Maternal reasons for requesting planned cesarean section in Norway: a qualitative study

Prevalence of obstetric violence in high-income countries: A systematic review of mixed studies and meta-analysis of quantitative studies

INTRODUCTION

Obstetric violence, or mistreatment of women in obstetric care, can have severe consequences such as fear of future childbirth, post-traumatic stress disorder, and depression.

MATERIAL AND METHODS

The primary objective was to estimate the prevalence of obstetric violence in high-income countries. The secondary objective was to extract the main domains of obstetric violence perceived by women from qualitative studies. Following prospective registration (PROSPERO CRD42023468570), PubMed, Web of Science, Scopus, CINAHL, Embase, and Cochrane Library were searched with no restrictions. Included studies were cross-sectional, cohort, mixed methods, and qualitative studies based on populations from high-income countries. The review was conducted by two independent reviewers. Risk of bias was assessed. Rates of obstetric violence were pooled using random effects model, computing 95% confidence intervals (CI) and assessing heterogeneity using I2 statistic. Funnel plots and Egger's test were used to detect potential reporting biases and small-study effects.

RESULTS

Of the 1821 records screened, 25 studies were included: 14 quantitative and 2 mixed methods studies, comprising 60 987 women, and 9 qualitative studies were included, comprising an additional 4356 women. 81.25% of quantitative studies, including the quantitative component of the mixed methods studies, were considered satisfactory or better regarding risk of bias. The prevalence of obstetric violence was overall 45.3% (95% CI 27.5-63.0; I2 = 100.0%). The prevalence of specific forms of mistreatment was also estimated. Lack of access to analgesia was 17.3% (95% CI 6.9-27.7; I2 = 99.7%). Ignored requests for help was 19.2% (95% CI 11.7-26.6; I2 = 99.0%). Shouting and scolding 19.7% (95% CI 13.0-26.4; I2 = 98.7%). The use of fundal pressure during the second stage of labor (Kristeller maneuver) was 30.3% (95% CI 22.1-38.5; I2 = 97.6%). There was no funnel asymmetry. Lack of information and/or consent were the most frequent domains extracted from the qualitative articles and the qualitative component of the mixed methods studies.

CONCLUSIONS

The results demonstrate that obstetric violence is a prevalent problem that women in high-income countries experience. Lack of information and/or consent were the domains most frequently described in the qualitative studies and the qualitative component of the mixed methods studies.

A cluster analysis of reasons behind fear of birth among women in Sweden

BACKGROUND

Fear of birth is common and complex, caused by a variety of reasons. The aim was to investigate the prevalence of pre-established reasons in relation to fear, and to identify profiles of women based on their reported reasons behind fear of birth.

METHODS

A cross-sectional Swedish study of women with self-reported fear of birth who completed an online survey. Descriptive statistics, chi-square test, crude and adjusted odds ratios with 95% confidence intervals were used in the analysis of pre-established reasons in relation to self-reported severe fear. A Kappa-means cluster analysis was performed in order to group reasons, that were further investigated in relation to women's background variables.

RESULTS

A total of 1419 women completed the survey. The strongest reason behind fear of birth was to be forced to give birth vaginally. Four clusters were identified and labeled: minor complexity (reference group), relative minor complexity, relative major complexity, and major complexity. Cesarean section preference, previous mental health problems, being younger, primiparity, and exposure to domestic violence were factors related to cluster grouping.

CONCLUSIONS

Women with fear of birth have various reasons and diverse complexities behind their fear. Health care providers need to investigate these reasons and support pregnant women with childbirth fear, based on their needs.

Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system

OBJECTIVE

Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

METHODS

This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

RESULTS

A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

CONCLUSION

This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Infant Infections Following Cesarean Delivery on Maternal Request: A Population-Based Cohort Study

OBJECTIVES

Investigations about cesarean delivery (CD) on maternal request (CDMR) and infant infection risk frequently rely on administrative data with poorly defined indications for CD. We sought to determine the association between CDMR and infant infection using an intent-to-treat approach.

METHODS

This was a population-based cohort study of low-risk singleton pregnancies with a term live birth in Ontario, Canada between April 2012 and March 2018. Subjects with prior CD were excluded. Outcomes included upper and lower respiratory tract infections, gastrointestinal infections, otitis media, and a composite of these 4. Relative risk and 95% CI were calculated for component and composite outcomes up to 1 year following planned CDMR versus planned vaginal deliveries (VDs). Subgroup and sensitivity analyses included age at infection (≤28 vs. >28 days), type of care (ambulatory vs. hospitalisation), restricting the cohort to nulliparous pregnancies, and including individuals with previous CD. Last, we re-examined outcome risk on an as-treated basis (actual CD vs. actual VD).

RESULTS

Of 422 134 pregnancies, 0.4% (1827) resulted in a planned CDMR. After adjusting for covariates, planned CDMR was not associated with a risk of composite infant infections (adjusted relative risk 1.02; 95% CI 0.92-1.11). Findings for component infection outcomes, subgroup, and sensitivity analyses were similar. However, the as-treated analysis of the role of delivery mode on infant risk for infection demonstrated that actual CD (planned and unplanned) was associated with an increased risk for infant infections compared to actual VD.

CONCLUSIONS

Planned CDMR is not associated with increased risk for neonatal or infant infections compared with planned VD. Study design must be carefully considered when investigating the impact of CDMR on infant infection outcomes.

Psychometric properties of the experiences of maternity care scale among Iranian women

BACKGROUND

Assessing women's perceptions of the care they receive is crucial for evaluating the quality of maternity care. Women's perceptions are influenced by the care received during pregnancy, labour and birth, and the postpartum period, each of which with unique conditions, expectations, and requirements. In England, three Experience of Maternity Care (EMC) scales - Pregnancy, Labour and Birth, and Postnatal - have been developed to assess women's experiences from pregnancy through the postpartum period. This study aimed to validate these scales within the Iranian context.

METHODS

A methodological cross-sectional study was conducted from December 2022 to August 2023 at selected health centers in Tabriz, Iran. A panel of 16 experts assessed the qualitative and quantitative content validity of the scales and 10 women assessed the face validity. A total of 540 eligible women, 1-6 months postpartum, participated in the study, with data from 216 women being used for exploratory factor analysis (EFA) and 324 women for confirmatory factor analysis (CFA) and other analyses. The Childbirth Experience Questionnaire-2 was employed to assess the convergent validity of the Labour and Birth Scale, whereas women's age was used to assess the divergent validity of the scales. Test-retest reliability and internal consistency were also examined.

RESULTS

All items obtained an impact score above 1.5, with Content Validity Ratio and Content Validity Index exceeding 0.8. EFA demonstrated an excellent fit with the data (all Kaiser-Meyer-Olkin measures > 0.80, and all Bartlett's p < 0.001). The Pregnancy Scale exhibited a five-factor structure, the Labour and Birth Scale a two-factor structure, and the Postnatal Scale a three-factor structure, explaining 66%, 57%, and 62% of the cumulative variance, respectively, for each scale. CFA indicated an acceptable fit with RMSEA ≤ 0.08, CFI ≥ 0.92, and NNFI ≥ 0.90. A significant correlation was observed between the Labour and Birth scale and the Childbirth Experience Questionnaire-2 (r = 0.82, P < 0.001). No significant correlation was found between the scales and women's age. All three scales demonstrated good internal consistency (all Cronbach's alpha values > 0.9) and test-retest reliability (all interclass correlation coefficient values > 0.8).

CONCLUSIONS

The Persian versions of all three EMC scales exhibit robust psychometric properties for evaluating maternity care experiences among urban Iranian women. These scales can be utilized to assess the quality of current care, investigate the impact of different care models in various studies, and contribute to maternal health promotion programs and policies.

"I need to make sense of my birth experience": A descriptive qualitative study of postnatal women's opinions, and expectations about postnatal debriefing

BACKGROUND

Evidence shows that women feel valued and satisfied after discussing their birth experiences. However, uncertainties persist surrounding the concept of postnatal debriefing practice.

AIM

To explore the opinions and expectations of women relating to postnatal debriefing and their experiences when the postnatal debriefing is not presented.

METHOD

A descriptive qualitative study of 20 postnatal women was conducted using in-depth semi-structured interviews from April-May 2023. Thematic analysis was applied to the data collected in interviews.

RESULTS

Analysis of interview data generated three main themes and nine sub-themes. Women wanted to make sense of their birth experience They expressed their opinions on the components of postnatal debriefing They advocated for all women to be offered this practice by known healthcare professionals who interact with them They do not want to only talk about their birth experience but also meet their needs Women agree that expectations related to birth determine the need for the practice. They hoped for psychological adaptation by relieving their distress and gaining a sense of closure. The discussion process was expected to prevent reflection of trauma to the future and provide transition to the postnatal period.

CONCLUSION

The present study explored women perceptions and expectations of postnatal debriefing. Healthcare professionals should behave sensitively to women's expectations and needs in relation to their birth experience. Further research is warranted to clarify the components and effects of postnatal debriefing practice to develop consolidated guidance.

Association between hepatitis B virus replication during pregnancy and perinatal outcomes: a retrospective cohort study

BACKGROUND

The effect of hepatitis B virus (HBV) replication during pregnancy on the outcomes of pregnancies remains to be elucidated.

OBJECTIVES

This study aimed to investigate the association between HBV replication and adverse maternal and infant outcomes.

METHODS

We retrospectively analysed the clinical data of 836 pregnant inpatients with hepatitis B surface antigen positivity who delivered at two provincial tertiary grade A hospitals in the Fujian province between June 2016 and October 2020.

RESULTS

The incidence of intrahepatic cholestasis of pregnancy, hypertensive syndrome complicating pregnancy, gestational diabetes mellitus, preterm birth, macrosomia, growth restriction, and vaginal infections did not differ in the HBV replication and non-replication groups (p > 0.05); however, the rates of caesarean section (p = 0.017; OR, 1.423; 95% CI, 1.065-1.902) and neonatal jaundice (p < 0.001; OR, 2.361; 95% CI, 1.498-3.721) were higher in the replication group than that in the non-replication group. After using propensity score analysis to adjust for alanine transaminase and aspartate aminotransferase levels in both groups, the replication group was still found to have an increased risk for caesarean section (p < 0.001; OR, 2.367; 95% CI, 1.668-3.359) and their infants had higher rates of neonatal jaundice (p < 0.001; OR, 12.605; 95% CI, 4.456-35.656).

CONCLUSIONS

Our findings contribute to a better understanding of the association between maternal HBV replication status and perinatal outcomes. Pregnant women with HBV replication face an increased risk of caesarean section, and their infants appear to have a higher risk for neonatal jaundice.

Making the cut on caesarean section: a logistic regression analysis on factors favouring caesarean sections without medical indication in comparison to spontaneous vaginal birth

BACKGROUND

In the absence of medical necessity, opting for caesarean sections exposes mothers and neonates to increased risks of enduring long-term health problems and mortality. This ultimately results in greater economic burden when compared to the outcomes of spontaneous vaginal births. In Switzerland around 33% of all births are by caesarean section. However, the rate of caesarean sections without medical indication is still unknown. Therefore, we devise an identification strategy to differentiate caesarean sections without medical indication using routine data. In addition, we aim to categorize the influencing factors for women who undergo spontaneous vaginal births as opposed to those with caesarean sections without medical indication.

METHOD

We use Swiss Federal Statistics data including 98.3% of all women giving birth from 2014 to 2018. To determine non-medically indicated caesarean sections in our dataset, we base our identification strategy on diagnosis-related groups, diagnosis codes, and procedure classifications. Subsequently, we compare characteristics of women who give birth by non-medically CS and external factors such as the density of practicing midwives to women with spontaneous vaginal birth. Logistic regression analysis measures the effect of factors, such as age, insurance class, income, or density of practicing midwives on non-medically indicated caesarean sections.

RESULTS

Around 8% of all Swiss caesarean sections have no medical indication. The regression analysis shows that higher age, supplemental insurance, higher income, and living in urban areas are associated with non-medically indicated caesarean sections, whereas a higher density of midwives decreases the likelihood of caesarean sections without medical indication.

CONCLUSIONS

By identifying non-medically indicated caesarean sections using routine data, it becomes feasible to gain insights into the characteristics of impacted mothers as well as the external factors involved. Illustrating these results, our recommendation is to revise the incentive policies directed towards healthcare professionals. Among others, future research may investigate the potential of midwife-assisted pregnancy programs on strengthening spontaneous vaginal births in absence of medical complications.

Vaginal birth after cesarean or recurrent elective cesarean section: What are the decision making processes of pregnant women in Turkey? A phenomenological study

What is known about deciding the mode of delivery after cesarean section (CS) is limited. Our aim was explore women's decision-making process since pregnancy. Constant comparative analysis was used in the analysis. COREQ checklist was used in reporting. The main theme was inability of having control. Four categories emerged; reasons for wanting VBAC, VBAC experiences, reasons for RCS, and RCS experiences. Women did not have an absolute say in their decisions. RCS experiences were defined as traumatic and VBAC experiences were defined as achievement that provided strength and pride. Findings contribute to the literature on increasing the success of VBAC the importance and encouraging healthcare professionals.

Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis

BACKGROUND

Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use.

METHODS

We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success.

RESULTS

We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components.

CONCLUSION

We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby.

Optimising maternity care for a subsequent pregnancy after a psychologically traumatic birth: A scoping review

BACKGROUND

Psychological birth trauma is recognised as a significant and ubiquitous sequelae from childbirth, with the incidence reported as up to 44%. In a subsequent pregnancy, women have reported a range of psychological distress symptoms from anxiety, panic attacks, depression, sleep difficulties and suicidal thoughts.

AIM

To summarise evidence on optimising a positive pregnancy and birth experience for a subsequent pregnancy following a psychologically traumatic pregnancy and identify research gaps.

METHODS

This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR check list. Six databases were searched using key words relating to psychological birth trauma and subsequent pregnancy. Utilising agreed criteria, relevant papers were identified, and data were extracted and synthesised.

RESULTS

A total of 22 papers met the inclusion criteria for this review. All papers addressed different aspects of what was important to women in this cohort, summarised as women wanting to be at the centre of their care. Pathways of care were diverse ranging from free birth to elective caesarean. There was no systematic process for identifying a previously traumatic birth experience and no education to enable clinicians to understand the importance of this.

CONCLUSION

For women who have experienced a previous psychologically traumatic birth, being at the centre of their care, in their subsequent pregnancy, is a priority. Embedding woman-centred pathways of care for women with this experience, as well as multidisciplinary education on the recognition and prevention of birth trauma, should be a research priority.

Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis

Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3-8 weeks' follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.

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.

Conflicting attitudes between clinicians and women regarding maternal requested caesarean section: a qualitative evidence synthesis

BACKGROUND

Caesarean section (CS) can be a life-saving operation but might also negatively affect the health of both the woman and the baby. The aim of this study was to synthesize and contrast women's and clinicians' attitudes toward maternal-requested CS, and their experiences of the decision-making process around CS.

METHODS

The databases of CINAHL, MEDLINE, PsycInfo and Scopus were screened. All qualitative studies that answered the study question and that were assessed to have minor or moderate methodological limitations were included. Synthesised findings were assessed using GRADE-CERQual.

RESULTS

The Qualitative Evidence Synthesis included 14 qualitative studies (published 2000-2022), involving 242 women and 141 clinicians. From the women's perspectives, two themes arose: women regarded CS as the safest mode of birth; and women's rights to receive support and acceptance for a CS request. From the clinicians' perspectives, four themes emerged: clinicians were concerned about health risks associated with CS; demanding experience to consult women with a CS request; conflicting attitudes about women's rights to choose a CS; and the importance of respectful and constructive dialogue about birthing options.

CONCLUSION

Women and clinicians often had different perceptions regarding the right of a woman to choose CS, the risks associated with CS, and the kind of support that should be part of the decision-making process. While women expected to receive acceptance for their CS request, clinicians perceived that their role was to support the woman in the decision-making process through consultation and discussion. While clinicians thought it was important to show respect for a woman's birth preferences, they also felt the need to resist a woman's request for CS and encourage her to give birth vaginally due to the associated increases in health risks.

Predictors of successful vaginal birth after a cesarean section in Ethiopia: a systematic review and meta-analysis

BACKGROUND

The rates of successful vaginal birth after previous cesarean section (VBAC) have been increasing with minimal complication. Successful vaginal birth after cesarean section improves maternal and fetal outcomes by shortening the length of hospital stay, avoiding abdominal surgery, decreasing the risk of infections and hemorrhage, and decreasing injury of the bladder and bowel. Despite a few single studies stating different predictors of successful VBAC, there is a lack of nationwide data to show the determinants of successful VBAC. Thus, this meta-analysis aimed to determine the predictors of successful VBAC in Ethiopia.

METHODS

A systematic literature search was performed from PubMed, Web of Sciences, EMBASE, CINAHL, and Google scholar until July 25, 2022. The quality of included studies was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist. The analysis was executed using Stata 14 statistical software. Heterogeneity was evaluated statistically using Cochran's Q-statistic and quantified by the I² value. A random-effects model was used to estimate the determinants of successful vaginal birth after a cesarean section if substantial heterogeneity was detected across included studies; otherwise, a fixed-effects model was used.

RESULTS

Women living in rural residence (AOR: 2.14; 95% CI: 1.01, 4.52), history of previous spontaneous vaginal delivery (AOR: 2.92; 95% CI: 2.02, 4.23), previous successful vaginal birth after previous cesarean section (AOR: 5.29; 95% CI: 2.20, 12.69), history of stillbirth (AOR: 1.57; 95% CI: 1.20, 2.04), cervical dilation of ≥ 4 cm at admission (AOR: 2.14; 95% CI: 1.27, 3.61), spontaneous ruptured membranes at admission (AOR: 1.32; 95% CI: 1.17, 1.48) were independent determinants of successful vaginal birth after previous cesarean section.

CONCLUSION

The results of this meta-analysis showed that successful VBAC was influenced by past and present obstetric conditions and other predictors. Thus, it is recommended that obstetric care providers should emphasize those factors that lead to successful vaginal birth during counseling and optimal selection of women for the trial of labour after cesarean section.

SYSTEMATIC REVIEW AND META-ANALYSIS REGISTRATION

PROSPERO CRD42022329567.

Challenging norms: Making non-normative choices in childbearing. Results of a meta ethnographic review of the literature

OBJECTIVE

Women have the right to make choices during pregnancy and birth that sit outside clinical guidelines, medical recommendations, or normative expectations. Declining recommended place or mode of birth, routine intervention or screening can be considered 'non-normative' within western cultural and social expectations around pregnancy and childbirth. The aim of this review is to establish what is known about the experiences, views, and perceptions of women who make non-normative choices during pregnancy and childbirth to uncover new understandings, conceptualisations, and theories within existing literature.

METHODS

Using the meta-ethnographic method, and following its seven canonical stages, a systematic search of databases was performed, informed by eMERGe guidelines.

FINDINGS

Thirty-three studies met the inclusion criteria. Reciprocal translation resulted in three third order constructs - 'influences and motivators', 'barriers and conflict and 'knowledge as empowerment'. Refutational translation resulted in one third order construct - 'the middle ground', which informed the line of argument synthesis and theoretical insights.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings of this review suggest that whilst existing literature from a range of high-income countries with similar healthcare systems to the UK have begun to explore non-normative decision-making for discrete episodes of care and choices, knowledge based, theoretical and population gaps exist in relation to understanding the experiences of, and wider social processes involved in, making non-normative choices across the UK maternity care continuum.

“I shut it out”: expectant mothers’ fear of childbirth after a traumatic birth—a phenomenological study

Purpose

To describe expectant mothers’ experiences of fear of childbirth after a previous traumatic birth.

Method

Qualitative, individual, in-depth interviews were conducted with eight expectant mothers between September and November 2020. Data were analysed using a descriptive phenomenological approach.

Results

We identified four interconnected constituents: Suboptimal midwifery care, loss of control and agency; insufficient time and capacity to process a traumatic birth experience; “The baby has to be delivered!”, and finally, the path to a new childbirth with the hope of mastering fears.

Conclusion

Findings reveal an association between a previous history of traumatic birth and a fear of childbirth in expectant mothers. The trauma they experienced whilst giving birth strongly impacted their subsequent pregnancy, making it difficult for them to deal with the new pregnancy and impending birth. Women who have experienced a traumatic birth need to have the opportunity to process the trauma. Routines must therefore be developed that identify, support and follow up with the women. If these women are identified and given the help they need, this may help prevent and/or alleviate fear of childbirth in their subsequent pregnancy.

Interventions targeting healthcare providers to optimise use of caesarean section: a qualitative comparative analysis to identify important intervention features

BACKGROUND

Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers.  METHODS: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS.

RESULTS

We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components.

CONCLUSION

We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits.

Traumatic Childbirth Experiences of New Parents: A Meta-Synthesis

Childbirth is usually a joyous occasion. However, a significant proportion of parents experienced traumatic childbirths and suffered post-traumatic consequences, which needs urgent attention. Therefore, this review aimed to explore and understand the traumatic childbirth experiences of parents. A systematic review of qualitative studies was done. The consolidated evidence was meta-summarized and meta-synthesized based on Sandelowski and Barroso's approach for synthesizing qualitative research. Seven electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to April 2020. Retrieved studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and 19 studies were included in this review. All included studies were meta-summarized and meta-synthesized. An overarching theme, "traumatic birth: an evolving voyage," with three main themes, (1) "proceedings to traumatic birth," (2) "internal and external battles," and (3) "muddling through to beating the odds," and 10 subthemes were identified. Overall, parents felt fluctuations of emotions that seemed to be never-ending journeys. They expressed that various factors led to their traumatic birth experiences, especially health care providers' dismissive attitudes. Parents commonly reported feelings of powerlessness and fear for the safety of mothers and infants. Their constant battles to overcome traumatic experiences affected some of their relationships. To deal with the trauma, some mothers displayed avoidance behaviors while others relied on social support. As health care providers play important roles in influencing outcomes of childbirth, they should be mindful of the care provided during labors and childbirths.

Evaluation of obstetric and neonatal outcomes and cesarean section rates of Syrian and Turkish adolescent pregnant women according to the Robson ten group classification system

Aim: Our research has two purposes. To begin with, we sought to determine whether there were any differences in maternal and newborn outcomes between Syrian adolescent and adult pregnant women living in Turkey after the Syrian civil war and Turkish adolescent and adult pregnant women. Second, we wanted to examine and compare the rates of cesarean section (CS) and spontaneous vaginal delivery (SVD) in adolescent and adult pregnant women using the Robson ten group classification system (RTGCS). Material and Method: Our study investigated data from a retrospective cross-sectional study of 1823 Turkish and Syrian pregnant women who gave birth between September 2020 and August 2021 in a tertiary reference hospital in Turkey's Mediterranean area. Our study enrolled 838 pregnant adolescent girls between the ages of 13 and 19 and 985 pregnant adult women between the ages of 20 and 47. Results: The probability of adolescent pregnancy is 3.081 times greater among Syrian refugees than among Turkish natives (p

"From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury

OBJECTIVE

Few studies have investigated women's experiences of daily life after childbirth complicated by obstetric anal sphincter injury (OASI). The aim of the present study was to explore experiences related to recovery, sexual function, relationships and coping strategies among women affected by OASI.

METHODS

In-depth interviews were conducted using a purposive sample of 11 women affected by OASI. Women were interviewed 1-2 years after their first childbirth. Inductive qualitative content analysis was applied.

RESULTS

The theme "From hell to healed" illustrates women's experiences of recovery, relationships and sexual function after OASI. Three categories addressing women's perceptions emerged: "Challenged to the core", "At the mercy of the care provider" and "For better or for worse". Support from partners and family and comprehensive care were important elements for the experiences of coping and healing from OASI. Elements that negatively influenced women's experiences were the pain and physical symptoms of pelvic floor dysfunction, normalization of symptoms by heath care providers, and unrealistic expectations about how this period in life should be experienced.

CONCLUSION

OASI greatly affects women's experiences of their first years with their newborn child, relationships, social context and sexuality. For some women, OASI negatively affects everyday life for a long period after childbirth. However, others heal and cope quite quickly. Health care professionals need to identify and pay attention to women with persisting problems after OASI so that they can be directed to the right level of care.

Cesarean delivery in Norwegian nulliparous women with singleton cephalic term births, 1967-2020: a population-based study

Background

Nulliparous women contribute to increasing cesarean delivery in the Nordic countries and advanced maternal age has been suggested as responsible for rise in cesarean delivery rates in many developed countries. The aim was to describe changes in cesarean delivery rates among nulliparous women with singleton, cephalic, term births by change in sociodemographic factors across 50 years in Norway.

Methods

We used data from the Medical Birth Registry of Norway and included 1 067 356 women delivering their first, singleton, cephalic, term birth between 1967 and 2020. Cesarean delivery was described by maternal age (5-year groups), onset of labor (spontaneous, induced and pre-labor CD), and time periods: 1967–1982, 1983–1998 and 1999–2020. We combined women’s age, onset of labor and time period into a compound variable, using women of 20–24 years, with spontaneous labor onset during 1967–1982 as reference. Multivariable regression models were used to estimate adjusted relative risk (ARR) of cesarean delivery with 95% confidence interval (CI).

Results

Overall cesarean delivery increased both in women with and without spontaneous onset of labor, with a slight decline in recent years. The increase was mainly found among women < 35 years while it was stable or decreased in women >  = 35 years. In women with spontaneous onset of labor, the ARR of CD in women >  = 40 years decreased from 14.2 (95% CI 12.4–16.3) in 1967–82 to 6.7 (95% CI 6.2–7.4) in 1999–2020 and from 7.0 (95% CI 6.4–7.8) to 5.0 (95% CI 4.7–5.2) in women aged 35–39 years, compared to the reference population. Despite the rise in induced onset of labor over time, the ARR of CD declined in induced women >  = 40 years from 17.6 (95% CI 14.4–21.4) to 13.4 (95% CI 12.5–14.3) while it was stable in women 35–39 years.

Conclusion

Despite growing number of Norwegian women having their first birth at a higher age, the increase in cesarean delivery was found among women < 35 years, while it was stable or decreased in older women. The increase in cesarean delivery cannot be solely explained by the shift to an older population of first-time mothers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04755-3.

Prediction of Emergency Cesarean Section Using Machine Learning Methods: Development and External Validation of a Nationwide Multicenter Dataset in Republic of Korea

This study was a multicenter retrospective cohort study of term nulliparous women who underwent labor, and was conducted to develop an automated machine learning model for prediction of emergent cesarean section (CS) before onset of labor. Nine machine learning methods of logistic regression, random forest, Support Vector Machine (SVM), gradient boosting, extreme gradient boosting (XGBoost), light gradient boosting machine (LGBM), k-nearest neighbors (KNN), Voting, and Stacking were applied and compared for prediction of emergent CS during active labor. External validation was performed using a nationwide multicenter dataset for Korean fetal growth. A total of 6549 term nulliparous women was included in the analysis, and the emergent CS rate was 16.1%. The C-statistics values for KNN, Voting, XGBoost, Stacking, gradient boosting, random forest, LGBM, logistic regression, and SVM were 0.6, 0.69, 0.64, 0.59, 0.66, 0.68, 0.68, 0.7, and 0.69, respectively. The logistic regression model showed the best predictive performance with an accuracy of 0.78. The machine learning model identified nine significant variables of maternal age, height, weight at pre-pregnancy, pregnancy-associated hypertension, gestational age, and fetal sonographic findings. The C-statistic value for the logistic regression machine learning model in the external validation set (1391 term nulliparous women) was 0.69, with an overall accuracy of 0.68, a specificity of 0.83, and a sensitivity of 0.41. Machine learning algorithms with clinical and sonographic parameters at near term could be useful tools to predict individual risk of emergent CS during active labor in nulliparous women.

Tocophobia and Women's Desire for a Caesarean Section: a Systematic Review

Introduction:The rate of cesarean sections has been continuously increasing in most industrialized countries in recent years. It has been observed that the rate of cesarean sections has increased in the last thirty years and is now between 0.4 and 65%. A significant percentage of women, ranging from 1-20%, request a caesarean section without a medical indication. Aim:The aim of this study is to systematically review the available international literature concerning the phenomenon of tocophobia leading to woman`s desire for a caesarean section. Methods: The methodology followed, included an advanced search in various scientific databases and retrieval of the relevant quantitative studies. Results:We found a total of seven papers, all in English, which examined the correlation between tocophobia and women's desire for a caesarean section. Conclusions:One of the primary reasons behind women's desire to give birth through a caesarean delivery is the pathological fear associated with the labor process, known under the scientific term "tocophobia". According to the findings of this review, the prevalence of tocophobia ranged between 7-25% among primiparous women and 7.7-16.25% among multiparous ones. Approximately 7-18.6% of women with tocophobia asked for an elective cesarean section without any medical indication. Clinical treatment of tocophobia is required when the condition has a negative impact on the pregnant woman's quality of life and her bond with the embryo, as well as when it affects her decision regarding the method of childbirth.

Effect of Hypnobirthing Training on Fear, Pain, Satisfaction Related to Birth, and Birth Outcomes: A Randomized Controlled Trial

We aimed to determine the effect of Hypnobirthing training on fear of childbirth (FOC), birth pain, birth satisfaction and birth outcomes. This randomized controlled trial study was conducted with 80 nulliparous pregnant who were divided into two groups (experimental group n = 40 and control n = 40) in a maternity hospital. The couples received the training in groups(4 weeks, once a week, 3-hour, group session). The mean score of hypnobirthing group for the whole Wijma Birth Expectancy/Experience Scale was significantly lower than that of the routine care group (p < .001).In the latent, active, and transitional phases of labor, the Visual Analog Scale (VAS)scores of the experimental groups were found to be significantly lower than those of the control group (p < .001).The experimental group's rates of birth intervention were significantly lower and their deliveries period were shorter, than those that of the routine control group (p < .001).In addition, the vaginal delivery rates (p = .037)and the scores for the Birth Satisfaction Scale-Revised (BSS-R) were also found to be higher than those of the control group (p < .001).

The Effect of Skin-to-Skin Contact on Postoperative Depression and Physical Recovery of Parturients after Cesarean Section in Obstetrics and Gynecology Department

The effect of skin-to-skin contact (SSC) on postpartum depression and physical rehabilitation of cesarean section women was explored. 280 parturients undergoing cesarean section were selected and were rolled into two groups randomly. The parturients in the control group (Con group, 140 cases) received routine care, and those in the experimental group (Exp group, 140 cases) received SSC on the basis of routine care. The postpartum depression and physical recovery of parturients in two groups were compared. It was found that, in the Exp group, the number of pregnant women with no or with very mild depression was much more 85% vs. 55%), the number of women with adequate lactation was more (53 cases vs. 27 cases), the first lactation time (FLT) was dramatically shorter (41.25 ± 4.81 h vs. 58.43 ± 5.43 h), the breastfeeding success rate (BFSR) and breastfeeding rate (BFR) were obvious higher, the days for uterine involution was much shorter (6.96 ± 1.13 days vs. 9.47 ± 1.75 days), the descent of uterine fundus 24 hours after delivery (24 h-DUF) was obviously larger (3.17 ± 0.26 mm vs. 1.56 ± 0.43 mm), the duration of lochia (DOL) was remarkably shorter (33.21 ± 5.32 days vs. 25.32 ± 3.54 days), and the Visual Analogue Scale (VAS) score was lower (4.88 ± 0.32 points vs. 3.41 ± 0.53 points), showing statistical differences for all above indicators (P < 0.05). It suggested that SSC could effectively relieve the postpartum depression of uterine parturients, promote the lactation, increase the BFR, facilitate uterine involution, and alleviate chronic uterine inflammation and postpartum pain, showing high clinical application and promotion value.

Changes in maternal risk factors and their association with changes in cesarean sections in Norway between 1999 and 2016: A descriptive population-based registry study

BACKGROUND

Increases in the proportion of the population with increased likelihood of cesarean section (CS) have been postulated as a driving force behind the rise in CS rates worldwide. The aim of the study was to assess if changes in selected maternal risk factors for CS are associated with changes in CS births from 1999 to 2016 in Norway.

METHODS AND FINDINGS

This national population-based registry study utilizes data from 1,055,006 births registered in the Norwegian Medical Birth Registry from 1999 to 2016. The following maternal risk factors for CS were included: nulliparous/≥35 years, multiparous/≥35 years, pregestational diabetes, gestational diabetes, hypertensive disorders, previous CS, assisted reproductive technology, and multiple births. The proportion of CS births in 1999 was used to predict the number of CS births in 2016. The observed and predicted numbers of CS births were compared to determine the number of excess CS births, before and after considering the selected risk factors, for all births, and for births stratified by 0, 1, or >1 of the selected risk factors. The proportion of CS births increased from 12.9% to 16.1% (+24.8%) during the study period. The proportion of births with 1 selected risk factor increased from 21.3% to 26.3% (+23.5%), while the proportion with >1 risk factor increased from 4.5% to 8.8% (+95.6%). Stratification by the presence of selected risk factors reduced the number of excess CS births observed in 2016 compared to 1999 by 67.9%. Study limitations include lack of access to other important maternal risk factors and only comparing the first and the last year of the study period.

CONCLUSIONS

In this study, we observed that after an initial increase, proportions of CS births remained stable from 2005 to 2016. Instead, both the size of the risk population and the mean number of risk factors per birth continued to increase. We observed a possible association between the increase in size of risk population and the additional CS births observed in 2016 compared to 1999. The increase in size of risk population and the stable CS rate from 2005 and onward may indicate consistent adherence to obstetric evidence-based practice in Norway.

Interventions to treat fear of childbirth in pregnancy: a systematic review and meta-analysis

Background

Between 5% and 14% of women suffer from fear of childbirth (FOC) which is associated with difficulties during birth and in postnatal psychological adjustment. Therefore, effective interventions are needed to improve outcomes for women. A systematic review and meta-analysis was used to identify effective interventions for treating women with FOC.

Methods

Literature searches were undertaken on online databases. Hand searches of reference lists were also carried out. Studies were included in the review if they recruited women with FOC and aimed to reduce FOC and/or improve birth outcomes. Data were synthesised qualitatively and quantitatively using meta-analysis. The literature searches provided a total of 4474 citations.

Results

After removing duplicates and screening through abstracts, titles and full texts, 66 papers from 48 studies were identified for inclusion in the review. Methodological quality was mixed with 30 out of 48 studies having a medium risk of bias. Interventions were categorised into six broad groups: cognitive behavioural therapy, other talking therapies, antenatal education, enhanced midwifery care, alternative interventions and interventions during labour. Results from the meta-analysis showed that most interventions reduced FOC, regardless of the approach (mean effect size = −1.27; z = −4.53, p < 0.0001) and that other talking therapies may reduce caesarean section rates (OR 0.48, 95% CI 0.48–0.90).

Conclusions

Poor methodological quality of studies limits conclusions that can be drawn; however, evidence suggests that most interventions investigated reduce FOC. Future high-quality randomised controlled trials are needed so that clear conclusions can be made.

Trends and sociodemographic inequalities in the use of caesarean section in Indonesia, 1987-2017

INTRODUCTION

Caesarean section (CS) rates are increasing globally. CS can be a live-saving procedure when medically indicated, but it comes with higher risks for women and newborns when done without medical indication. Crucially, inequalities in who receives CS exist, both within and across countries. Understanding factors driving increasing rates and inequalities of CS is imperative to optimise the use of this life-saving intervention. This study aimed to investigate trends of CS use and inequalities across sociodemographic characteristics in Indonesia over a 30-year period.

METHODS

Seven waves of the Indonesia Demographic and Health Survey were used to estimate trends and inequalities in CS from 1987 to 2017. Relative and absolute inequalities across a range of sociodemographic characteristics were estimated and trends in inequalities were assessed through changes in rate ratio and rate difference.

RESULTS

The proportion of facility-based births in Indonesia has increased in the past 30 years, coinciding with an increase in CS rate (CSR) (1991 CSR: 1.6% (95% CI 1.3 to 1.9); 2017 CSR: 17.6% (95% CI 16.7 to 18.5)). Higher rates of CS are observed mostly in Western Indonesia, while lower CSRs are observed in Eastern Indonesia. Inequalities of CSRs in Indonesia are observed across type of health facility (public/private), regions, places of residence, wealth quintiles and maternal education, with the highest CSRs in more affluent and educated groups. Widening absolute inequalities of CS are observed across all sociodemographic characteristics, except facility type, where CSR gaps between public and private facilities have closed on both relative and absolute scales.

CONCLUSION

This study provides evidence of increasing trends in CSRs and widening absolute inequalities in CSRs across different sociodemographic groups of women in Indonesia. The context of increasing CSRs across society, however, may have resulted in more stable relative inequalities. Improving understanding of the drivers of these trends in Indonesia and, particularly, of women's and providers' perspectives and preferences for childbirth, should be prioritised to optimise the use of CS.

Preferences of women with low obstetric risk for cesarean or vaginal birth in Poland: Areas for intervention

BACKGROUND

In Poland, the rate of cesarean birth (CB) is 43%, which is much higher than the European average of 27%. Optimizing the CB birth rate is of critical importance, especially among women with low-risk pregnancies. However, the determinants of cesarean preference among low-risk women in Poland have not been well explored.

METHODS

This cross-sectional study included 1011 pregnant women and aimed to identify associations between selected determinants of women's preferences for CB vs. vaginal birth (VB) in Poland. A descriptive questionnaire was distributed online, and a theoretical model was validated against empirically gathered data. Group comparisons were performed using the Welch t test for continuous data or chi-square test for categorical data. All statistical analyses were performed using R (R Core Team, 2018).

RESULTS

The mean age of women preferring CB (30.46 years) was 1.25 years higher than that of women preferring VB (29.21 years). Pregnant women who expressed a preference for CB tended to be multigravid, inhabited cities, and were characterized by higher levels of anxiety and depression. Moreover, the majority of women who underwent a previous CB asserted their intention to repeat the procedure for the current pregnancy.

CONCLUSIONS

The primary factors that were correlated with high CB preference among the low-risk group included age, previous childbirth experiences, and anxiety. The underlying reasons that drive birth preferences remain poorly understood. However, women who have previously undergone difficult childbirth experiences and are afraid of pain require specialized care.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BACKGROUND

A high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the "Two-child Policy" in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.

METHODS

Data were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.

RESULTS

The rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984-9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116-14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311-0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007-16.455).

CONCLUSIONS

"Maternal request" has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

How do pregnant women's perceptions of obstetric forceps change according to their demographic background: a cross sectional study

Background

Women’s attitudes towards obstetric forceps likely contribute to declining use and opportunities for residency training, but formal documentation of women’s attitudes towards obstetric forceps is currently limited. A clearer understanding should help guide our attempts to preserve its use in modern obstetrics and to improve residency training. Our objective is to document women’s attitudes towards obstetric forceps and the influence basic demographic variables have on those attitudes.

Methods

A cross sectional study was performed. We developed a one-time anonymous structured 5-question survey that was given to all women with low-risk pregnancies presenting to our medical center for prenatal care between October 2018–December 2018. The questionnaire asked for the woman’s self-reported age, race, education level and insurance type. The five questions were as follows: (1) Do you think forceps should be used to deliver babies, (2) Is forceps safe for the baby, (3) Is forceps safe for the mother, (4) Do you think forceps can help to lower the cesarean section rate, (5) Do you think physicians in training should learn to place forceps on a real patient. We calculated means and proportions for the responses according to the overall group and various subgroups. Statistical analysis included Kruskall-Wallis or Mann-Whitney tests as appropriate. Results were also adjusted by regression using a Generalized Linear Model. Power calculation showed sample size of 384 was required.

Results

A total of 499 women returned the questionnaire. Response rate was 56.8% (499/878). The findings suggest that women’s perceptions towards forceps are generally negative. Women with white ethnicity, college education or higher and private insurance did have more favorable views than their counterparts, but the majority still had unfavorable views. Age was not shown to have a significant effect on maternal attitude.

Conclusion

Women’s views towards forceps use in the University of Kansas Medical Center are negative and may be contributing to the decline of its use. Improving women’s perceptions of forceps would require multiple different strategies rather than a single focused easily-implemented message. If forceps training continues, such training will rely on a minority of women who will accept forceps use in childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03854-x.

Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences

Background

Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS.

Methods

Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual.

Results

We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021.

Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence).

Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence).

Conclusions

A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS.

Birth outcomes following cesarean delivery on maternal request: a population-based cohort study

BACKGROUND

Data on the effect of cesarean delivery on maternal request (CDMR) on maternal and neonatal outcomes are inconsistent and often limited by inadequate case definitions and other methodological issues. Our objective was to evaluate the trends, determinants and outcomes of CDMR using an intent-to-treat approach.

METHODS

We designed a population-based retrospective cohort study using data on low-risk pregnancies in Ontario, Canada (April 2012-March 2018). We assessed temporal trends and determinants of CDMR. We estimated the relative risks for component and composite outcomes used in the Adverse Outcome Index (AOI) related to planned CDMR compared with planned vaginal delivery using generalized estimating equation models. We compared the Weighted Adverse Outcome Score (WAOS) and the Severity Index (SI) across planned modes of delivery using analysis of variance.

RESULTS

Of 422 210 women, 0.4% (n = 1827) had a planned CDMR and 99.6% (n = 420 383) had a planned vaginal delivery. The prevalence of CDMR remained stable over time at 3.9% of all cesarean deliveries. Factors associated with CDMR included late maternal age, higher education, conception via in vitro fertilization, anxiety, nulliparity, being White, delivery at a hospital providing higher levels of maternal care and obstetrician-based antenatal care. Women who planned CDMR had a lower risk of adverse outcomes than women who planned vaginal delivery (adjusted relative risk 0.42, 95% confidence interval [CI] 0.33 to 0.53). The WAOS was lower for planned CDMR than planned vaginal delivery (mean difference -1.28, 95% CI -2.02 to -0.55). The SI was not statistically different between groups (mean difference 3.6, 95% CI -7.4 to 14.5).

INTERPRETATION

Rates of CDMR have not increased in Ontario. Planned CDMR is associated with a decreased risk of short-term adverse outcomes compared with planned vaginal delivery. Investigation into the long-term implications of CDMR is warranted.

When Fear Surrounding Childbirth Leads Women to Request a Planned Cesarean Birth

Fear surrounding childbirth requires a more in-depth understanding from women’s perspectives, especially those who request a planned cesarean due to that fear. Therefore, we explored primiparous and multiparous women’s lived experiences of fear surrounding childbirth in relation to their decision to request a planned cesarean birth. We used Colaizzi’s (1978) phenomenological method to interview 16 women from 4 provinces and to analyze the data. Women expressed numerous fears and most experienced more than one fear. Most feared their baby/babies being injured or dying during childbirth or developing complications themselves. Others feared experiencing a traumatic birth. Women described numerous emotional and physical manifestations of fear, and all believed that a planned cesarean birth would provide more control over the birth process. For some, the birth of their healthy baby/babies began a healing process, whereas others noted that their fear subsided or resolved upon confirmation that they would have a planned cesarean.

Rationale of indications for caesarean delivery and associated factors among primigravidae in Tanzania

Objective

This study aimed to determine the prevalence of modes of delivery and associated maternal and newborn outcomes among singleton primigravidae in the Iringa region of Tanzania.

Methods

A cross-sectional, analytical hospital-based study was conducted in the Iringa region among 356 singleton primigravidae between April and August 2018. Convenience sampling and consecutive collection of data using a face-to-face interviewer-administered questionnaire was done.

Results

A total of 356 singleton primigravid women with a mean age of 22.0 years (range: 15–49) participated in the study. The majority of the participants (73.0%, n = 250) were in the 20–35 age group. Caesarean and vaginal delivery were performed in 41.3% (n = 147) and 58.7% (n = 209) of the cases, respectively. The maternal height and weight of the newborn were significantly associated with caesarean delivery; (p = 0.001) and (p = 0.029), respectively. After adjusting for all variables, birth asphyxia (AOR = 3.25, 95% CI: 1.867–5.646, p = 0.000) and low birth weight (AOR = 0.03, 95% CI: 0.003–0.211, p = 0.001) were associated with caesarean delivery.

Conclusions

The findings of our study indicated the prevalence of caesarean section to be three times more than that recommended by the World Health Organization. Pregnant women with a height of less than 150 cm should be considered for caesarean section. Therefore, it is necessary for stakeholders in the health sector to formulate guidelines for absolute indications for caesarean section.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai'i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state's largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai'i.

Why do pregnant women prefer cesarean birth? A qualitative study in a tertiary care center in Southern Thailand

Background

Increasing worldwide rates of cesarean section are of global concern. In recent years, cesarean births upon maternal request have become a hotly debated issue. Hence, this study aimed to explore maternal reasons for cesarean preference without medical indications.

Methods

A descriptive qualitative study was conducted, using in-depth interviews with 27 pregnant women who preferred cesarean birth, attending antenatal care in Songklanagarind Hospital from September 2018 to June 2019. Data were analyzed using content analysis.

Results

Maternal reasons for cesarean preference were classified into six main categories: fear of childbirth, safety concerns related to health risk perceptions, negative previous birth experiences, positive attitudes toward cesarean birth, access to biased information and superstitious beliefs in auspicious birth dates. Most women had more than one reason for opting cesarean birth.

Conclusion

Several reasons for cesarean birth preference have been elucidated. One striking reason was superstitious beliefs in auspicious birth dates, which are challengable for obstetricians to deal with. Obstetricians should explore the exact reasons why women request cesarean birth in order to prevent or diminish unnecessary cesarean births.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03525-3.

The effect of internet-based guided self-help cognitive-behavioral therapies on Iranian women's psychological symptoms and preferred method of childbirth

PURPOSE

The effectiveness of an Internet-based guided self-help cognitive-behavioral therapy (I-GSH-CBT) was assessed in alleviating childbirth fear (CBF), depression, anxiety, and stress of pregnant women during the first delivery.

DESIGN AND METHODS

In a quasi-experimental study, pregnant women in the intervention group used the I-GSH-CBT program during pregnancy. The Wijma Delivery Expectancy/Experience Questionnaire, and the Depression, Anxiety, and Stress Scale 42-item (DASS-42) questionnaires were used to collect the psychometric data.

FINDINGS

Implementing the I-GSH-CBT significantly reduced CBF, DASS-42 scores, and cesarean section preference.

PRACTICE IMPLICATIONS

The I-GSH-CBT program effectively decreases the adverse mood symptoms in nulliparous pregnant women.

How to reach trustworthy decisions for caesarean sections on maternal request: a call for beneficial power

Caesarean delivery is a common and life-saving intervention. However, it involves an overall increased risk for short-term and long-term complications for both mother and child compared with vaginal delivery. From a medical point of view, healthcare professionals should, therefore, not recommend caesarean sections without any anticipated medical benefit. Consequently, caesarean sections requested by women for maternal reasons can cause conflict between professional recommendations and maternal autonomy. How can we assure ethically justified decisions in the case of caesarean sections on maternal request in healthcare systems that also respect patients' autonomy and aspire for shared decisions? In the maternal-professional relationship, which can be characterised in terms of reciprocal obligations and rights, women may not be entitled to demand a C-section. Nevertheless, women have a right to respect for their deliberative capacity in the decision-making process. How should we deal with a situation of non-agreement between a woman and healthcare professional when the woman requests a caesarean section in the absence of obvious medical indications? In this paper, we illustrate how the maternal-professional relationship is embedded in a nexus of power, trust and risk that reinforces a structural inferiority for women. To accommodate for beneficial use of power, these decision processes need to be trustworthy. We propose a framework, inspired by Lukes' three-dimensional notion of power, which serves to facilitate trust and allows for beneficial power in shared processes of decision-making about the delivery mode for women requesting planned C-sections.

Validation of the Wijma delivery expectancy/experience questionnaire for pregnant women in Malawi: a descriptive, cross-sectional study

BACKGROUND

Fear of childbirth is a common health concern for women during pregnancy. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) is widely used to measure childbirth fear during pregnancy. However, this instrument is yet to be validated in Malawi, Africa. Our study aimed to assess the psychometric properties of the W-DEQ questionnaire in Malawi.

METHODS

Healthy pregnant women in the third trimester (N = 476) at a district hospital in Malawi were included. Fear of childbirth, depressive symptoms, and quality of life were assessed using the W-DEQ, the Edinburg Postnatal Depression Scale, and the World Health Organization Quality of Life scale, respectively. The construct validity, reliability, and convergent validity of the W-DEQ were examined using exploratory and confirmatory factor analyses, Cronbach's alpha, and Pearson correlations.

RESULTS

The mean age of participants was 28.2 (standard deviation = 6.8) years. Exploratory and confirmatory factor analysis of the Malawian version of the W-DEQ indicated a multidimensional structure with three factors: fear, negative appraisal, and a lack of self-efficacy, with acceptable goodness of model fit. The Malawian version of the W-DEQ showed a satisfactory internal consistency (α = 0.84) and was significantly correlated with depressive symptoms (r = 0.23, p < 0.001) and quality of life (r = - 0.17 ~ -0.26, ps < 0.05).

CONCLUSIONS

Our findings support the Malawian W-DEQ version being a reliable and valid instrument for measuring childbirth fear in African women.

Tensions and interplay: A qualitative study of access to patient-centered birth counseling of maternal cesarean requests in Norway

OBJECTIVE

This study aimed to explore women's access to patient-centered counseling for concerns initiating cesarean requests in absence of obstetric indications in pregnancy, and to identify tensions, barriers and facilitators affecting such care.

DESIGN, SETTING AND INFORMANTS

This qualitative study (June 2016 to August 2017) obtained data through semi-structured in-depth interviews with 17 women requesting planned C-section during birth counseling at a university hospital in Norway and focus group discussions with 20 caregivers (9 midwives and 11 obstetricians) employed at the same hospital. Analysis was carried out by systematic text condensation, a method for thematic analysis in medical research, presented within the frames of Levesque and colleagues' conceptual framework of access to patient-centered care.

FINDINGS

The analysis revealed that there were considerable tensions in care seeking and provision of counseling for maternal requests for C-section. There was a prominent culture of vaginal delivery among caregivers and women. The appropriateness of CS on maternal request was debated and caregivers revealed diverging attitudes and practices when agreement with women was not reached. Women's views on their entitlement to choose were divided, but the majority of women did not support complete maternal choice. Midwife-led counseling were highly appreciated among woman as well as obstetricians.

IMPLICATIONS FOR PRACTICE

Tensions and barriers in care seeking and provision of counseling for women requesting C-section for non-obstetric reasons, call for standardized counseling in order for equal and adequate care to be provided across health care institutions and providers. Dialogue-based decision-making and midwife-led care may improve satisfaction of care, enhance spontaneous vaginal deliveries and avoid future conflicts.

Isthmocele and ovarian stimulation for IVF: considerations for a reproductive medicine specialist

STUDY QUESTION

What is the risk of developing intracavitary fluid (ICF) during ovarian stimulation in patients with an isthmocele after previous caesarean section (CS) delivery?

SUMMARY ANSWER

In patients with an existing isthmocele, the risk of developing ICF during hormonal stimulation for IVF is almost 40%; therefore, special attention has to be paid to exclude fluid accumulation during stimulation and particularly at the time of transfer, in which case the reproductive outcomes of frozen embryo transfer (FET) cycles appear to be uncompromised.

WHAT IS KNOWN ALREADY

Lately, there is an increasing focus on the long-term impact of CS delivery on the health and future fertility of the mother. Development of an isthmocele is one of the sequelae of a CS delivery. The presence of ICF in combination with an isthmocele has been described previously, and the adverse effect of endometrial fluid on implantation is well recognised by reproductive medicine specialists. Accumulation of ICF has been previously described in patients with hydrosalpinx, less commonly in patients with polycystic ovary syndrome undergoing ovarian stimulation for IVF/ICSI, and even in some patients without any identifiable reason. Assisted reproductive techniques (ARTs) are a means to overcome infertility. Reproductive medicine specialists commonly see patients with secondary infertility with a history of having had one or more previous CS and with ultrasound confirmation of an isthmocele. However, the available data pertaining to the prevalence of intracavitary fluid during ovarian stimulation in patients with ultrasound confirmation of an isthmocele is limited. Furthermore, data on the influence of ICF in a stimulated cycle on the ART outcome of a subsequent FET cycle is scarce and merits further studies.

STUDY DESIGN, SIZE, DURATION

A prospective observational exploratory study was performed in IVI Middle East Fertility Clinic, Abu Dhabi, from June 2018 to March 2019, and retrospective analysis of the reproductive outcomes was performed until July 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients with secondary infertility, defined as a minimum of 1 year of infertility after a previous successful pregnancy, undergoing ovarian stimulation for IVF/ICSI and having a history of one or more previous CS with ultrasonographic visible isthmocele, were included (n = 103). Patients were monitored as a clinical routine with vaginal ultrasound examinations during ovarian stimulation for IVF/ICSI treatment. All patients included in the study were asked to complete a questionnaire regarding their previous obstetric history. Development of ICF was recorded as well as changes in the measurements of the isthmocele during the course of ovarian stimulation. Reproductive outcomes of FET cycles of the patients with an isthmocele were retrospectively compared to those of patients with infertility and without isthmocele in our clinic during the same time period.

MAIN RESULTS AND THE ROLE OF CHANCE

Patients with an existing isthmocele after previous CS have a risk of ~40% of developing ultrasonographic visible fluid in the endometrial cavity during the course of ovarian stimulation. Development of ICF was significantly correlated with the depth of the isthmocele on Day 2/3 (P = 0.038) and on the day of trigger (−1/−2 days) (P = 0.049), circumference of the isthmocele on the day of trigger (−1/−2 days) (P = 0.040), distance from the C-scar to the external os (P = 0.036), number of children delivered (P = 0.047) and number of previous CS (P = 0.035). There was a statistically significant increase in the parameters related to the size of the isthmocele during ovarian stimulation. No significant differences in the reproductive outcome (pregnancy rate and rates of biochemical and ectopic pregnancies, miscarriages and ongoing/delivered pregnancies) after FET were found between the patients with and without an isthmocele, when ICF was excluded prior to embryo transfer procedure.

LARGE-SCALE DATA

NA.

LIMITATIONS, REASONS FOR CAUTION

This study was not primarily designed to investigate the causes of ICF during ovarian stimulation or to evaluate the reproductive outcomes. Further, the small number of reported reproductive outcomes may be seen as a limitation.

WIDER IMPLICATIONS OF THE FINDINGS

The data highlights the need for an increased awareness on the part of reproductive medicine specialists towards the potentially adverse impact of an isthmocele on ART treatment, as there is a potential to develop intracavitary fluid during ovarian stimulation for IVF. The increase in the circumference of the isthmocele may increase embryo transfer difficulty.

STUDY FUNDING/COMPETING INTEREST(S)

No funding of the study has to be reported. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

This prospective study was registered with clinicaltrials.gov. under the number NCT03518385.