Attitudes of midwives in Sweden toward a woman's refusal of an emergency cesarean section or a cesarean section on request

Caesarean section on maternal request: a qualitative study of conflicts related to shared decision-making and person-centred care in Sweden

BACKGROUND

Today, person-centred care is seen as a cornerstone of health policy and practice, but accommodating individual patient preferences can be challenging, for example involving caesarean section on maternal request (CSMR). The aim of this study was to explore Swedish health professionals' perspectives on CSMR and analyse them with regard to potential conflicts that may arise from person-centred care, specifically in relation to shared decision-making.

METHODS

A qualitative study using both inductive and deductive content analysis was conducted based on semi-structured interviews. It was based on a purposeful sampling of 12 health professionals: seven obstetricians, three midwives and two neonatologists working at different hospitals in southern and central Sweden. The interviews were recorded either in a telephone call or in a video conference call, and audio files were deleted after transcription.

RESULTS

In the interviews, twelve types of expressions (sub-categories) of five types of conflicts (categories) between shared decision-making and CSMR emerged. Most health professionals agreed in principle that women have the right to decide over their own body, but did not believe this included the right to choose surgery without medical indications (patient autonomy). The health professionals also expressed that they had to consider not only the woman's current preferences and health but also her future health, which could be negatively impacted by a CSMR (treatment quality and patient safety). Furthermore, the health professionals did not consider costs in the individual decision, but thought CSMR might lead to crowding-out effects (avoiding treatments that harm others). Although the health professionals emphasised that every CSMR request was addressed individually, they referred to different strategies for avoiding arbitrariness (equality and non-discrimination). Lastly, they described that CSMR entailed a multifaceted decision being individual yet collective, and the use of birth contracts in order to increase a woman's sense of security (an uncomplicated decision-making process).

CONCLUSIONS

The complex landscape for handling CSMR in Sweden, arising from a restrictive approach centred on collective and standardised solutions alongside a simultaneous shift towards person-centred care and individual decision-making, was evident in the health professionals' reasoning. Although most health professionals emphasised that the mode of delivery is ultimately a professional decision, they still strived towards shared decision-making through information and support. Given the different views on CSMR, it is of utmost importance for healthcare professionals and women to reach a consensus on how to address this issue and to discuss what patient autonomy and shared decision-making mean in this specific context.

Uncharted territory: a narrative review of parental involvement in decision-making about late preterm and early term delivery

Almost 30% of live births in England and Wales occur late preterm or early term (LPET) and are associated with increased risks of adverse health outcomes throughout the lifespan. However, very little is known about the decision-making processes concerning planned LPET births or the involvement of parents in these. This aim of this paper is to review the evidence on parental involvement in obstetric decision-making in general, to consider what can be extrapolated to decisions about LPET delivery, and to suggest directions for further research.A comprehensive, narrative review of relevant literature was conducted using Medline, MIDIRS, PsycInfo and CINAHL databases. Appropriate search terms were combined with Boolean operators to ensure the following broad areas were included: obstetric decision-making, parental involvement, late preterm and early term birth, and mode of delivery.This review suggests that parents' preferences with respect to their inclusion in decision-making vary. Most mothers prefer sharing decision-making with their clinicians and up to half are dissatisfied with the extent of their involvement. Clinicians' opinions on the limits of parental involvement, especially where the safety of mother or baby is potentially compromised, are highly influential in the obstetric decision-making process. Other important factors include contextual factors (such as the nature of the issue under discussion and the presence or absence of relevant medical indications for a requested intervention), demographic and other individual characteristics (such as ethnicity and parity), the quality of communication; and the information provided to parents.This review highlights the overarching need to explore how decisions about potential LPET delivery may be reached in order to maximise the satisfaction of mothers and fathers with their involvement in the decision-making process whilst simultaneously enabling clinicians both to minimise the number of LPET births and to optimise the wellbeing of women and babies.

Midwives' experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies

PROBLEM

Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines.

BACKGROUND

Women's reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives' and their perception of personal/professional risk in such situations.

AIM

To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations.

METHODS

Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings.

FINDINGS

Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women's rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of 'being torn', and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to.

CONCLUSION

Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women's right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.

I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth

Background

No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended.

Methods

In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations.

Results

More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences.

Conclusions

Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

Is it the decision of women to choose a cesarean section as the mode of birth? A review of literature on the views of stakeholders

BACKGROUND

A debate on the decision of women to choose a cesarean section as the mode of birth in uncomplicated pregnancies from the views of relevant stakeholders.

MAIN TEXT

Using five electronic databases, a literature search was conducted for studies published from January 2003 to December 2016. Studies on a woman's right to request or to choose a cesarean section as the mode of birth in uncomplicated pregnancies were included. Fifty-five articles were identified (39 research studies and 16 opinion-based articles). Among health professionals, obstetricians were the most supportive of this right. It is argued that although women reported wanting to choose the mode of birth, with the safety of their babies as the priority, they also relied on the advice of their maternity care provider and considered it the responsibility of their obstetrician to make the decision. A higher proportion of the general public in countries with well-developed private healthcare accepted that a woman should have the freedom to choose the mode of birth.

CONCLUSIONS

This review provided a debate on the choice of pregnant women in uncomplicated pregnancies on the mode of birth from various stakeholders. Further research is required to explore what the meanings of autonomy of pregnant women to choose the mode of birth, and the process that they go through when making this decision.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives’ motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients’ needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

Caring for women making unconventional birth choices: A meta-ethnography exploring the views, attitudes, and experiences of midwives

INTRODUCTION

Women can face opposition when exerting autonomous decision-making regarding their birth choices, particularly when the decisions involve going against medical advice and/or outside of national guidelines. Termed 'unconventional birth choices', some research has explored women's reasons and experiences of making such choices, but less is known about the midwives caring for them.

OBJECTIVES

To synthesize existing qualitative literature on the views, attitudes, and experiences of midwives caring for women who make unconventional birth choices.

METHODS

A systematic search and meta-ethnography informed by Noblit and Hare and Schutz was undertaken. Eight databases were searched using predetermined search terms, alongside author, reference, citation chasing, and hand searching. Searches were conducted in July 2016 and updated in October 2017. Qualitative studies published since 1993 in English were included. Included studies were subjected to quality appraisal, conducted independently by two reviewers. Analysis was informed by the interpretative meta-ethnography methods.

MAIN RESULTS

Five studies met the inclusion criteria. Eight subthemes emerged. These resulted in three higher level interpretative themes emerged: perceptions of women's decision making, conflicting tensions as caregivers, ways of working with-woman.

CONCLUSIONS

Midwives can play a pivotal role in ensuring that respectful maternity care includes supporting women in their birthing decisions. Whilst limited research has been undertaken in this area, available insights suggest that midwives' views in this area are situated along a spectrum from 'willingly facilitative' to 'reluctantly accepting'. Views were influenced by context, as well as prior philosophies and values. While further research is needed, this study offers insights into the challenges women can face in seeking unconventional birth choices if they require support from midwives to do so.

Less or more? Maternal requests that go against medical advice

PROBLEM AND BACKGROUND

This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth.

METHODS

All Dutch midwives and (trainee) gynaecologists were invited to fill out a questionnaire specifically designed for the purposes of this study. Holistic midwives were analysed separately from regular community midwives.

FINDINGS

Most maternity care providers in the Netherlands receive requests for less care than recommended at least once a year. The most frequently maternal requests were declining testing for gestational diabetes (66.3%), opting for a home birth in case of a high risk pregnancy (65.3%), and declining foetal monitoring during labour (39.6%). Holistic midwives are more convinced of an increasing demand for less care than community midwives (73.1% vs. 35.2%, p=<0.001). More community midwives than hospital staff reported to have declined one or more request for less care than recommended (48.6% vs. 27.9%, p=<0.001). The majority of hospital staff also receive at least one request for an elective caesarean section every year.

DISCUSSION AND CONCLUSION

Requests for more and less care than indicated during pregnancy and childbirth are equally prevalent in this study. However, a request for less care is more likely to be declined than a request for more care. Counselling women who disagree with their care provider demands time. In case of requests for less care, second best care should be considered.

Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on 'birthing outside the system'

OBJECTIVE

to identify and analyze literature exploring women׳s motivations to 'birth outside the system'.

DESIGN

scoping review and thematic analysis of (mostly) qualitative studies.

FINDINGS

fifteen studies of women choosing an unassisted birth, homebirth in countries where homebirth was not integrated into the maternity care system, or a midwife-attended high-risk homebirth were identified from Sweden, USA, Australia, Canada and Finland. Five main themes emerged as the most important factors: (1) resisting the biomedical model of birth by trusting intuition, (2) challenging the dominant discourse on risk by considering the hospital as a dangerous place, (3) feeling that true autonomous choice is only possible at home, (4) perceiving birth as an intimate or religious experience, and (5) taking responsibility as a reflection of true control over decision-making.

KEY CONCLUSIONS

concerns over consent, intervention and loss of the birthing experience may be driving women away from formal healthcare. There is a lack of fit between the health needs of pregnant women and the current system of maternity care. Biomedical and alternative ׳outside the system׳ discourses on authoritative knowledge, risk, autonomy and responsibility must be negotiated to find a common ground wherein a dialogue can take place between client and health professional.

IMPLICATIONS FOR PRACTICE

more research is needed to explore the scope of the phenomenon of women birthing outside the system and the experiences of midwives and obstetricians in the care of such women. This knowledge can be used to improve the maternity care system, so that fewer women will choose to withdraw from it.

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care

BACKGROUND

All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP).

AIM

To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation.

METHODS

Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs.

FINDINGS

MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without).

CONCLUSIONS

MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).

Attitudes of Swedish midwives towards management of extremely preterm labour and birth

OBJECTIVE

the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals.

DESIGN

this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis.

PARTICIPANTS

the answers from midwives (n=259) were collected in a prospective SWEMID study.

SETTING

the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden.

FINDINGS

in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents.

KEY CONCLUSIONS

midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience.

IMPLICATIONS FOR PRACTICE

based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth.