Women's experiences of decision-making and beliefs in relation to planned caesarean section: A survey study.

BACKGROUND: The caesarean section (CS) rate is over 25% in many high-income countries, with a substantial minority of CSs occurring in women with low-risk pregnancies. CS decision-making is influenced by clinician and patient beliefs and preferences, and clinical guidelines increasingly stipulate the importance of shared decision-making (SDM). To what extent SDM occurs in practice is unclear. AIMS: To identify women's birth preferences and SDM experience regarding planned CS. MATERIAL AND METHODS: Survey of women at eight Sydney hospitals booked for planned CS. Demographic data, initial mode of birth preferences, reason for CS, and experiences of SDM were elicited using questions with multiple choice lists, Likert scales, and open-ended responses. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Responses of women who perceived their CS as 'requested' vs 'recommended' were compared. RESULTS: Of 151 respondents, repeat CS (48%) and breech presentation (14%) were the most common indications. Only 32% stated that at the beginning of pregnancy they had a definite preference for spontaneous labour and birth. Key reasons for wanting planned CS were to avoid another emergency CS, prior positive CS experience, and logistical planning. Although 15% of women felt pressured (or were unsure) about their CS decision, the majority reported positive experiences, with over 90% indicating they were informed about CS benefits and risks, had adequate information, and understood information provided. CONCLUSIONS: The majority (85%) of women appeared satisfied with the decision-making process, regardless of whether they perceived their CS as requested or recommended.

Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section.

BACKGROUND: Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM: To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS: A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS: Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION: Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION: Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.

What are women's mode of birth preferences and why? A systematic scoping review.

BACKGROUND: The optimal caesarean section rate is estimated to be between 10-15%; however, it is much higher in high and many middle-income countries and continues to be lower in some middle and low-income countries. While a range of factors influence caesarean section rates, women's mode of birth preferences also play a role. The aim of this study was to map the literature in relation to women's mode of birth preferences, and identify underlying reasons for, and factors associated with, these preferences. METHOD: Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018, and reference lists of included studies were examined. FINDINGS: A total of 65 studies were included. While the majority of women prefer a vaginal birth, between 5-20% in high-income countries and 1.4 to 50% in low-middle-income countries prefer a caesarean section. The six main reasons or factors associated with a mode of birth preference were: (1) perceptions of safety; (2) fear of pain; (3) previous birth experience; (4) encouragement and dissuasion from health professionals; (5) social and cultural influences; and (6) access to information and educational levels. CONCLUSION: To help ensure women receive the required care that is aligned with their preferences, processes of shared decision-making should be implemented. Shared decision-making has the potential to reduce the rate of unnecessary interventions, and also improve the willingness of women to accept a medically-indicated caesarean section in low-income countries.