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.

How Giving Birth Makes Sense: A Questionnaire Study on Existential Meaning-Making Among Mothers Giving Birth Preterm or at Term

BACKGROUND

Women's reflections on existential meaning-making in relation to giving birth may seem indistinct in maternity services and have not been thoroughly explored in secular contexts. However, research suggests that childbirth accentuates spiritual and existential considerations and needs even in secular contexts highlighting the importance of care for such needs in maternity care practices. The objectives of this study were two-fold: Firstly, to explore how first-time mothers, living in a secular context, experience their first birth in relation to existential meaning-making. Secondly, to describe the relationship between existential meaning-making reflections and gestational week at birth.

METHODS

A nationwide cross-sectional study in Denmark based on the questionnaire "Faith, existence and motherhood" was conducted in 2011. Eight core items related to birth experience informed this study. The cohort was sampled from the Danish Medical Birth Registry and consisted of 913 mothers having given birth 6-18 months previously. Twenty-eight per cent had given birth preterm (PT) and 72% had given birth at full-term (FT). A total of 517 mothers responded.

RESULTS

In relation to the birth of their first child, both FT and PT mothers answered, that they had existential meaning-making reflections. The consent to the 8 items ranged from 17 to 73% among FT mothers and from 19 to 58% among PT mothers. Mothers who gave birth preterm mainly identified the negative aspects of birth, whereas mothers, who gave birth at full-term, to a higher degree identified positive aspects.

CONCLUSIONS

Findings suggest that not only traumatic birth events accentuate existential reflections, but that even normal childbirth to most mothers is an existential event. However, the quality of existential reflections differs when comparing normal and traumatic birth. The study points towards change in education and organization of maternity care to better care for existential needs and reflections specific to every new mother and birthing woman.

Ethics of infant relinquishment, cultural considerations, and obstetric conveniences

Ethical issues relating to infant relinquishment, caring for culturally diverse women, the importance of shared power between women and their caregivers, and the provision of evidence-based practice versus reliance on obstetric conveniences are addressed in this article. Respectful care of women relinquishing their infants including use of appropriate language demonstrates moral and ethical nursing practice; providing cultural competent care of multilinguistic, multicultural, and multiethnic childbearing women and their families is an ethical imperative. Nurses practicing ethically will foster adoption of best practices on perinatal and neonatal units, and generate a clearly articulated vision of woman and family centered organizational culture. In ethical terms, this demonstrates respect for others as well as beneficence. Promoting the use of ethical nursing practice and evidence-based practice requires that nurses identify change agents, those who are champions and facilitators of evidence-based practice, and then reward such innovators and make sure that clinical guidelines be developed based on best practices.

Attitudes and preferences of young women with low and high fear of childbirth

We examined constructions of labor and birth for 461 Canadian women who attended the University of British Columbia (Canada) and participated in an online survey about pregnancy and birth, using a combination of Likert items and open-ended questions. We performed a content analysis of women's open-ended responses about their feelings toward birth and analyzed comments of women with high and low fear of childbirth separately. Students with high fear of birth described childbirth as a frightening and painful ordeal and viewed obstetric interventions as a means to make labor and birth more manageable. Students with low fear constructed birth as a natural event and regarded interventions more critically. Students in both groups supported women's autonomous maternity care decisions. Our findings contribute to care providers' and educators' knowledge about preferences and fears expressed by the next generation of maternity care consumers and potential strategies to reduce their fear of childbirth.

Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian University students

OBJECTIVE

to examine attitudes towards birth that may be common among young adults who have been socialised into a medicalised birth culture. Specifically, we were interested in examining factors that might be associated with fear of birth and preferences for elective obstetric interventions among the next generation of maternity care consumers.

DESIGN

secondary analysis of an online survey of university students.

SETTING

British Columbia, Canada.

PARTICIPANTS

students from the University of British Columbia (n=3680). A quarter of the sample comprised Asian students, which allowed for analysis of cultural differences in attitudes towards birth. Both male and female students participated in the study; results are reported for the full sample, and by gender.

MEASUREMENTS

a six item fear of childbirth scale was developed, as well as a 4 item index that measures students' concerns over physical changes following pregnancy and birth and a 2 item scale that assesses students' attitudes towards obstetric technology.

FINDINGS

as we hypothesised, students who were more fearful of birth preferred epidural anaesthesia and birth by CS. Worries over physical changes following pregnancy and birth, favourable attitudes towards obstetric technology, and exposure to pregnancy and birth information via the media were also significantly associated with a preference for CS. Fear of birth scores were highest among students who reported that the media had shaped their attitudes towards pregnancy and birth. Asian students had significantly higher fear of birth scores and were more likely to prefer CS, compared to Caucasian students.

IMPLICATIONS FOR PRACTICE

young adults are contemplating pregnancy and birth in an increasingly technology-dependent society. Educational programmes aimed at reducing fear of childbirth and concerns over physical changes following pregnancy and childbirth might contribute to vaginal birth intentions among young adults. Midwives may use the findings to identify and counsel nulliparas who exhibit fear of birth and other childbirth attitudes that may predispose them to choose elective obstetric interventions.

A case study of maternal response to the implied antepartum diagnosis of inevitable labor dystocia

Two pregnant women, one obese and one of extremely small stature, received antepartum recommendations from their health care providers to schedule cesarean births. In response, both women sought providers who would support their desire to attempt vaginal birth. The women's perspectives on their birth experiences along with the pertinent medical record data from their pregnancies and births provide a reminder about the inherent normalcy of birth amid the current culture of interventive obstetrical practices.

Teaching physiologic birth in maternal-newborn courses in undergraduate nursing programs: current challenges

For low-risk childbearing women, fewer technological interventions are associated with better physical and psychosocial outcomes; yet, the number of unmedicated physiologic births is decreasing. As a result, fewer undergraduate nursing students experience caring for women who choose physiologic birth, which presents a challenge for nurse educators and implications for preparing students to provide appropriate care for all childbearing women after the students graduate. This exploratory descriptive qualitative study was conducted among 150 randomly selected undergraduate nursing programs in the United States to explore the challenges of educating nursing students about low-intervention birth. Four themes described current challenges: lack of placement opportunities, education versus clinical practice, evidence-based support of physiologic birth, and the need for more research on pedagogical strategies that effectively educate future nurses to advocate for minimal intervention birth options for all women.

Caesarean-section, my body, my choice: The construction of ‘informed choice’ in relation to intervention in childbirth

The notion of choice, especially of informed choice, is a central tenet of maternity services in most western countries; it also underpins debate about rising rates of intervention that are now a feature of childbirth in many of these countries. Our study investigated the shaping of understanding and practice in relation to these rising rates of intervention in childbirth in the New Zealand context. Critical hermeneutics was used to analyse the data from interviews with nine midwives and obstetricians, and six focus groups with 33 women. This article reports on the notion of choice, which featured prominently in all the interviews. It became clear that women’s choices were strongly influenced and determined by social change, by the gendering of women, and by values such as control, predictability, convenience, the ‘quick fix’ and the normalization of surgery. We argue that the prevailing notion of ‘informed’ choice obscures the structural and social influences on ‘choice’.