Effects of Cesarean Delivery on Parental Depression,Marital Adjustment,and Mother Infant Interaction

Abstract: To further our understanding of the effects of cesarean delivery on maternal and paternal depression, marital adjustment, and mother-infant interaction during perinatal and three-month postpartum feeding, data were prospectively collected on 80 primiparous married women and their infants, and 76 of their husbands. There were 56 vaginal deliveries and 24 cesarean section deliveries. Data were collected by interview at the latter part of the second trimester and three months postpartum by examination of the mothers' and infants' medical records, and by observation of mother-infant feedings at two days and three months postpartum. The infants' birthweight, weeks of gestation, and Apgar scores at five minutes, maternal age at delivery, and maternal and child health index risk scores were not significantly different between the two groups. Mothers who had cesarean delivery had significantly higher labor index risk scores than those with vaginal birth. The mothers and fathers were not significantly different on levels of depression or marital adjustment prenatally or at three months postpartum. There were no significant differences in mother-infant behaviors during the feedings observed. That we found no differences after cesarean and vaginal delivery would support the theory that mothers respond to infants' behavioral repertoire and not to the mode of delivery.     

Recent patterns in cesarean delivery in the United States

The United States cesarean rate has risen from 5.5 per 100 deliveries in 1970 to 24.1 per 100 deliveries in 1986 according to the National Hospital Discharge Survey. Less than 10 per cent of mothers have a vaginal birth after a prior cesarean. Women spend an average of 5.0 days in the hospital for a cesarean delivery, but only 2.6 days for a vaginal delivery. The rise in cesareans is partly responsible for a concurrent increase in postpartum sterilization. If age-specific cesarean rates continue the steady pattern of increase observed since 1970, 40 per cent of births could be by cesarean by the year 2000.     

Mothers without Companionship During Childbirth: An Analysis within the Millennium Cohort Study

ABSTRACT: Background: Studies have highlighted the benefits of social support during labor but no studies focused on women who choose to be unaccompanied or who have no companion available at birth. Our goals were, first, to identify characteristics of women who are unaccompanied at birth and compare these to those who had support and, second, to establish whether or not being unaccompanied at birth is a risk marker for adverse maternal and infant health outcomes. Methods: The sample comprised 16,610 natural mother‐infant pairs, excluding women with planned cesarean sections in the Millennium Cohort Study. Multivariable regression models were used to examine, first, sociodemographic, cultural, socioeconomic, and pregnancy characteristics in relation to being unaccompanied and, second, being unaccompanied at birth in relation to labor and delivery outcomes, maternal health and health‐related behaviors, parenting, and infant health and development. Results: Mothers who were single (vs not single), multiparous (vs primiparous), of black or Pakistani ethnicity (vs white), from poor households (vs nonpoor), with low levels of education (vs high levels), and who did not attend antenatal classes (vs attenders) were at significantly higher risk of being unaccompanied at birth. Mothers unaccompanied at birth were more likely to have a preterm birth (vs term), an emergency cesarean section (vs spontaneous vaginal delivery) and spinal pain relief or a general anesthetic (vs no pain relief), a shorter labor, and lower satisfaction with life (vs high satisfaction) at 9 months postpartum. Their infants had significantly lower birthweight and were at higher risk of delayed gross motor development (vs normal development). Conclusions: Being unaccompanied at birth may be a useful marker of high‐risk mothers and infants in need of additional support in the postpartum period and beyond. (BIRTH 35:4 December 2008)     

Neonatal Mortality for Primary Cesarean and Vaginal Births to Low‐Risk Women: Application of an “Intention‐to‐Treat” Model

ABSTRACT: Background: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an “intention‐to‐treat” methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low‐risk women. Methods: Low‐risk births were singleton, term (37–41 weeks’ gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention‐to‐treat methodology, a “planned vaginal delivery” category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a “planned cesarean delivery” category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. Results: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. (BIRTH 35:1 March 2008)     

Maternal health outcomes two years after term breech delivery

Objective. To evaluate maternal health outcomes two years after term breech delivery.

Design. This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed.

Results. One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility.

Conclusion. Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.     

Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage U.S. National Survey

Abstract: Background: Prevalence rates of women in community samples who screened positive for meeting the DSM‐IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two‐stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP). Methods: In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale‐Self Report (PSS‐SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire‐2 (PHQ‐2). Results: Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS‐SR. A total of 18 percent of women scored above the cutoff score on the PSS‐SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health‐promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well‐being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ‐2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey. Conclusion: In this two‐stage national survey the high percentage of mothers who screened positive for meeting all the DSM‐IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic. (BIRTH 38:3 September 2011)     

A review of issues surrounding medically elective cesarean delivery

The rate of cesarean delivery has increased dramatically over the past decade. Medically elective cesareans are a major factor contributing to this rise. This article discusses the most recent evidence on the perinatal risks of cesarean delivery versus vaginal birth, the economic impact of elective cesarean delivery, and ethical principles related to cesareans performed without medical indication. Physicians' rationales and responses to the issues are reviewed and the recommendations and guidelines of professional organizations are summarized. Available evidence does not lend support to a current shift in clinical practice. Research is needed to adequately compare outcomes of planned cesarean delivery and planned vaginal birth. Until evidence supports medically elective cesarean as a birth option that optimizes outcomes for low-risk mothers and their infants, obstetric care providers should continue to support evidenced-based decision making that includes advocacy for vaginal delivery as the optimal mode of birth.     

Women's Attitudes Toward Mode of Delivery in South Korea—a Society with High Cesarean Section Rates

Abstract: Background : In South Korea, cesarean section rates (i.e., the proportion of all live births delivered by cesarean section) approached 40 percent in 2000. The relative contribution of physicians and women to this high rate has been a source of debate. This study explored attitudes toward mode of delivery among South Korean women. Methods : A nationwide cross‐sectional telephone survey of 505 Korean women aged 20 to 49 years was conducted using a proportionate quota and systematic random sampling method. The response rate was 57.3 percent. Data were collected using a structured questionnaire consisting of 7 questions about vaginal and cesarean delivery. Results : Over 95 percent of women preferred vaginal delivery during pregnancy and were willing to recommend this method to others. Of the women who delivered by cesarean section, 10.6 percent stated that they had requested a cesarean birth. Attitudes toward vaginal or cesarean delivery differed significantly according to a woman's education level. Conclusions : Most study participants showed more favorable attitudes toward vaginal delivery than cesarean delivery. This result does not support the assumption that the upsurge of cesarean section rates in South Korea is associated with women's positive attitudes toward cesarean section. The main cause of the rapid rise of cesarean section rates in South Korea during the past two decades have its origins in health care practitioners and the health care system in which they work.     

Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births

OBJECTIVE: To compare the outcomes and costs associated with primary cesarean births with no labor (planned cesareans) to vaginal and cesarean births with labor (planned vaginal). METHODS: Analysis was based on a Massachusetts data system linking 470,857 birth certificates, fetal death records, and birth-related hospital discharge records from 1998 and 2003. We examined a subset of 244,088 mothers with no prior cesarean and no documented prenatal risk. We then divided mothers into two groups: those with no labor and a primary cesarean (planned primary cesarean deliveries-3,334 women) and those with labor and either a vaginal birth or a cesarean delivery (planned vaginal-240,754 women). We compared maternal rehospitalization rates and analyzed costs and length of stay. RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000). The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days). CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices. LEVEL OF EVIDENCE: II.     

Women’s Autonomy and Scheduled Cesarean Sections in Brazil: A Cautionary Tale

ABSTRACT: Background: In Brazil, one‐fourth of all women deliver in the private sector, where the rate of cesarean deliveries is extremely high (70%). Most (64%) private sector cesareans are scheduled, although many women would have preferred a vaginal delivery. The question this study addresses is whether childbearing women were induced to accept the procedure by their physicians, and if so, how? Methods: Three face‐to‐face structured interviews were conducted with 1,612 women (519 private sector and 1,093 public sector) early in pregnancy, approximately 1 month before their due date, and approximately 1 month postpartum. For all private sector patients having a scheduled cesarean section, women’s self‐reported reasons given for programming surgical delivery were classified into three groups according to obstetrical justification. Results: After loss to follow‐up (19.2% of private sector and 34.4% of public sector), our final sample included 1,136 women (419 private sector and 717 public sector). Compared with public sector participants in the final sample, on average, private sector participants were older by 3.4 years (28.7 vs 25.3 yr), had 0.4 fewer previous deliveries (0.6 vs 1.0), and had 3.4 more years of education (11.0 vs 7.6 yr). The final samples also differed slightly with respect to preference for vaginal delivery: 72.3 percent among those in the private sector and 79.6 percent in public sector. The cesarean section rate was 72 percent in the private sector and 31 percent in the public sector. Of the women with reports about the timing of the cesarean decision, 64.4 percent had a scheduled cesarean delivery in the private sector compared with 23.7 percent in the public sector. Many cesarean sections were scheduled for an “unjustified” medical reason, especially among women who, during pregnancy, had declared a preference for a vaginal delivery. Among 96 women in this latter group, the reason reported for the procedure was unjustified in 33 cases. On the other hand, more cesarean deliveries were scheduled for “no medical justification,” including physician’s or the woman’s convenience, among women who preferred to deliver by cesarean (35/65). The incidence of real medical reasons for a scheduled cesarean section diagnosed before the onset of labor among private sector patients who had no previous cesarean birth and who wanted a vaginal delivery was 13 percent (31/243). Conclusions: The data suggest that doctors frequently persuaded their patients to accept a scheduled cesarean section for conditions that either did not exist or did not justify this procedure. The problem identified in this paper may extend well beyond Brazil and should be of concern to those with responsibility for ethical behavior in obstetrics. (BIRTH 35:1 March 2008)     

Maternal health outcomes two years after term breech delivery.

OBJECTIVE: To evaluate maternal health outcomes two years after term breech delivery. DESIGN: This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. RESULTS: One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. No differences in maternal experiences concerning breastfeeding, taking care of her child and the relationship with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility. CONCLUSION: Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.     

Persistent pulmonary hypertension of the newborn following elective cesarean delivery at term

Objective.?To evaluate the frequency of persistent pulmonary hypertension of the newborn (PPHN) following elective cesarean at greater than 34 weeks' gestation in an academically affiliated community hospital.

Methods.?Retrospective cohort study involving chart review of 300 newborns with PPHN between 1999 and 2006. Infants less than 34 weeks' or with congenital anomalies were excluded. Subjects were divided into two groups: (1) intended vaginal delivery and (2) elective cesarean.

Results.?A total of 125 neonates were included. In all, 46 were delivered vaginally, 53 by cesarean after a trial of labor, and 26 by elective cesarean. No statistically significant differences were noted between groups in birth weight, gestational age, or length of stay. The crude relative risk (RR) of PPHN in cesareans prior to labor (elective cesareans) when compared to intended vaginal deliveries was 2.0 (95% CI 1.3–3.1). The RR of PPHN in elective cesareans when compared to spontaneous labor resulting in vaginal deliveries was 3.4 (95% CI 2.1–5.5). The adjusted RRs for these outcomes comparing the same delivery groups when considering gestational age at birth (less vs. equal to or more than 37 weeks') were 2.2 (95% CI 1.4–3.4) and 3.7 (95% CI 2.3–6.1), and birth weight (less vs. equal to or more than 2500 g) were 1.9 (95% 1.3–3.0) and 3.4 (95% CI 2.1–5.5), respectively. The incidence of PPHN in the elective cesarean group was 6.9 per 1000 deliveries. The number of cesareans to be avoided to prevent one case of PPHN in this cohort was 387 (number needed to harm, 95% CI 206.8–3003.1).

Conclusions.?Our findings include a high rate of PPHN following elective cesarean delivery, and suggest that physicians should consider this added morbidity when performing elective cesareans.     

Postpartum Early Hospital Discharge and Follow-up Practices in Canada and the United States

Background: Although official guidelines and recent legislation have addressed early postpartum hospital discharge and follow-up, little is known about the practices of obstetricians in Canada and the United States on this issue. Methods: Questionnaires were mailed to two separate random samples of 2000 Fellows of the American College of Obstetricians and Gynecologists (ACOG) in the United States and all Canadian Fellows. Practices and perceptions were compared with those recommended in the literature, recent legislation, and guidelines of ACOG and American Academy of Pediatrics (AAP). Results: In contrast to concerns expressed in the medical literature and official AAP/ACOG guidelines, many physicians considered potential psychosocial and demographic risk factors relatively unimportant in making early discharge decisions, preferring to emphasize aspects of the patient's medical condition, hospital course, and social support. Although the official guidelines encourage follow-up for all patients discharged early, additional visits are routinely advised by only 39 percent of obstetricians after vaginal delivery and by 68 percent after cesarean section. After vaginal delivery 39 percent of obstetricians used telephone follow-up and 37 percent after cesarean delivery. Moreover, although the official guidelines recommend follow-up within 48 hours of discharge, only one-half of the obstetricians surveyed advised follow-up at this time. In contrast to the guidelines, most obstetricians defined early discharge as that occuring within 24 hours after vaginal delivery and 72 hours after cesarean delivery; most defined optimal lengths of stay within the 48-hour (after vaginal delivery) and 96-hour (after cesarean delivery) periods considered short by the guidelines. Conclusions: Current postpartum early discharge and follow-up practices emphasize the physical health of the mother and place little emphasis on social risk. They appear to be influenced by perceptions of the appropriateness of the length of stay and are not in agreement with professional guidelines. (BIRTH 25:3 September 1998)     

Changes in Cesarean Delivery in the United States, 1988 and 1993

ABSTRACT: The rate of cesarean delivery in the United States (22.8% in 1993) has remained stable since the mid-1980s after dramatic increases during the 1970s and early 1980s. The primary cesarean rate (16.3 cesareans in 1993 per 100 women with no history of previous cesarean delivery) was also stable from 1988 to 1993. During this same period, the rate of vaginal birth after previous cesarean (VBAC) doubled, from 12.6 to 25.4 percent. In both 1988 and 1993, rates of cesarean delivery were higher in the South than in other regions, for mothers 35 years or older than for younger women, for proprietary than for nonprofit or state and local government hospitals, and for women with private insurance than for women with Medicaid or self-pay as the expected source of payment. Even if VBAC rates continue to increase at the same rate as in the past, the Year 2000 goal of an overall cesarean rate of 15 percent cannot be met without reducing the primary cesarean rate by 50 percent.     

Severe perineal lacerations during vaginal delivery: the University of Miami experience

OBJECTIVE: After childbirth-related third- or fourth-degree perineal lacerations, the estimated incidence of wound disruption, fecal incontinence, or fistula ranges from 1% to 10%. Risk factors associated with severe laceration were analyzed at a single large teaching institution.Study Design: This study consisted of an analysis of data from the delivery database of Jackson Memorial Hospital, University of Miami, from 1989 through 1995. Included were vaginal deliveries for which complete information was available on maternal age, parity, ethnicity (white, black, or Hispanic), birth weight, episiotomy versus no episiotomy, type of episiotomy, and delivery (normal spontaneous, vacuum, or forceps). Multiple gestations, cases of shoulder dystocia, cesarean deliveries, patients with a history of cesarean delivery, and babies weighing <500 g at birth were excluded from this study. Both univariate and multivariate analyses were performed with variables such as maternal age, race, birth weight, type of episiotomy if any, and type of vaginal delivery. RESULTS: Among the 71,959 women who were delivered at our institution during the 7-year study period, 50,210 met the inclusion criteria. Through time there had been a decline in the use of episiotomy in general and of midline episiotomy in particular. The annual total number of deliveries also decreased. The episiotomy procedure per se and the type of episiotomy as well as birth weight, assisted vaginal delivery, and older maternal age were identified as independent risk factors associated with third- and fourth-degree perineal lacerations. CONCLUSION: Although episiotomy is an important risk factor for severe lacerations after vaginal delivery, there are other significant independent risk factors, such as maternal age, birth weight, and assisted vaginal delivery, that should be considered in counseling and making decisions regarding delivery modality. Older patients who are being delivered of a first child are at higher risk for severe laceration. Midline episiotomy and assisted vaginal delivery should therefore be avoided in this population whenever possible, especially in the presence of a large baby.     

Does pain relief during delivery decrease the risk of postnatal depression?

BACKGROUND: To test the hypothesis that sufficient pain relief during delivery decreases the risk of postnatal depression. METHODS: As part of a prospective follow-up study of the risk factors for postnatal depression and its impact on the mother-infant interaction and child development, 185 parturients filled in the Edinburgh Postnatal Depression Scale (EPDS), first during the first postpartum week and again (n = 162) 4 months later. The incidence and the risk of high EPDS scores was calculated according to the mode of delivery and the mode of pain relief during vaginal delivery, also after adjusting for the length of labor. RESULTS: Mothers who received epidural/paracervical blockade during their delivery spent less time in the delivery room than mothers in the nitrous oxide/acupuncture group (p = 0.033) or mothers with no pain relief (p = 0.026) and had shorter length of labor than mothers without pain relief (p = 0.04). The adjusted risk of depressive scores at the first postnatal week was decreased in the epidural/paracervical group when compared with no analgesia group (OR: 0.25, 95% CI: 0.09-0.72). This difference was not shown at 4 months postpartum. Elective or emergency cesarean section did not increase the risk of high EPDS scores at the first week or at 4 months postpartum. CONCLUSION: The mode of pain relief during vaginal delivery seems to be associated with the incidence of postpartum depression, especially immediately after delivery.     

Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain

Objective: To investigate whether spontaneous vaginal birth with mediolateral episiotomy has any long-term impact on urinary and/or fecal incontinence, sexual dysfunction and perineal pain in primiparous women.

Methods: This matched case-control study included 150 women between 25 and 35 years old who had a singleton childbirth at least five years previously. Patients were grouped as; women who had a spontaneous vaginal delivery with mediolateral episiotomy (Group 1), an elective cesarean delivery (Group 2), and who had no delivery (Group 3). Controls were matched for age and delivery time. Urinary/fecal incontinence were questioned and Female Sexual Function Index (FSFI) questionnaire was completed. Total FSFI and domain scores were compared. Statistical evaluation was performed using One-way ANOVA test or χ² test. Statistical significance was defined as p?Results: No women had urinary/fecal incontinence nor sexual dysfunction. Mean total FSFI points in Group 1 were significantly lower than in Groups 2 and 3 (p?=?0.001). There were significant differences in sexual desire between groups 1 and 3 (p?=?0.005), in arousal and in orgasm between both groups 1 and 2 (p?=?0.001 and p?=?0.038, respectively) and groups 1 and 3 (p?=?0.001 and p?=?0.001, respectively). There was no significant difference between groups 2 and 3 in any parameters or total points.

Conclusions: Vaginal delivery with mediolateral episiotomy is not associated with urinary and/or fecal incontinence and sexual dysfunction but associated with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years.     

Does Cesarean Section Reduce Postpartum Urinary Incontinence? A Systematic Review

ABSTRACT: Background: The impact of delivery mode on the development of urinary incontinence has been much debated. The primary objective of this systematic review was to compare the prevalence of postpartum urinary incontinence after cesarean section compared with vaginal birth. Methods: The MEDLINE (1966–2005) and CINAHL (1982–2005) databases were searched for reports specifying postpartum prevalence or incidence of unspecified, stress, urge, and mixed urinary incontinence by mode of birth. Primary authors were contacted to request unpublished data about severity, parity, and timing of cesarean section. All data were entered into Review Manager software, and odds ratio (OR), absolute risk reduction, and number needed to prevent were calculated. Results: Cesarean section reduced the risk of postpartum stress urinary incontinence from 16 to 9.8 percent (OR = 0.56 [0.45, 0.68], number needed to prevent = 15 [12,22]) in 6 cross‐sectional studies, and from 22 to 10 percent in 12 cohort studies (OR=0.48 [0.39, 0.58], number needed to prevent = 10 [8,13]). Differences persisted by parity and after exclusion of instrumental delivery, but risk of severe stress urinary incontinence and urge urinary incontinence did not differ by mode of birth. Conclusions: Although short‐term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent by mode of birth. Risk of postpartum stress urinary incontinence must be considered in the context of associated maternal and newborn morbidity and mortality. (BIRTH 34:3 September 2007)     

“It's All the Rage These Days”: University Students' Attitudes Toward Vaginal and Cesarean Birth

Background: At 30 percent, British Columbia has the highest cesarean section rate in Canada. Little is known about the childbirth views and birthing preferences of college‐aged women and men. The objectives of this study were to document (a) the prevalence of cesarean versus vaginal delivery as the preferred mode of delivery among nonpregnant university students without a history of childbirth, (b) the reasons for reported childbirth preferences, and (c) confidence in vaginal birth as a predictor of childbirth preference. Methods: A cohort of 3,680 male and female university students without a history of childbirth participated in an online survey of childbirth preferences. The study used a mixed methods approach (quantitative thematic analysis and logistic regression modeling). Prevalence of, and reasons for, preferred mode of delivery were analyzed separately for male and female respondents. Results: Most men and women responded that they preferred vaginal delivery, with 9 percent stating a preference for cesarean delivery. Reasons for preferred mode of delivery were similar for men and women. For women, confidence in vaginal birth emerged as a significant predictor of childbirth preference. Conclusions: Results indicate that a preference for cesarean section is linked to fear of childbirth and driven by low confidence in vaginal birth. Educational strategies targeting university‐aged men and women may be helpful in alleviating fears of vaginal birth and providing evidence‐based information about different birth options.