we should find indications for the increasing CS rate. The aim of our study was to estimate the change of CS rate of Beijing Obstetrics and Gynecology Hospital and to find the variation of the indications.From January 1995 to December 2014, the CS rate of Beijing Obstetrics and Gynecology Hospital was analyzed. For our analysis, we selected 14,642 and 16,335 deliveries respectively that occurred during the year 2011 and 2014, to analyze the difference of indications, excluding incomplete data and miscarriages or termination of pregnancy before 28 weeks of gestation because of fatal malformations, intrauterine death, or other reasons.The average CS rate during the past 20 years was 51.15%. The highest caesarean delivery rate was 60.69% in 2002; however, the caesarean delivery rate declined to 34.53% in 2014. The obviously different indications were caesarean delivery on maternal request and previous CS delivery. The rate of CS due to maternal request in 2014 was decreased by 8.16% compared with the year 2011. However, the percentage of pregnancy women with a previous CS delivery increased from 9.61% to 20.42% in 3 years. Along with the decline of CS rate, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014 compared with that in 2011.After a series of measures, the CS rate declined indeed. Compared with 2011, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014. Caesarean delivery on maternal request (CDMR) cannot improve the maternal-fetal prognosis compared with the spontaneous vaginal delivery. With the releasing of China's 2 children policy, more CS will be implemented due to previous CS. There is a need for further research that evaluates interventions for increasing VBAC rates that target clinicians.

"Too posh to push": the rise and rise of a catchphrase

BACKGROUND

The phrase "too posh to push" was coined over 14 years ago to describe maternal request for cesarean section in the absence of clinical indications. The phrase was readily taken up and used by the United Kingdom media despite limited evidence that many women request cesarean sections or have an aversion to vaginal birth. The objectives of this study were to explore the way in which the phrase was used; the context and themes associated with it.

METHODS

To better understand the part the news media might play in public and health care professionals' perceptions, all articles using the phrase in eight UK national weekday newspapers from 1999 to 2011 (n = 335) were subjected to content analysis.

RESULTS

Key themes have changed over the years but some themes, such as celebrity cesareans, the risks of cesarean section, and the rising cesarean rate, have remained. Four different definitions of the term "too posh to push" were identified. Levels of usage of these terms changed over time. Misinterpretation of the National Sentinel Cesarean Section Audit results and a tendency to confuse elective cesarean section with maternal request for a cesarean have suggested that more "too posh to push" cesareans occurred than is probably the case.

CONCLUSION

The phrase seems to have become well established. It is likely that press handling of the topic has continued to contribute to the impression that cesarean purely for maternal request is common. The association with celebrity continues to fuel press interest in the topic.

The impact of hospital revenue on the increase in Caesarean sections in Norway. A panel data analysis of hospitals 1976-2005

BACKGROUND

There has been a marked increase in the number of Caesarean sections in many countries during the last decades. In several countries, Caesarean sections are carried out in more than 20 per cent of births. These high Caesarean section rates give cause for concern, both from an economic and a medical perspective. A general opinion among epidemiologists is that the increase in the number of Caesarean sections during the last decade has been greater than could be expected in relation to medical risk factors. Therefore, other explanations must be sought. We studied one potential explanation; the effect that the increase in hospital revenue per bed during the period 1976-2005 has had on the Caesarean section rate in Norway. During this period, hospital revenue increased by about 260% (adjusted for inflation).

METHODS

The analyses were carried out using data from the Medical Birth Registry 1976-2005 from Norway. The data were merged with data about hospital revenue, which were obtained from Statistics Norway. The analyses were carried out using annual data from 46 hospitals. A fixed effect regression model was estimated. Relevant medical control variables were included.

RESULTS

The elasticity of the Caesarean section rate with respect to hospital revenue per bed was 0.13 (p < 0.05). This represents an increase in the Caesarean section rate from the basis year 1976 to the final year 2005 of about 35 per cent. Most of the variables measuring characteristics of the health status of the mother and child had the expected effects.

CONCLUSION

The increase in hospital revenue explains only a small part of the increase in the Caesarean section rate in Norway during the last three decades. The increase in the Caesarean section rate is considerably greater than could be expected, based on the increase in hospital revenue alone. The strength of our study is that we have estimated a cause and effect relationship. This was done by using fixed effects for hospitals, a lagged revenue variable and by including an extensive set of control variables for the risk factors of the mother and the baby.

The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care

BACKGROUND

the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships.

AIM

critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services.

METHOD

a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers.

FINDINGS

maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance.

CONCLUSION

the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

Caesarean section in the absence of need: a pathologising paradox for public health?

Caesarean section in the absence of need: a pathologising paradox for public health? This qualitative study explored the discourses constructing women's choice for a caesarean section, in the absence of clinical indication. The research was informed from the theoretical ideas of poststructuralism that presumes people's reality is shaped discursively through the discourses they encounter. A Foucauldian discourse analysis was undertaken of the transcripts of participant's interviews and the texts of both professional and popular media before inductively discerning the prevailing discourses that influence the choice of caesarean in the absence of need. In shaping women's choice in childbirth the discourses of autonomy, convenience and desire alongside fear and risk were identified in the talk and texts of women, childbirth professionals and popular culture. For the purposes of this article we have confined our focus to the findings related to how caesarean is represented in both professional and popular discourse and include feminist discussions around childbirth as an embodied practice. We contend that the discourses of autonomy, desire and risk unite with broader societal discourses to expose a pathologising paradox in which normal bodily performance emerges as abnormal and the abnormal as normal. The trend has implications for both future healthy populations and the equitable distribution of maternity resources.

Hidden costs associated with the universal application of risk management in maternity care

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

Elective caesarean section: a case study

Caesarean section as a means of delivering babies has been around for centuries with numerous references to the procedure appearing in ancient writings (Simm & Matthew 2008). It is now the most common major surgical intervention carried out on women in the world, with between 23% and 30% of deliveries in the UK performed by caesarean section (Beech 2004). This rate is all the more surprising when one considers that caesarean section accounted for just 5.3% of UK births in 1973 (Kitzinger 1998). This rising rate has many implications for both clinical practice and the NHS. An Audit Commission report (1997) suggested that each 1% rise in the caesarean section rate would cost the NHS five million pounds per year. However, the increased rate also has clinical implications, with some studies suggesting that maternal mortality is three to seven times greater following abdominal rather than vaginal birth and maternal morbidity is proportionately even greater, even with elective procedures (McCourt et al 2004).

Japanese women's experiences from pregnancy through early postpartum period

Declining availability and accessibility of perinatal health care are emergent social concerns. Based on the Listening to Mothers-II (LTM-II) surveys, we describe a total of 20 Japanese women's perinatal experiences. Data were qualitatively compared with those of U.S. women, using a theoretical framework for evaluation of primary health care. Japanese women overcame their worries by engaging in healthy behaviors, accepting hardships such as labor pain, and receiving assurance from health professionals and modern technology. We found that while U.S. and Japanese women's perinatal experiences reflected their unique cultural values and social context, a cross-cultural universality of birthing women's experiences exists.

Do expert patients get better treatment than others? Agency discrimination and statistical discrimination in obstetrics

We address models that can explain why expert patients (obstetricians, midwives and doctors) are treated better than non-experts (mainly non-medical training). Models of statistical discrimination show that benevolent doctors treat expert patients better, since experts are better at communicating with the doctor. Agency theory suggests that doctors have an incentive to limit hospital costs by distorting information to non-expert patients, but not to expert patients. The hypotheses were tested on a large set of data, which contained information about the highest education of the parents, and detailed medical information about all births in Norway during the period 1967-2005 (Medical Birth Registry). The empirical analyses show that expert parents have a higher rate of Caesarean section than non-expert parents. The educational disparities were considerable 40 years ago, but have become markedly less over time. The analyses provide support for statistical discrimination theory, though agency theory cannot be totally excluded.

Patient source of learning about health technologies and ratings of trust in technologies used in their care

In order to design effective health technologies and systems, it is important to understand how patients learn and make decisions about health technologies used in their care. The objective of this study was to examine patients' source of learning about technologies used in their care and how the source related to their trust in the technology was used. Individual face-to-face and telephone interviews were conducted with 24 patients. Altogether, 13 unique sources of information about technology were identified and three major themes emerged: outside of the work system vs. inside the work system; when the health information was provided; the medium used. Patients used multiple sources outside of the healthcare work system to learn about technologies that will be used in their care. Results showed a relationship between learning about technologies from web sources and trust in technologies but no relationship between learning about technologies from healthcare providers and trust in technologies. STATEMENT OF RELEVANCE: The value of considering human attitudes about elements in health systems has been illustrated. This research shows a relationship between patient attitudes about medical technologies used in their care and healthcare work system design. Results show that patient attitudes are formed about technologies used in their care by sources within and outside of the sociotechnical work system.

Trust in Medical Technology by Patients and Health Care Providers in Obstetric Work Systems

Multiple types of users (i.e. patients and care providers) have experiences with the same technologies in health care environments and may have different processes for developing trust in those technologies. The objective of this study was to assess how patients and care providers make decisions about the trustworthiness of mutually used medical technology in an obstetric work system. Using a grounded theory methodology, we conducted semi-structured interviews with 25 patients who had recently given birth and 12 obstetric health care providers to examine the decision-making process for developing trust in technologies used in an obstetric work system. We expected the two user groups to have similar criteria for developing trust in the technologies, though we found patients and physicians differed in processes for developing trust. Trust in care providers, the technologies' characteristics and how care providers used technology were all related to trust in medical technology for the patient participant group. Trustworthiness of the system and trust in self were related to trust in medical technology for the physician participant group. Our findings show that users with different perspectives of the system have different criteria for developing trust in medical technologies.

Recovery after caesarean birth: a qualitative study of women's accounts in Victoria, Australia

BACKGROUND

The caesarean section rate is increasing globally, especially in high income countries. The reasons for this continue to create wide debate. There is good epidemiological evidence on the maternal morbidity associated with caesarean section. Few studies have used women's personal accounts of their experiences of recovery after caesarean. The aim of this paper is to describe women's accounts of recovery after caesarean birth, from shortly after hospital discharge to between five months and seven years after surgery.

METHOD

Women who had at least one caesarean birth in a tertiary hospital in Victoria, Australia, participated in an interview study. Women were selected to ensure diversity in experiences (type of caesarean, recency), caesarean and vaginal birth, and maternal request caesarean section. Interviews were audiotaped and transcribed verbatim. A theoretical framework was developed (three Zones of clinical practice) and thematic analysis informed the findings.

RESULTS

Thirty-two women were interviewed who between them had 68 births; seven women had experienced both caesarean and vaginal births. Three zones of clinical practice were identified in women's descriptions of the reasons for their first caesareans. Twelve women described how, at the time of their first caesarean section, the operation was performed for potentially life-saving reasons (Central Zone), 11 described situations of clinical uncertainty (Grey Zone), and nine stated they actively sought surgical intervention (Peripheral Zone).Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean.

CONCLUSION

The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms.

[Increased rate of Caesarean sections--causes and consequences]

BACKGROUND

A rise in the rate of caesarean sections has been observed in most parts of the developed world during the last decades. Causes and consequences are much debated.

MATERIAL AND METHODS

Non-systematic literature search in PubMed.

RESULTS

The increased rate of caesarean sections can be explained by both medical non-medical factors. Among the medical factors are increases in maternal age and body mass index, as well as changes in obstetric practise and technology. Some non-medical factors are caesarean section requested by the mother, fear of litigation among caregivers and inappropriate organization of maternity care. Caesarean section is associated with maternal postpartum morbidity, reduced fertility and placental complications in a subsequent pregnancy. For the child, caesarean section is associated with postpartum respiratory morbidity, less breast-feeding and possibly more atopic disease. For society, caesarean section is more costly than vaginal delivery.

INTERPRETATION

There are many and complex causes of the rise in caesarean section rates in industrialized countries. The procedure has inherent negative consequences (short- and long-term) for mother and child, as well as being an economic burden to society. There is every reason to attempt prevention of a further increase in caesarean section rates.

Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery

OBJECTIVE

To determine the age-stratified risk of intrapartum and neonatal mortality as well as morbidities of clinical relevance after elective cesarean delivery (ECD).

METHODS

This work was a cohort study including 56 549 prospectively recorded late-preterm and term deliveries. We analyzed the effect of cesarean delivery (CD) before the onset of labor on the following multiple neonatal outcomes before hospital discharge, compared with planned vaginal delivery (PVD) and emergency CD: mortality, birth depression, special care admission, and respiratory morbidity. We adjusted for confounders by multivariate analysis and stratified the risk according to gestational age (GA).

RESULTS

Mortality and morbidities had a strong GA-related trend with the lowest incidences consistently found between 38 and 40 weeks of gestation independent of delivery mode. Compared with infants delivered via PVD, infants delivered via ECD had significantly higher rates of mortality (adjusted risk ratio [aRR]: 2.1), risk of special care admission (aRR: 1.4), and respiratory morbidity (aRR: 1.8) but not of depression at birth (aRR: 1.1). Compared with emergency CD, newborns delivered via ECD had less depression at birth (aRR: 0.6) and admission to special care (aRR: 0.8), but mortality (aRR: 0.8) and respiratory morbidity (aRR: 1.0) rates were similar.

CONCLUSIONS

Gestational age-specific risk estimates are lowest between 38 and 40 weeks and should be included in the informed-consent process. The information should also be used to allow for appropriate preparation with respect to adequate staff and equipment. ECD is consistently associated with increased intrapartum and neonatal mortality, risk of admission, and respiratory morbidity compared with PVD and has no advantage over emergency CD in terms of mortality. Neonatal morbidities are lower after ECD than emergency CD only with term births. Our data provide evidence that ECD should not be performed before term.

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.

The emergence of high-tech birthing

The journey from "normal" to high-tech childbirth has taken place gradually over the past century. This article gives a historic review of maternity care and defines normal birth according to care practices adapted from the World Health Organization. The issues facing today's consumers, care providers, and caregivers that have led to the high-tech approach to birth are discussed. Recommendations for nursing practice are proposed to balance a normal approach to childbirth with a high-tech clinical environment.

Is non-directive counseling for patient choice cesarean delivery ethically justified?

The current controversy concerning patient choice cesarean delivery potentially affects all women of child-bearing age and the physicians who care for them. The purpose of this paper is to address three salient issues within the patient choice cesarean delivery controversy. First, is performing patient choice cesarean delivery consistent with good professional medical practice? Second, how should physicians respond to or counsel patients who request patient choice cesarean delivery? And, third, should patient choice cesarean delivery be routinely offered to all pregnant women?

Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an "intention-to-treat" model

BACKGROUND

The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an "intention-to-treat" methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low-risk women.

METHODS

Low-risk births were singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention-to-treat methodology, a "planned vaginal delivery" category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a "planned cesarean delivery" category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors.

RESULTS

The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35-2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries.

CONCLUSIONS

The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication.

A critique of the literature on women's request for cesarean section

BACKGROUND

The influence of women's birth preferences on the rising cesarean section rates is uncertain and possibly changing. This review of publications relating to women's request for cesarean delivery explores assumptions related to the social, cultural, and political-economic contexts of maternity care and decision making.

METHOD

A search of major databases was undertaken using the following terms: "c(a)esarean section" with "maternal request,""decision-making,""patient participation,""decision-making-patient,""patient satisfaction,""patient preference,""maternal choice,""on demand," and "consumer demand." Seventeen papers examining women's preferred type of birth were retrieved.

RESULTS

No studies systematically examined information provided to women by health professionals to inform their decision. Some studies did not adequately acknowledge the influence of obstetric and psychological factors in relation to women's request for a cesarean section. Other potential influences were poorly addressed, including whether or not the doctor advised a vaginal birth, women's access to midwifery care in pregnancy, information provision, quality of care, and cultural issues.

DISCUSSION

The psychosocial context of obstetric care reveals a power imbalance in favor of physicians. Research into decision making about cesarean section that does not account for the way care is offered, observe interactions between women and practitioners, and analyze the context of care should be interpreted with caution.

Are there "unnecessary" cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications

BACKGROUND

The belief that many women demand cesarean sections in the absence of clinical indications appears to be pervasive. The aim of this study was to examine whether, and in what context, maternal requests for cesarean section are made.

METHODS

Quantitative and qualitative methods were used. The overall study comprised 4 substudies: 23 multiparous and 41 primiparous pregnant women were asked to complete diaries recording events related to birth planning and expectations; 44 women who had considered, or been asked to consider, cesarean section during pregnancy were interviewed postnatally; 24 consultants and registrars in 3 district hospitals and 1 city hospital were interviewed; 5 consultants with known strong views about cesarean section were also interviewed; and 785 consultants from the United Kingdom and Eire completed postal questionnaires.

RESULTS

No woman requested cesarean section in the absence of, what she considered, clinical or psychological indications. Fear for themselves or their baby appeared to be major factors behind women's requests for cesarean section, coupled with the belief that cesarean section was safest for the baby. Most obstetricians reported few requests for cesarean section, but nevertheless, cited maternal request as the most important factor affecting the national rising cesarean section rate. Several obstetricians discussed the significance of women's fears and the importance of taking the time to talk to women about these fears.

CONCLUSIONS

Existing evidence for large numbers of women requesting cesarean sections in the absence of clinical indications is weak. This study supports the thesis that these women comprise a small minority. Psychological issues and maternal perceptions of risk appear to be significant factors in many maternal requests. Despite this finding, maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward.