Women's preference for cesarean delivery and differences between Taiwanese women undergoing different modes of delivery

Preferred mode of delivery and its associated factors in pregnant women with a previous cesarean scar at a tertiary care hospital in Ethiopia: institutional-based cross-sectional study

BACKGROUND

Vaginal births after cesarean or elective repeat cesarean sections (CS) are the options for delivery after one cesarean scar. However, there is a lack of data regarding the preferred next mode of delivery in Ethiopia after a previous cesarean section. Thus, this study assessed the preferred mode of delivery and determinants after one previous CS in the antenatal clinic at the University of Gondar Comprehensive Specialized Hospital (UoGCSH).

METHODS

An institutional-based cross-sectional study was conducted among pregnant mothers with one previous CS at UoGCSH from March to August 2022. Structured questionnaires were used to collect the data. The collected data were entered, cleaned, and edited using Epi-data 4.6 and exported to SPSS version 26 for analysis. A binary logistic regression was performed to assess the determinants of the preferred mode of delivery. A p-value of < 0.05 at the 95% confidence level (CI) was considered statistically significant.

RESULTS

The majority, 71.5% (95% CI: 64.7, 77.1), of participants preferred the trial of labor after cesarean (TOLAC) as their mode of delivery. Mothers who were married (AOR = 4.47, 95% CI: 1.19-16.85), had a diploma educational level (AOR = 3.77, 95% CI: 1.84-12.36), had previous post-cesarean complications (AOR = 3.25, 95% CI: 1.08-9.74), and knew about the success of the trial of labor after cesarean (AOR = 13.56, 95% CI: 4.52-37.19) were found to prefer the trial of labor compared with their counterparts.

CONCLUSION

This study concluded that most pregnant mothers preferred labor trials after one CS, which is a bit lower but comparable with recommended practice guidelines. Providing adequate information and counseling mothers to make informed decisions about their preferred mode of delivery could be substantial.

Maternal suicide attempts and deaths in the first year after cesarean delivery

BACKGROUND

Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally.

METHOD

All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models.

RESULTS

Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32-1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88-2.36).

CONCLUSIONS

Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.

Cesarean delivery and early childhood diseases in Bangladesh: An analysis of Demographic and Health Survey (BDHS) and Multiple Indicator Cluster Survey (MICS)

Introduction

The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.

Methods

We used four nationally representative data sets from multiple indicator cluster survey (MICS, 2012 and 2019) and Bangladesh Demographic and Health Survey (BDHS, 2011and 2014) and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases (fever, short or rapid breaths, cough, blood in stools, and diarrhea) as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.

Results

In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% [Risk Ratio (RR): 1.05, 95% CI: 0.95, 1.17, p = 0.33]. However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [(2011 BDHS RR: 1.22, 95% CI: 1.08, 1.38) and (2019 MICS RR: 1.21, 95% CI: 1.08, 1.35)] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.

Conclusion

Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in China: A mixed-methods systematic review

BACKGROUND

China has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.

METHODS AND FINDINGS

We conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms 'caesarean section', 'preference', 'choice', 'knowledge', 'attitude', 'culture', 'non-clinical factors', and 'health professionals-patient relations' between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%-17%) and 21% in late pregnancy (95% CI 15%-26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%-20%), 22% in late pregnancy (95% CI 18%-25%), and 30% postpartum (95% CI 19%-40%). Women's preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%-13%). One longitudinal study reported that the preference for CS among women's partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women's perceptions of CS as preferable were based on prioritising the baby's and woman's health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals' preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women's preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).

CONCLUSIONS

Despite a minority of women expressing a preference for CS, individual, health system, and socio-cultural factors converge, contributing to a high CS rate in mainland China, Hong Kong, and Taiwan. In order to reduce unnecessary CSs, interventions need to address all these non-clinical factors and concerns.

SYSTEMATIC REVIEW REGISTRY

Prospero CRD42016036596.

Assessment of the efficacy of group counselling using cognitive approach on knowledge, attitude, and decision making of pregnant women about modes of delivery

The choice of casarean deliveries by mothers is highly influenced by inadequate knowldge and negative attitudes towards vaginal birth. In this semi-experimental study, we compared knowledge, attitude, and decision making about modes of delivery between nulliparous pregnant women who received eight sessions of group consultation and those who took routine prenatal education. Contrary to the control group, the improvement of knowledge and attitudes were significant in the consultation group (p < 0.001), as well as mothers' decisions for vaginal birth (p = 0.03). Group consultation is an appropriate approach to improving knowledge, attitudes, and tendencies of mothers toward natural birth.

Tanzanian Mothers' Cultural Beliefs and Misinformation Regarding the Reasons for Their Cesarean Sections

BACKGROUND

In Tanzania, cesarean section (CS) rates have been steadily increasing, yet little is known about mothers' understanding of the medical rationale for their CSs.

AIM

To identify mothers' cultural understandings of the rationale for their CSs.

METHODS

Design: A qualitative descriptive design was employed.

Setting: A government hospital in the western region in Tanzania.

Participants: A total of 117 mothers were interviewed using convenience sampling post CS.

FINDINGS

Forty percent of the mothers were younger than 18 years, with more than 50% having had five or more live babies. Among multigravida women, 40.2% had had one or more previous CSs.

The emergent themes were lack of dietary knowledge, use of local herbs, delays in coming to hospital, avoiding stressful labor pains and no ability to exercise, and no personal preferences of “push or go for an operation.”

CONCLUSION

Pregnant women in Tanzania need improved health education to make informed choices about childbirth and be involved all processes of antepartum care decision making to achieve optimal birth outcomes.

Women's decision-making processes and the influences on their mode of birth following a previous caesarean section in Taiwan: a qualitative study

BACKGROUND

Vaginal birth after caesarean (VBAC) is an alternative option for women who have had a previous caesarean section (CS); however, uptake is limited because of concern about the risks of uterine rupture. The aim of this study was to explore women's decision-making processes and the influences on their mode of birth following a previous CS.

METHODS

A qualitative approach was used. The research comprised three stages. Stage I consisted of naturalistic observation at 33-34 weeks' gestation. Stage II involved interviews with pregnant women at 35-37 weeks' gestation. Stage III consisted of interviews with the same women who were interviewed postnatally, 1 month after birth. The research was conducted in a private medical centre in northern Taiwan. Using a purposive sampling, 21 women and 9 obstetricians were recruited. Data collection involved in-depth interviews, observation and field notes. Constant comparative analysis was employed for data analysis.

RESULTS

Ensuring the safety of mother and baby was the focus of women's decisions. Women's decisions-making influences included previous birth experience, concern about the risks of vaginal birth, evaluation of mode of birth, current pregnancy situation, information resources and health insurance. In communicating with obstetricians, some women complied with obstetricians' recommendations for repeat caesarean section (RCS) without being informed of alternatives. Others used four step decision-making processes that included searching for information, listening to obstetricians' professional judgement, evaluating alternatives, and making a decision regarding mode of birth. After birth, women reflected on their decisions in three aspects: reflection on birth choices; reflection on factors influencing decisions; and reflection on outcomes of decisions.

CONCLUSIONS

The health and wellbeing of mother and baby were the major concerns for women. In response to the decision-making influences, women's interactions with obstetricians regarding birth choices varied from passive decision-making to shared decision-making. All women have the right to be informed of alternative birthing options. Routine provision of explanations by obstetricians regarding risks associated with alternative birth options, in addition to financial coverage for RCS from National Health Insurance, would assist women's decision-making. Establishment of a website to provide women with reliable information about birthing options may also assist women's decision-making.

Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: A nationwide cohort study

BACKGROUND

Women who undergo cesarean birth might have an increased risk for poor mental health after childbirth, possibly because of maternal and neonatal physical problems, low parental confidence, and decreased levels of oxytocin. However, this relationship remains controversial and requires further examination. The study aimed to examine the effect of cesarean birth on postpartum stress, anxiety, and depression.

METHODS

This nationwide population-based cohort study was conducted using the Taiwan National Health Insurance Database. A total of 12 619 women who underwent cesarean birth and 12 619 control women who underwent vaginal birth were matched by propensity score based on age, socioeconomic status, residential urbanicity, antepartum comorbidity, and index year of delivery. We compared the incidence of stress, anxiety, and depression during the first postpartum year between cesarean and comparison groups by calculating incidence rate ratios (IRRs).

RESULTS

The cesarean group showed a significantly higher risk for stress symptoms (IRR 1.4 [95% confidence interval {CI} 1.02-1.92]), but not anxiety (IRR 1.14 [95% CI 0.95-1.38]) or depression (IRR 1.32 [95% CI 0.94-1.87]), although the IRRs were also greater than one. The cesarean group had a significantly higher risk of any of the above-listed three disorders than the comparison group (incidence 27.6 vs 23.4 per 1000 person-years; IRR 1.18 [95% CI 1.01-1.38]).

CONCLUSIONS

Cesarean birth was associated with an increased risk of postpartum stress symptoms. Health professionals should avoid unnecessary cesarean birth, pay attention to women who deliver by cesarean, and intervene appropriately in an attempt to improve mental health among postpartum women.

Personal, Interpersonal, and Organizational Predictors of the Mode of Delivery Among Urban Women: A Prospective Study With Socio-Ecological Approach

The aim of this prospective study was to investigate the predictors of choosing mode of delivery (MOD) among Iranian urban women applying the socio-ecological model. In 2015, a convenient sample of 530 pregnant women in urban regions of Urmia, Iran, was recruited to complete a socio-ecological approach-based questionnaire. Then, 1 week after childbirth, the women were followed up by telephone to be asked about their MOD (response rate = 81.88%). Logistic regression analysis showed that the odds of cesarean section (CS) among the women with university education, whose husbands were an employee in a governmental organization, who preferred a private hospital for delivery, and who selected the CS as the preferred MOD during pregnancy were significantly higher than their counterparts. Among all the factors, the socioeconomic status of the families was more influential in predicting the MOD among women. The cognitive factors like fear of childbirth may not be determinants for MOD if women are from privileged families.

Predictors of preference for caesarean delivery among pregnant women in Beijing

Objective

To evaluate factors associated with preference for caesarean or vaginal delivery among pregnant Chinese nulliparous and parous women.

Methods

In this cross-sectional study, a self-administered questionnaire was used to collect information on sociodemographic characteristics, preference/reasons for delivery mode, and knowledge of delivery complications.

Results

Of the 450 participants, 85 (18.9%) reported a preference for caesarean section (CS) pre-partum. Compared with women who would prefer a vaginal delivery, nulliparous women who preferred CS were more likely to be: ≥35 years; have no medical insurance; have had two or more pregnancies; have access to only one source of information about birthing options; knowledge of the complications of vaginal delivery and think doctors have no right to decide the type of delivery. For parous women who preferred CS, they were more likely to have had a previous caesarean delivery and live outside Beijing.

Conclusions

From this study conducted at a large, maternity centre in Beijing, the proportion of pregnant women with preference pre-partum for CS was moderate and their reasons were varied.

Differences between native and immigrant women in Taiwan in factors associated with caesarean section: A prospective observational study

This study aimed to examine the association of social support, social factors, and maternal complications with caesarean deliveries in native and immigrant women, and to explore the association between acculturation and caesarean deliveries in immigrant women in Taiwan. This prospective panel study was conducted from August 2012 through April 2014 and included 222 native and 147 immigrant pregnant women in Taiwan. Caesarean rates did not differ significantly between native and immigrant women, including the overall caesarean rate (28.8%, 32.0%), medically indicated caesarean (22.5%, 24.5%), and caesarean without medical indications (6.3%, 7.5%). Results of multiple logistic regression models revealed that maternal complications and household activity support were positively associated with caesarean deliveries. Both native and immigrant women with high levels of informational support were less likely to receive caesareans. Immigrant women who were older than 35 years, had a middle level socioeconomic status, and perceived a high level of acceptance of caesarean in Taiwan were more likely to have caesarean deliveries. Informational support was a protective factor for caesarean delivery, whereas household activity support offered by the family was positively associated with caesarean delivery. Perceived acceptance level in mainstream society could affect immigrant women's use of caesarean delivery.

Factors influencing the decision that women make on their mode of delivery: the Health Belief Model

Background

Childbirth is regarded as an important life event for women, and growing numbers of them are making the choice to give birth by Caesarean Delivery. The aim of this study was to identify the factors influencing the decision that women make on their mode of delivery, underpinned by the Health Belief Model.

Methods

This was a cross-sectional study. Hong Kong Chinese women aged 18–45, who were pregnant or had given birth within the last three years were recruited. The participants were asked to complete a structured self-administered questionnaire consisting of 62 questions.

Results

A total of 319 women were recruited, of whom 73 (22.9%) preferred to have a cesarean section delivery (CD). The results showed that women preferred CD because they were concerned about being pregnant at an advanced age, were worried about labor pain and perineum tearing, wanted to have a better plan for maternity leave, had chosen an auspicious date to deliver, and perceived that CD is a more convenience way to deliver. The perceived benefits and severity of a vaginal birth (VB), and the perceived benefits, severity, and cues to action of CD, affected the decision to undergo either a VB or CD.

Conclusions

The data indicated that the constructs of the Health Belief Model – perceived benefits, perceived severity, and cues to action – affect the decision that women make on their mode of delivery. This research indicates that there is value in designing educational programs for pregnant women to educate them on the benefits, risks, and severity of the two different modes of birth based on the constructs of HBM. This will enable women to be active participants in choosing the mode of birth that they believe is right for them.

Measuring patient-centered care: An updated systematic review of how studies define and report concordance between patients' preferences and medical treatments

OBJECTIVE

The purpose was to examine recent advances in measuring value concordance and to highlight best practices.

METHODS

The paper updates a prior systematic review. A systematic review of the literature from 2008 to 2012 identified articles that reported a relationship between patients' preferences concerning health outcomes and/or medical treatments, and treatment (intended or actual). Relevant articles were independently abstracted by two reviewers.

RESULTS

The search identified 3635 unique citations, the full text of 187 articles was examined, and 63 articles covering 61 studies were included, nearly a third more articles than identified in the original review. There were 72 different value concordance calculations, the majority of which were clearly reported with significance. More studies assessed knowledge, reported on the association between value concordance and knowledge, and included a decision aid compared to those in the original review.

CONCLUSION

There is increased reporting of value concordance in the literature. However, large differences exist in the way that the measure is defined and calculated. The variability makes it difficult to draw conclusions about the quality of care across studies.

PRACTICE IMPLICATIONS

Value concordance is a critical component of patient-centered care, and further attention is needed to establish standards for measurement and reporting.

Perinatal and childhood risk factors for early-onset type 1 diabetes: a population-based case-control study in Taiwan

BACKGROUND

Certain factors originating from the perinatal and childhood periods are suspected of contributing to the recent increasing trend of childhood type 1 diabetes (T1D) incidence. This study sought to investigate the relationships between various perinatal and childhood risk factors and T1D incidence in young children (<10 years).

METHODS

We used a nested case-control design based on 1,478,573 live births born in 2000-05 in Taiwan. Cases were 632 incident cases of T1D between 2000 and 2008. Ten matched controls for each case were randomly selected. Information on various perinatal risk factors was also identified from claim data. Multiple conditional logistic regression was employed to estimate odds ratio (OR) and 95 confidence interval (CI) of T1D.

RESULTS

Childhood infection was significantly associated with an increased risk of T1D (OR = 1.46, 95% CI = 1.23-1.73). Increased risk of T1D was also noted in children born to younger mothers (<25 years) (OR = 1.94, 95% CI = 1.34-2.81), older fathers (>30 years) (OR = 1.56 (95% CI = 1.16-2.10) to 1.57 (95% CI = 1.19-2.05), mothers with Caesarean section (CS) (OR = 2.35, 95% CI = 1.52-3.64), and mothers with gestational diabetes mellitus (OR = 4.36, 95% CI = 2.76-7.77). Fathers with T1D (OR = 7.36, 95% CI = 1.02-57.21) or type 2 diabetes (OR = 1.54, 95% CI = 1.04-2.26) were observed to substantially increase the risk of offspring T1D.

CONCLUSIONS

Certain modifiable perinatal factors such as infection and CS may predispose incidence of T1D in young children.

Caesarean delivery before 39 weeks associated with selecting an auspicious time for birth in Taiwan

BACKGROUND

Caesarean delivery before 39 weeks of gestation increases the risk of morbidity among infants. Taiwan has one of the highest caesarean rates in the world, but little attention has been paid to this issue. This study aimed to describe the rate of caesarean delivery before 39 weeks gestation among women who did not have labour signs and had a non-emergency caesarean delivery in Taiwan and to examine whether the phenomenon was associated with the Chinese cultural practice of selecting an auspicious time for birth.

METHODS

We recruited women at 15-28 weeks of pregnancy at 5 hospitals in northern Taiwan and followed them at 4 or 5 weeks after delivery using structured questionnaires. This analysis included 150 primiparous mothers with a singleton pregnancy who had a non-emergency caesarean delivery without the presence of labour signs.

RESULTS

Ninety-three of these women (62.0%) had caesarean deliveries before 39 weeks of gestation. Logistic regression analysis showed that women who had selected an auspicious time for delivery (OR=2.82, 95% CI: 1.15-6.95) and delivered in medical centres (OR=5.26, 95% CI: 2.25-12.26) were more likely to deliver before 39 weeks of gestation.

CONCLUSION

Non-emergency caesarean delivery before 39 weeks of gestation was common among the study women, and was related to the Chinese cultural practice of selecting an auspicious time for birth. Further studies are needed to examine the risks and benefits associated with timing of caesarean delivery in Taiwan in order to generate a consensus among obstetricians and give pregnant women appropriate information.

Do nurses have worse pregnancy outcomes than non-nurses?

BACKGROUND

Nurses encounter multiple occupational exposures at work which may harm their reproductive health. The purpose of the study was to compare pregnancy complications and outcomes including cesarean deliveries, tocolysis, miscarriage, and preterm labor between female nurses and comparable women who were not nurses in Taiwan.

METHODS

This nationwide population-based study was performed using the National Health Insurance Research Database from 1997 to 2008. We identified 3,656 pregnancies among 2,326 nurses and 111,889 pregnancies among 74,919 non-nurses. A generalized estimating equation was used to compare risks between the two groups.

RESULTS

The rates of tocolysis (28.6 vs 22.3%), miscarriage (6.0 vs 5.3%), and preterm labor (8.1 vs 4.4%) were significantly higher among nurses than non-nurses. After adjustment for background differences, nurses had significantly higher risks for cesarean section (adjusted OR 1.12 [95% confidence interval (CI) 1.03-1.22]), tocolysis (OR 1.18 [95% CI 1.09-1.29]), and preterm labor (OR 1.46 [95% CI 1.28-1.67]) than non-nurses.

CONCLUSIONS

Nurses are at higher risk for cesarean section, tocolysis, and preterm labor than non-nurses. Occupational exposure related to these adverse pregnancy outcomes should be examined. Strategies to decrease the risks should be developed to improve reproductive health among nurses.

Factors associated with preference for repeat cesarean in neyshabur pregnant women

BACKGROUND

Cesarean delivery is a surgery for deliver a baby. Women with previous cesarean delivery (CD) must often choose between a vaginal delivery (VD) and repeat CD. Our aim of this study was to investigate factors associated with preference for CD in Neyshabur pregnant women with previous CD.

METHODS

A cross-sectional study was conducted on all pregnant women (who had previous caesarean delivery) from February 20, 2011 to March 20, 2011 in Northeast of Iran (Neyshabur). Logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The mean age of pregnant women was 29.95 ± 4.94 years. In this study of the 292 pregnant women, 235 (80.5%) said they prefer CD. There was a statistically significant relation between preference for CD and the following variables: pregnant women's educational level (P < 0.001; OR = 3.86; 95% CI = 1.85-8.05) and doctor's advice (P = 0.021; OR = 3.55; 95% CI = 1.21-10.43). The pregnant women with a previous CD presented four-fold upper chance of choosing CD.

CONCLUSIONS

As observed in this study, most pregnant women with previous caesarean delivery prefer repeated caesarean delivery rather than VD in their subsequent pregnancy and educational level of pregnant women and doctor's advice were important factors that influenced this preference. This subject suggests the need to counsel pregnant women with an obstetrician before select delivery type.

Reasons for performing a caesarean section in public hospitals in rural Bangladesh

Background

It is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as “unnecessary”. Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure.

Methods

Retrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS.

Results

The commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and “post-term dates” were common indications for elective CS with “post dates” – the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to “lobby” for CS.

Conclusion

Factors other than evidence based practice or the presence of a clear medical indication influence providers’ decision to perform both elective and emergency CS in public hospitals in Bangladesh.

Change of childbirth preference after delivery among nulliparous Chinese women and their partners

AIM

The aim of the present study was to assess the effect of childbirth preference among nulliparous Chinese women and their partners on actual mode of delivery, and to assess women's change in preference from vaginal delivery to cesarean and the factors associated with this change.

METHODS

A cohort study was conducted from July to October 2011 in the First Hospital of Tsinghua University, Beijing. Nulliparous women at the gestational age of 36-40 weeks and their partners were included. Their childbirth preference was recorded twice: once in pregnancy and again 2 or 3 days post-partum.

RESULTS

Women preferring cesarean during pregnancy had a 3.9-fold higher chance of undergoing a cesarean than those preferring vaginal delivery (P = 0.004), while the partner's preference had no effect (P = 0.35). Preference for cesarean in the post-partum period increased significantly compared to that during pregnancy both among women, whose preference increased from 10.1% to 28.0%, and among their partners, whose preference increased from 7.8% to 16.7% (P < 0.001 for both). The rate of change in women's preference from vaginal delivery to cesarean was 26.0%. Women having high couple's monthly income, who were feeling depressed, whose partner preferred cesarean during pregnancy or who delivered by cesarean were more likely to experience this change due to fear of labor pain and perineal cutting and a greater perceived safety of cesarean.

CONCLUSION

Women's cesarean preference during pregnancy was associated with actual cesarean delivery. Inadequate quality of care in labor and delivery and overestimation of cesarean safety underlie post-partum women's increased preference for cesarean.

Why do some pregnant women prefer cesarean delivery in first pregnancy?

BACKGROUND

The increasing number of cesarean section is a great concern in many countries. In Iran cesarean section rate has been steadily rising from 35% in 2000 to 40% in 2005. Preferences for cesarean are often associated with some factors.

OBJECTIVE

To investigate factors associated with preference for cesarean delivery, with special emphasis on pregnant women's preferences in first pregnancy in Neyshabur (Northeast of Iran).

MATERIALS AND METHODS

In this cross-sectional study, written questionnaires were completed via face to face interview with 797 pregnant women in first pregnancy. Socio-demographic data, preference toward mode of delivery and factors associated with it were assessed by applying questionnaire. Univariate and multivariate analysis were performed to identify the independent variables associated with preference for cesarean delivery.

RESULTS

In this study observed that 18.6% of pregnant women preferred caesarean delivery in first pregnancy. The mean age of pregnant women that they preferred cesarean delivery was upper than pregnant women that they preferred vaginal delivery and this difference was statistically significant (p=0.006). There was a statistically significant relation between preference for cesarean delivery and the following variables: educational level (p<0.001), gestational age (p=0.003) spouse's age of pregnant women (p=0.001), physician's advice (p<0.001), and fear of delivery (p<0.001).

CONCLUSION

The results of this study show that the majority of pregnant women do not prefer caesarean delivery to vaginal delivery. Nevertheless the preference rate for cesarean delivery exceeded 15% that suggested by WHO and most important factors in pregnant women prefer cesarean deliveries are fear of delivery and physician's advice.

Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana program in India

BACKGROUND

Demand side financing (DSF) is a widely employed strategy to enhance utilization of healthcare. The impact of DSF on health care seeking in general and that of maternal care in particular is already known. Yet, its effect on financial access to care, out-of-pocket spending (OOPS) and provider motivations is not considerably established. Without such evidence, DSFs may not be recommendable to build up any sustainable healthcare delivery approach. This study explores the above aspects on India's Janani Suraksha Yojana (JSY) program.

METHODS

This study employed design and was conducted in three districts of Orissa, selected through a three-stage stratified sampling. The quantitative method was used to review the Health Management Information System (HMIS). The qualitative methods included focus groups discussions with beneficiaries (n = 19) and community intermediaries (n = 9), and interviews (n = 7) with Ministry of Health officials. HMIS data enabled to review maternal healthcare utilization. Group discussions and interviews explored the perceived impact of JSY on in-facility delivery, OOPS, healthcare costs, quality of care and performance motivation of community health workers.

RESULTS

The number of institutional deliveries, ante-and post-natal care visits increased after the introduction of JSY with an annual net growth of 18.1%, 3.6% and 5% respectively. The financial incentive provided partial financial risk-protection as it could cover only 25.5% of the maternal healthcare cost of the beneficiaries in rural areas and 14.3% in urban areas. The incentive induced fresh out-of-pocket spending for some mothers and it could not address maternal care requirements comprehensively. An activity-based community worker model was encouraging to augment maternal healthcare consumption. However, the existing level of financial incentives and systemic support were inadequate to motivate the volunteers optimally on their performance.

CONCLUSION

Demand side financial incentive could enhance financial access to maternal healthcare. However, it did not adequately protect households from financial risks. An effective integration of JSY with similar social protection or financial risk-protection measures may protect mothers substantially from potential out-of-pocket spending. Further, this integrated approach may help upholding more awareness on maternal health rights and entitlements. It can also address maternal health beyond 'maternal healthcare' and ensure sustainability through pooled financial and non-financial resources.