‘Off everyone's radar’: Australian women's experiences of medically necessary elective caesarean section

Introduction

despite an exponential rise in the number of medically initiated elective caesarean sections over the last two decades, women's experiences of this birth mode remain largely unknown. The aim of this study was to address this gap by describing women's experiences of medically necessary elective caesarean section.

Methods

a grounded theory approach was used to collect and analyse interview data collected from 28 Australian women who had an elective caesarean section for a medical reason, 14 of whom were also observed during their caesarean section. The analyses of the non-participant observations were used to contextualise the women's experiences.

Findings

prior to having their baby, women expected to play an active part in their caesarean section and to be supported to take up their ‘mother’ role as soon as their baby was delivered. Postnatally however, they reported having felt invisible, superfluous and disregarded during the event. There was evidence that hospital routines and processes contributed to women feeling displaced and unimportant in their baby's birth. Three sub-categories were formed from the analysis of the data that together are represented by the in-vivo label ‘off everyone's radar’. These were ‘just another case on an operating list’, ‘striving to be included while trying to behave’ and ‘unable to be my baby's mum’.

Discussion

our findings suggest that when women are ignored during childbirth, any fear they hold may escalate into peritraumatic disassociation, which in turn has implications for women's postnatal mental and emotional health in the short and long term. In addition, the separation of the mother–baby dyad was found to have a devastating impact on maternal–newborn attachment that lasted well into the postnatal period. To optimise women's childbirth satisfaction and foster their attachment to their baby, both of which are essential for ongoing emotional well-being, it is vital that they are located at the centre of their birth experience and that if at all possible they are not separated from their newborn.     

Why do women request caesarean section in a normal,healthy first pregnancy?

Background and context

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

Objective

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

Design

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

Setting

two states of Australia: Queensland and Western Australia.

Participants

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

Findings

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a ‘safe’ and ‘responsible’ choice.

Key conclusions and recommendations for practice

these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.     

‘Motherbirth or childbirth’? A prospective analysis of vaginal birth after caesarean blogs

Objective

vaginal birth after caesarean (VBAC) is a controversial issue with strong opinions for and against. The means in which women work through the different opinions and options using the internet should be of interest to midwives, obstetricians and policy makers. The aim of this study was to examine how women use English language internet blog sites to discuss the option of VBAC and what factors influence these women's decision to have a VBAC or repeat caesarean section.

Design

a qualitative study using internet blog sites as the source of data was undertaken. Google alerts were created to search for the term VBAC in internet blogs. These alerts were sent to the first author's email account daily for a one-year period (November 2007 to October 2008) and downloaded. The content was analysed using thematic analysis.

Findings

there were 311 blogs mentioning the word VBAC in the one-year period. Most of the blog sites and discussion originated from the USA. There were more blogs written during the Northern Hemisphere winter months than during other seasons. The main theme identified was a dichotomy in philosophical framework women held about birth; that is a ‘motherbirth’ or ‘childbirth’ framework. Whether women eventually wrote that they chose a VBAC or repeat caesarean or the extent to which they pursued their birth choice depended on whether they came from a perspective that a ‘good parent sacrifices themselves for their baby (prioritises the baby) and takes no risks’ (childbirth) or that ‘giving birth matters to the woman and a happy, healthy mother is a happy healthy baby (mother and baby have equal priority)’ (motherbirth). Several themes were identified including: surviving the damage; inadequate bodies; choice and control; fearing and trusting birth; negotiating the system; and minimising or overestimating risk.

Key conclusion

women filtered their decision making regarding VBAC through a belief system that prioritises according to their personal approaches.

Implications for clinical practice

blogging may be providing a valuable insight into factors that inform decision making and may provide a forum of information and support for women who have experienced a caesarean section.     

Why do primigravidae request caesarean section in a normal pregnancy? A qualitative study in Iran

Objective

to gain a deeper understanding of why Iranian primigravidae request caesarean section without any medical indication.

Design

qualitative study. Data were gathered through semi-structured interviews, and thematic analysis was undertaken.

Setting

four health care centres at Hamadan University of Medical Sciences, Hamadan, Iran.

Participants

14 primigravidae who requested caesarean section without any medical indication.

Findings

reasons for requesting caesarean section were related to fear of childbirth (labour pain, injury to mother or infant), complications after vaginal delivery (vaginal prolapse, urinary incontinence, sexual dysfunction), trust in obstetricians, and lack of trust in maternity ward staff.

Key conclusions and implications for practice

the main reasons given for requesting caesarean section show that there is urgent need for effective antenatal assessment to enable pregnant women to ask questions and express their concerns. In order to promote vaginal birth, there is a need to develop antenatal education and strategies to enhance women's knowledge, confidence and competence about vaginal birth. Health care providers should be re-educated about the observance of medical ethics and professional rules in their practices, and change their attitudes and behaviours to vaginal birth. Evaluation, improvement and change in maternity care policies are recommended to promote natural childbirth.     

Achieving normality: the key to status passage to motherhood after a caesarean section

Objective

to explore women's experiences of caesarean section.

Design

a qualitative study using a grounded theory approach. Data were collected using unstructured, tape-recorded interviews which took place between 1999 and 2000.

Setting

the South West of England.

Participants

twenty-one women who had experienced a caesarean section—either by choice or of necessity—and who were first- or second-time mothers.

Findings

four main categories emerged: expectations and reality, being in control, feelings of failure as a woman and feeling different. These all linked to the core category of achieving normality. Women strove to achieve normality after having a caesarean section. If they did not gain this sense of normality, the status passage to motherhood appeared to be more difficult.

Implications for practice

it is important for health-care professionals to identify and acknowledge the emotional and physical needs of women who experience a caesarean section. Improving communication and support antenatally and postnatally may have positive benefits for maternal well-being.     

‘My pain was stronger than my happiness’: Experiences of caesarean births from Lebanon

Objective

the rising trends in caesarean section have been partially attributed to women's requests. Many studies in developed and very few in developing countries have attempted to understand this phenomenon. This qualitative study explores experiences of women having caesarean section on demand in a middle-income country with a private health-care system.

Design

an inductive qualitative design, using face-to-face semi-structured interviews.

Setting

women were identified and recruited through a perinatal database and selected obstetricians' clinics in the Greater Beirut area in Lebanon.

Participants

a purposive sample of women who had a caesarean childbirth within the four months preceding the interview, were visited for an interview at home using a semi-structured interview guide. Thematic content analysis was conducted on a sub-sample of 22 women who requested a caesarean birth.

Findings

lack of information about caesarean sections fosters women's fear from labour pain and acts as the main impetus for women to consider caesareans as the pain free alternative. Findings reveal health-care providers' role in reinforcing beliefs about caesarean sections being the way for pain free deliveries by overestimating the safety of the procedure and disregarding postpartum health issues.

Key conclusion and implications for practice

caesarean birth is presented to women as a safe option for ‘pain free’ childbirth. This needs to be considered within the cultural context of understanding safety and pain as well as the dynamics of power in maternity care. Health-care professionals need to explore these dimensions and promote women's informed choice as well as encouraging the normality of birth.     

Water VBAC: Exploring a new frontier for women's autonomy

Background

although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted. Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes.

Method

in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit. The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted.

Findings

the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences. The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section. Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women's childbirth experience. This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences. Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth. The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care.

Conclusions

for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process. The value accorded to being able to exercise choice and control over their childbearing experience was high. These women's accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.     

First-time fathers' expectations and experiences of childbirth in relation to age

Objective

to investigate first-time fathers' expectations and experiences of childbirth and satisfaction with care in relation to paternal age.

Design

data from a randomised controlled trial of antenatal education were used for secondary analysis. Data were collected by questionnaires in mid-pregnancy and at three months after the birth. Comparisons by χ²-tests and Student's t-tests were made between men in three age groups: young men aged ≤27 years (n=188), men of average age 28–33 years (n=389) and men of advanced age ≥34 years (n=200).

Setting

the expectant fathers were recruited from 15 antenatal clinics spread over Sweden.

Participants

777 first-time fathers.

Findings

antenatal expectations and postnatal memory of the childbirth experience varied by paternal age. In mid-pregnancy, mixed or negative feelings about the upcoming birth were more prevalent in men of advanced age (29%) compared with men of average (26%) and young (18%) age (p<0.01), and they feared the event more than the youngest (mean on the Wijma Delivery Expectancy Questionnaire: advanced age 43.3; average age 42.9; young 38.7; p<0.01). The older men also assessed their partner's labour and birth as more difficult (advanced age 43%; average age 41%; young 32%; p=0.05) and had a less positive overall birth experience (advanced age 30%; average age 36%; young 43%; p<0.05). However, older fathers were more satisfied with care given during the intrapartum period: 52% were overall satisfied compared with 46% of the men of average age and 39% of young age (p=0.03).

Key conclusions

men of advanced age had more fearful and negative expectations during their partner's pregnancies and postnatally assessed the births as less positive and more difficult than younger men did. Despite this, older men were more satisfied with intrapartum care.

Implications for practice

knowledge about age-related differences in the expectations and experiences of first-time fathers may help midwives and doctors give more individualised information and support, with special attention to older men's expectations and experiences of the birth as such, and to younger men's perception of care.     

Childbirth fear in expectant fathers: Findings from a regional Swedish cohort study

Objective

to investigate the prevalence of childbirth related fear in Swedish fathers and associated factors.

Design

a regional cohort study. Data was collected by a questionnaire.

Setting

three hospitals in the middle-north part of Sweden

Participants

1047 expectant fathers recruited in mid-pregnancy during one year (2007) who completed the Fear of Birth Scale (FOBS).

Measurements

prevalence of childbirth fear and associated factors. Crude and adjusted odds ratios were calculated between men who scored 50 and above (childbirth fear) and those that did not (no fear). Logistic regression analysis was used to assess which factors contributed most to childbirth fear in fathers.

Findings

the prevalence of childbirth fear in men was 13.6%. Factors associated with childbirth related fear were as follows: Less positive feelings about the approaching birth (OR 3.4; 2.2–5.2), country of birth other than Sweden (OR 2.8; 1.3–6.1), a preference for a caesarean birth (OR 2.1; 1.7–4.1), childbirth thoughts in mid-pregnancy (OR 1.9; 1.1–2.0) and expecting the first baby (OR 1.8; 1.2–2.6).

Key conclusions

high levels of fear were associated with first time fathers and being a non-native to Sweden. Men with fear were more likely to experience pregnancy and the coming birth as a negative event. These men were also more likely to identify caesarean section as their preferred mode of birth.

Implications for practice

engaging expectant fathers in antenatal conversations about their experiences of pregnancy and feelings about birth provides health-care professionals with an opportunity to address childbirth fear, share relevant information and promote birth as a normal but significant life event.     

Influence on birthing positions affects women's sense of control in second stage of labour

Objective

to explore whether choices in birthing positions contributes to women's sense of control during birth.

Design

survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control.

Setting

midwifery practices in the Netherlands.

Participants

1030 women with a physiological pregnancy and birth from 54 midwifery practices.

Findings

in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves.

Key conclusions

women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value.

Implications for practice

midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.     

Going public: Do risk and choice explain differences in caesarean birth rates between public and private places of birth in Australia?

Background

women who birth in private facilities in Australia are more likely to have a caesarean birth than women who birth in public facilities and these differences remain after accounting for sector differences in the demographic and health risk profiles of women. However, the extent to which women's preferences and/or freedom to choose their mode of birth further account for differences in the likelihood of caesarean birth between the sectors remains untested.

Method

women who birthed in Queensland, Australia during a two-week period in 2009 were mailed a self-report survey approximately 3 months after birth. Seven hundred and fifty-seven women provided cross-sectional retrospective data on where they birthed (public or private facility), mode of birth (vaginal or caesarean) and risk factors, along with their preferences and freedom to choose their mode of birth. A hierarchical logistic regression was conducted to determine the extent to which maternal risk and freedom to choose one's mode of birth explain sector differences in the likelihood of having a caesarean birth.

Findings

while there was no sector difference in women's preference for mode of birth, women who birthed in private facilities had higher odds of feeling able to choose either a vaginal or caesarean birth, and feeling able to choose only a caesarean birth. Women had higher odds of having caesarean birth if they birthed in private facilities, even after accounting for significant risk factors such as age, body mass index, previous caesarean and use of assisted reproductive technology. However, there was no association between place of birth and odds of having a caesarean birth after also accounting for freedom to choose one's mode of birth.

Conclusions

these findings call into question suggestions that the higher caesarean birth rate in the private sector in Australia is attributable to increased levels of obstetric risk among women birthing in the private sector or maternal preferences alone. Instead, the determinants of sector differences in the likelihood of caesarean births are complex and are linked to differences in the perceived choices for mode of birth between women birthing in the private and public systems.     

Fears associated with childbirth among nulliparous women in Turkey

Objective

to describe fears associated with childbirth and reasons for the fears.

Design

a qualitative study. Data were gathered through semi-structured interviews and analysed using content-analysis method.

Setting

outpatient maternity clinic of a university hospital in Turkey.

Participants

19 nulliparous pregnant women who stated that they had fear related to childbirth.

Findings

women's fears were related to labour pain, birth-related problems and procedures, attitudes of health-care personnel and sexuality. The reasons for their fears included type and quality of childbirth information, personal characteristics and experiences, maternity ward environment and lack of confidence in health-care personnel. Seven of the women were considering an elective caesarean section. The role of husbands in the childbirth experience was not mentioned by any participants.

Key conclusions and implications for practise

women experience considerable fear related to impending childbirth. Considering the potential for negative findings caused by fear, and the likelihood of requesting a caesarean section, it is important for health professionals who provide antenatal care to explore fears related to childbirth. The development and evaluation of formal childbirth education is also recommended.     

Does counsellor's attitude influence change in a request for a caesarean in women with fear of birth?

Background

the attitudes of two counsellors towards women requesting a caesarean section due to fear of birth were identified. One emphasised the ability to overcome any emotional obstacle to vaginal birth (‘coping attitude’), and the other emphasised that the ultimate choice of mode of birth was the womans’ (‘autonomy attitude’). Two research questions were asked: (1) What are the predictors of change in a wish for a caesarean and of vaginal birth in women with fear of birth? (2) Does a change from an ‘autonomy attitude’ to a ‘coping attitude’ increase the number of women who change their request for a caesarean and who give birth vaginally?

Methods

the study population consisted of two samples of pregnant women with fear of birth and concurrent request for a caesarean, referred for crisis-oriented counselling at the antenatal clinic, University Hospital of North Norway between 2000–2002 (n=86) and 2004–2006 (n=107). Data were gathered from referral letters, counseling and antenatal, intra- and postpartum records.

Findings

a coping attitude of the counsellor was positively associated with change in the request for a caesarean and with vaginal birth. A change from an autonomy attitude to a coping attitude was associated with a significant increase in the percentage of women who changed their desire for a caesarean from 77 to 93, and who had a vaginal birth from 42 to 81.

Conclusion

a coping attitude was strongly associated with change in the desire for a caesarean and giving birth vaginally. A coping attitude can be learned through critical reflection and awareness of the counsellor's attitude, with measurable clinical results.     

Utilisation of skilled birth attendance in Northern Nigeria: A cross-sectional survey

Objective

to determine the level and determinants for utilisation of Skilled Birth Attendance (SBA).

Methods

a population-based survey using a structured questionnaire was conducted in Goya and Tundunya political wards of Katsina state from May to June 2012. Four hundred women aged 15–49 years who had delivered a baby within two years prior to the study were asked about birth attendance during antenatal care (ANC), childbirth and postnatal period of their most recent birth. Logistic regression analysis was performed to obtain independent predictors of skilled birth attendance (SBA).

Findings

of the 400 women recruited for the study, 145 (36.3%) received antenatal care, 52 (13%) had their births assisted by skilled personnel and 88 (22%) received postnatal care from skilled birth attendants. Of the 52 women who had their births attended by skilled birth attendants only 29 (56%) had their births in a health facility. Maternal education, husband's occupation, presence of complication and previous place of childbirth were found to be statistically significant predictors for SBA utilisation. Barriers to SBA utilisation identified included lack of health care provider, lack of equipment and supplies and poverty. Enablers mentioned included availability of staff, husband's approval and affordable service.

Conclusion

women are more likely to utilise SBA with the availability of skilled personnel, strengthening of the health system and intervention to remove user fees for maternal health services. Joint effort should be made by government and community leaders to promote girl's education and to encourage men's involvement in maternal health services.     

Behind the myth – few women prefer caesarean section in the absence of medical or obstetrical factors

Objective

to describe the prevalence of women’s preference for caesarean section as expressed in mid pregnancy, late pregnancy and one year post partum. An additional aim was to identify associated factors and investigate reasons for the preference.

Design

mixed methods. Data were collected from 2007 to 2008 through questionnaires distributed to a Swedish regional cohort of women. The survey was part of a longitudinal study of women’s attitudes and beliefs related to childbirth. One open question regarding the reasons for the preferred mode of birth was analysed using content analysis.

Setting

three hospitals in the county of Västernorrland in the middle of Sweden.

Participants

1506 women were recruited at the routine ultrasound screening during weeks 17 to 19 of their pregnancy.

Findings

a preference for caesarean section was stated by 7.6% of women during mid pregnancy and by 7.0% in late pregnancy. One year post partum 9.8% of the women stated that they would prefer a caesarean section if they were to have another baby. This was related to their birth experience. There were more multiparous women who wished for a caesarean section. Associated factors irrespective of parity were fear of giving birth and a ‘strongly disagree’ response to the statement regarding that the preferred birth should be as natural as possible. Among multiparous women the strongest predictors were previous caesarean sections, particularly those that were elective, and a previous negative birth experience. Women’s comments on their preferred mode of birth revealed five categories: women described caesarean section as their only option relating to obstetrical and/or medical factors; several women stated ambivalent feelings and almost as many described their previous birthing experiences as a reason to prefer a caesarean birth; childbirth-related fear and caesarean section as a safe option were the remaining categories.

Key conclusions

rising caesarean section rates seem to be related to factors other than women’s preferences. Ambivalence towards a way of giving birth is common during pregnancy. This should be of concern for midwives and obstetricians during antenatal care. Information and counselling should be frequent and comprehensive when a discussion on caesarean section is initiated by the pregnant woman. A negative birth experience is related to a future preference for caesarean section and this should be considered by caregivers providing intrapartum care.     

Womens' attitudes and beliefs of childbirth and association with birth preference: A comparison of a Swedish and an Australian sample in mid-pregnancy

Background

the rate of caesarean in Australia is twice that of Sweden. Little is known about women's attitudes towards birth in countries where the caesarean rate is high compared to those where normal birth is a more common event.

Objectives

to compare attitudes and beliefs towards birth in a sample of Australian and Swedish women in mid-pregnancy.

Participants

women from rural towns in mid Sweden (n=386) and north-eastern Victoria in Australia (n=123).

Methods

questionnaire data was collected from 2007 to 2009. Levels of agreement or disagreement were indicated on sixteen attitude and belief statements regarding birth. Principal components analysis (PCA) identified the presence of subscales within the attitudes inventory. Using these subscales, attitudes associated with preferred mode of birth were determined. Odds ratios were calculated at 95% CI by country of care.

Results

the Australian sample was less likely than the Swedish sample to agree that they would like a birth that: ‘is as pain free as possible' OR 0.4 (95% CI: 0.2–0.7), ‘will reduce my chance of stress incontinence' OR 0.2 (95% CI: 0.1–0.8), ‘will least affect my future sex life' OR 0.3 (95% CI: 0.2–0.6), ‘will allow me to plan the date when my baby is born' OR 0.4 (95% CI: 0.2–0.7) and ‘is as natural as possible' OR 0.4 (95% CI: 0.2–0.9). They were also less likely to agree that: ‘if a woman wants to have a caesarean she should be able to have one under any circumstances’ OR 0.4 (95% CI: 0.2–0.7) and ‘giving birth is a natural process that should not be interfered with unless necessary’ OR 0.3 (95% CI: 0.1–0.7). Four attitudinal subscales were found: ‘Personal Impact of Birth', ‘Birth as Natural Event', ‘Freedom of Choice' and ‘Safety Concerns'. Women who preferred a caesarean, compared to those who preferred a vaginal birth, across both countries were less likely to think of ‘Birth as a natural event’.

Key conclusions

the Australian women were less likely than the Swedish women to hold attitudes and beliefs regarding the impact of pregnancy and birth on their body, the right to determine the type of birth they want and to value the natural process of birth. Women from both countries who preferred caesarean were less likely to agree with attitudes related to birth as a natural event.