Caesarean Section on Maternal Request-Ethical and Juridic Issues: A Narrative Review

Pregnant women autonomy when choosing their method of childbirth: Scoping review

This paper has as its theme the autonomy of pregnant women in relation to choosing the method of birth for their child. The objective was to carry out a scoping review to study the literature and evidence of how autonomy is being offered to parturient women. Study design and location: In October 2023, a search was carried out using the terms "pregnant women" AND "delivery" AND "autonomy" in the following databases: PubMed, Web of Science, Scopus, Scielo and LILACS. The search included articles from 2016 to 2023. Of the 179 articles found, 15 met the criteria and were selected for this review. Results: the pregnant woman's autonomy in choosing the method of childbirth is influenced by several factors, such as the obstetrician's recommendation, the medical team, and negative and positive experiences. Thus, when this autonomy is shared with the obstetrician, the obstetrician recommends cesarean section as the safest route, but does not explain the benefits and harms of both routes (vaginal and cesarean section), causing the woman to accept the cesarean section. Midwives recommend vaginal birth because they believe it to be natural and safe and explain the benefits and harms of both methods, respecting the pregnant woman's choice of the method she prefers. Conclusion: women have the fundamental right to choose their method of birth and must be properly guided throughout prenatal care, whether by an obstetrician or a midwife, about the options, risks and benefits of each method of childbirth, respecting the ethical principle of beneficence.

Risk Factors of Perinatal Negative Mood and Its Influence on Prognosis: A Retrospective Cohort Study

Background

Maternal anxiety or depression in the perinatal period has a high prevalence. The negative emotion during the puerpera is unfavorable to the process of childbirth and also affects the recovery and the quality of life in postpartum patients significantly. The present study aimed to elucidate the risk factors of negative emotion in perinatal women and its influence on prognosis to provide a reference for improving maternal prognosis.

Methods

Initially, 350 expectant mothers were randomly enrolled in the present study between August 2021 and August 2022. Among these, after applying the established inclusion and exclusion criteria, 314 patients were eventually selected. The independent risk factors of negative emotion and poor prognosis were analyzed through binary logistics regression and multiple linear regression. Follow-up was conducted via telephone, email, and a follow-up visit one month after discharge.

Results

Among the included patients, 18 (5.7%) had prenatal anxiety, 16 (5.1%) had prenatal depression, 31 (9.9%) had postnatal anxiety, and 28 (8.9%) had postnatal depression. Perinatal negative emotional risk factors include age, marital relationship, regular prenatal examination, E2 level, 5-HT level before and after delivery, family monthly income, neonatal health, breastfeeding time, intrapartum hemorrhage, constipation and other complications. The development of postpartum negative emotions is a risk factor for maternal prognosis.

Conclusion

The results showed that the risk factors of perinatal depression and anxiety were complex. In order to improve the quality of life of pregnant women, maintain their long-term emotional stability, and promote their postpartum recovery, it may be considered to promote the use of screening tools to identify women at risk of anxiety and depression before and after delivery, and timely psychological counseling for patients with high risk factors to promote their mental health.

From evidence to tailored decision-making: a qualitative research of barriers and facilitating factors for the implementation of non-clinical interventions to reduce unnecessary caesarean section in Romania

OBJECTIVE

To improve understanding of the drivers of the increased caesarean section (CS) rate in Romania and to identify interventions to reverse this trend, as well as barriers and facilitators.

DESIGN

A formative research study was conducted in Romania between November 2019 and February 2020 by means of in-depth interviews and focus-group discussions. Romanian decision-makers and high-level obstetricians preselected seven non-clinical interventions for consideration. Thematic content analysis was carried out.

PARTICIPANTS

88 women and 26 healthcare providers and administrators.

SETTINGS

Counties with higher and lower CS rates were selected for this research-namely Argeș, Bistrița-Năsăud, Brașov, Ialomița, Iași, Ilfov, Dolj and the capital city of București (Bucharest).

RESULTS

Women wanted information, education and support. Obstetricians feared malpractice lawsuits; this was identified as a key reason for performing CSs. Most obstetrics and gynaecology physicians would oppose policies of mandatory second opinions, financial measures to equalise payments for vaginal and CS births and goal setting for CS rates. In-service training was identified as a need by obstetricians, midwives and nurses. In addition, relevant structural constraints were identified: perceived lower quality of care for vaginal birth, a lack of obstetricians with expertise in managing complicated vaginal births, a lack of anaesthesiologists and midwives, and family doctors not providing antenatal care. Finally, women expressed the need to ensure their rights to dignified and respectful healthcare through pregnancy and childbirth.

CONCLUSION

Consideration of the views, values and preferences of all stakeholders in a multifaceted action tailored to Romanian determinants is critical to address relevant determinants to reduce unnecessary CSs. Further studies should assess the effect of multifaceted interventions.

The influence of prenatal dexamethasone administration before scheduled full-term cesarean delivery on short-term adverse neonatal outcomes: a retrospective single-center cohort study

Objective

There has been a gradual increase in the prevalence of cesarean section deliveries and more healthcare professionals are considering the prophylactic use of corticosteroids before planned full-term cesarean sections. However, the association between dexamethasone administration before full-term cesarean delivery and short-term adverse neonatal outcomes is unclear. This study analyzed the disparities in short-term adverse neonatal effects in neonates born via full-term elective cesarean delivery with or without antenatal dexamethasone treatment.

Study design

This single-center retrospective cohort study involved neonates aged 37-39 weeks. The primary neonatal outcomes included various short-term adverse events, including neonatal admission to the neonatal intensive care unit, neonatal access to the special care baby unit, transient neonatal respiratory distress, respiratory distress syndrome, and the requirement of intravenous antibiotics or ventilatory support. Multiple logistic regression analysis was used to assess the association between these outcomes and dexamethasone exposure while adjusting for covariates.

Results

Of the 543 neonates included in the study, 121 (22.2%) had been exposed to prenatal dexamethasone. When compared with the control group, the dexamethasone-exposed group exhibited significantly higher rates of transient neonatal respiratory distress, respiratory distress syndrome, administration of intravenous antibiotics, the need for ventilatory support, and longer duration of neonatal hospitalization (P < 0.05). The association between dexamethasone exposure and short-term adverse neonatal outcomes remained significant after adjusting for potential confounders (odds ratio: 12.76, 95% confidence interval: 6.9-23.62, P < 0.001).

Conclusion

The dexamethasone-exposed group had a higher likelihood of experiencing short-term adverse outcomes when compared with non-exposed neonates, suggesting that dexamethasone may have detrimental effects on infants delivered at full term. This implies the importance of exercising caution when contemplating the use of antenatal corticosteroids.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Cesarean section rates in Turkey 2018-2023: Overview of national data by using Robson ten group classification system

Objective

Cesarean section (CS) rates continue to rise globally because of various factors. Medically unnecessary cesarean operations have no benefit to the mother or child's health. Since the World Health Organization (WHO) has determined that the acceptable CS rate should not be more than 10-15%, it also stated the use of a classification system to compare different patient groups and facilities. Turkey has the highest CS rates globally and has been rising over the years. This study aims to assess CS rates between 2018 and 2023 using National Health Data and to analyze them according to the Robson classification system and WHO reference values to discuss possible measures against increasing rates.

Materials and Methods

In this study, we assessed the rates of CSs between 2018 and 2023; the CS rate including all 5-years and analysis of CS rates for each Robson group as advocated by WHO. Also, another assessment was done of the facilities where the CSs were applied (Public, private, or university hospitals).

Results

The total number of births recorded between 2018 and2023 was 6.161.976. The overall CS rate was 57.55%. The number of total CS operations was 3.546.049. The primary CS rate was 28.83% (N:1.776.503). Significant differences were observed between the public and private centers for each Robson group.

Conclusion

The CS rates of Groups 1-4 are obviously higher than expected. The CSs of these groups cumulatively affect the rates of other groups. Nulliparous women have CSs mostly in private hospitals. There is a need for improvements in the health system in this regard for better maternal and child health.

A bit of medical paternalism? A qualitative study on power relations between women and healthcare providers when deciding on mode of birth in five public maternity wards of Argentina

BACKGROUND

Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used.

METHODS

This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories.

RESULTS

Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth.

CONCLUSIONS

Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place.

Development of a Framework for On-Demand Caesarean Section in Romania

BACKGROUND

Caesarean section rates have continued to trend upward in most countries, including Romania, creating a number of economic challenges. In the public health system, there is no regulation for performing Caesarean sections on demand; it is often done unlawfully, and in private hospitals, it is a real business. Thus, this study aims to investigate the budgetary impact at a hospital level and the profit per procedure by introducing on-demand caesarean sections for a fee.

METHODS

This study was conducted in one of the largest maternity units in Western Romania-the "Bega" Maternity Clinic of the Timisoara County Emergency Hospital. For the analysis, the difference between a proposed occupancy rate (between 50 and 85%, increasing every 5 percent) and the actual occupancy rate was calculated. Considering that this difference can be used to admit patients to receive Caesarean sections on demand for a fee, the profit that could be obtained during the study period was calculated.

RESULTS

It is reported that between 238 (proposed occupancy rate of 50%) and 4683 patients (a proposed occupancy rate of 85%) could have benefited from on-demand caesarean section surgery in 2017-2019. Between RON 419,999 and RON 8,551,636 could be obtained in the 3 years of study by implementing caesarean section against payment.

CONCLUSION

The implementation of a system of on-demand payment for caesarean sections in Romania would bring significant profits to the hospital budget.