Background
When asked about their preferred way of giving birth, most women favor a vaginal birth with as few interventions as possible, and without anesthesia [
1‐
3]. This preference is not reflected in the high number of obstetric interventions in most middle- and high-income countries [
4,
5], even for low-risk pregnancies. For example, large-scale studies in the US and Canada indicate that 60–90% of women who had planned to have a vaginal birth underwent one of the following interventions: induction of labor around term, epidural or spinal anesthesia, amniotomy, episiotomy, instrumental vaginal birth, or cesarean section (CS). Studies in Germany and the US suggest that the observed increase in CS in recent decades is mainly attributable to somewhat subjective criteria or relative indications such as fetal distress or arrest of cervical dilation [
6‐
8]. Other factors such as higher age at childbirth, the related increase in multiple birth rates, or obesity and associated risks cannot entirely explain the increase in CS [
9].
Women’s concern to ensure a safe birth may also contribute to the increase in obstetric interventions, although the actual benefits of some interventions are disputed [
4,
10]. For example, in a Canadian survey of 6421 women, 79.8% said they were satisfied with their overall birth experience, even though the rate of obstetric interventions was high [
11]. In most regions of the world, the average fertility rate has declined by more than 50% over the last hundred years, which may explain the increased emphasis on safety and control during pregnancy and childbirth [
7,
12]. Some women actually favor interventions for a quicker and ideally painless childbirth rather than a vaginal birth with no intervention [
2], especially if they feel anxious about giving birth or have had previous negative experiences [
3,
5].
Given most women’s expressed preference for a vaginal birth and the effect of social conditions on preferences, the extent to which the increase in obstetric interventions reflects their own safety concerns or medical indications remains unclear. Importantly, this also raises questions about the role of informal coercion in seeking women’s consent to interventions. The term
informal coercion encompasses a range of measures on the continuum between self-determination and formal coercion, including inducement, persuasion, manipulation, pressure, and threats (cf. [
13‐
19]). In most jurisdictions,
formal coercion during birth is only permissible under specific circumstances—i.e., when women lack decision-making capacity [
20]. In psychiatry, informal coercion is sometimes advocated as a means of avoiding formal coercion [
21,
22] such as forced medication or feeding. In obstetrics and gynecology, formal coercion is far less common because women in labor generally have decision-making capacity. However, informal coercion might be used during childbirth to urge women to accept obstetric interventions. From an ethical and legal standpoint, such interventions are admissible only if the woman can accept or decline them freely, with proper information and guidance from health care professionals (HCP), and without undue influence or coercion [
23].
Research on the quality of maternity care in low-income countries has reported evidence of inadequate professional standards, including disrespectful, abusive, or violent behaviors [
2,
24‐
26]. In high-income countries, subtler approaches such as informal coercion may be more prevalent, as health care systems emphasize respect for patient autonomy and human rights [
24]. Vedam et al. [
27] reported that many women feel coerced by HCP, and that their physical needs and complaints are trivialized. In a representative study of 2400 women in the US, about 15% of those who underwent induction of labor, epidural anesthesia, or CS felt pressured to accept the treatment, and about half of those who favored a vaginal birth rather than a CS were not afforded this opportunity [
1]. For women who felt pressured, the risk of labor induction was twice as high, and the risk of CS was six times as high even in the absence of any medical indication. In another cross-sectional study of 2700 women in the US, 28% of women who gave birth in hospital reported some form of mistreatment—most often in the form of unsupportive care, being shouted at or scolded, violation of privacy, or being forced to accept specified treatments [
24].
While conflicts between women and HCP may be quite open, informal coercion can take covert forms that may or may not be apparent to women or HCP. For example, HCP report that they frequently “pull the dead baby card”, holding the mother responsible for a potential adverse outcome, regardless of whether the baby is actually at risk [
28,
29]. It follows that women’s reports of coercion depend on their level of knowledge about childbirth in general and about the rationale for a given obstetric intervention [
28,
30].
As the extent of restrictions on women’s self-determination during childbirth remains unknown, the goals of the current study were a) to assess the prevalence and forms of informal coercion during childbirth in Switzerland; b) to identify individual and contextual factors that contribute to informal coercion; and c) to determine whether and how informal coercion is associated with childbirth satisfaction and postpartum depression.
Results
Survey response
In total, 7663 women accessed the first survey page and provided informed consent. Most participants (6625, 86.5%) were recruited through Facebook; the remainder (1026, 13.5%) were recruited through other channels. Of these, 428 women (5.6%) were excluded from the final analysis because their most recent birth was more than 12 months previously. Additionally, 16 responses (0.22%) were excluded after checking the comments, mainly because the birth was not in Switzerland or because they were duplicate entries. Of the remaining 7226 women who started the questionnaire and met all of the eligibility criteria, 6054 (83.8%) completed it. Regarding missing data in all completed questionnaires, one question (birth duration) had 10.4% missing data, six items had less than 4% and all other items had less than 1%.
Demographics
Table
2 shows descriptive statistics for selected demographic information and birth characteristics in both the survey and census data. The census data were used to weight the sample data for all subsequent analyses. The survey sample overrepresented Swiss women who had a non-instrumental vaginal delivery and did not give birth in a hospital. Descriptive statistics for additional sociodemographic variables and pregnancy and birth characteristics of the survey sample are summarized in Additional file
2: Table S2.
Table 2
Selected demographic and birth-related variables: final survey and census data
Maternal age (years) |
18–23 | 195 (3.2%) | 3130 (3.6%) |
24–27 | 707 (11.7%) | 10,498 (12.2%) |
28–31 | 1682 (27.8%) | 22,940 (26.6%) |
32–35 | 1950 (32.3%) | 26,984 (31.3%) |
36–39 | 1179 (19.5%) | 16,573 (19.2%) |
40+ | 332 (5.5%) | 6007 (7.0%) |
Marital status |
Married/Registered partnership | 4440 (73.5%) | 63,359 (73.6%) |
Single* | 1601 (26.5%) | 22,773 (26.4%) |
Nationality |
Swiss | 4927 (81.6%) | 51,772 (60.1%) |
Neighboring state | 607 (10.1%) | 9810 (11.4%) |
Other | 504 (8.4%) | 24,550 (28.5%) |
Major regions |
Espace Mittelland | 1666 (27.6%) | 18,392 (21.4%) |
North-West Switzerland | 757 (12.5%) | 11,643 (13.5%) |
Eastern Switzerland | 706 (11.7%) | 11,645 (13.5%) |
Lake Geneva Region | 1203 (19.9%) | 17,085 (19.8%) |
Central Switzerland | 539 (8.9%) | 8290 (9.6%) |
Ticino | 285 (4.7%) | 2493 (2.9%) |
Zurich | 879 (14.6%) | 16,584 (19.3%) |
Place of birth |
Hospital | 5457 (90.6%) | 83,256 (96.7%) |
Birthing center | 338 (5.6%) | 2151 (2.5%) |
At home | 228 (3.8%) | 725 (0.8%) |
Mode of delivery |
Non-instrumental vaginal birth | 3952 (65.3%) | 49,429 (57.4%) |
Forceps or vacuum birth | 693 (11.4%) | 9492 (11.0%) |
Cesarean section | 1409 (23.3%) | 27,211 (31.6%) |
Nulliparous | 3505 (57.9%) | 41,734 (48.5%) |
Table
3 shows descriptive data for the three aspects of informed consent (
Information,
Time,
Agreement) and the three forms of informal coercion (
Opposition,
Intimidation,
Manipulation) for different delivery modes and selected interventions. Similar procedures or procedures that co-occur frequently exhibited a similar pattern of ratings for informed consent and informal coercion. Women who had a planned CS reported high levels of being adequately informed, having enough time to decide, and agreeing with the decision. In comparison, women who underwent an unplanned CS or induction of labor (which often co-occur) reported lower levels of
Information and
Time and returned the highest ratings for opposing the procedure and feeling manipulated. Overall, emergency CS is associated with the highest rate of informal coercion, as 37% of those who had an emergency CS felt intimidated. The lowest ratings for informed consent relate to instrumental birth and episiotomy; only about 30% of the women felt adequately informed regarding both interventions. Only about 20% of the women who had an instrumental birth and 17% of those who had an episiotomy felt they had sufficient time to make their decision. Finally, only about half of the women who had an amniotomy received adequate information about the procedure (53%) and had enough time to decide (56%).
Table 3
Absolute and relative frequencies of informed consent and informal coercion by delivery mode or intervention
Planned cesarean section | 427 (90.7%) | 427 (90.7%) | 451 (95.8%) | 35 (7.4%) | 142 (30.1%) | 25 (5.3%) |
Unplanned cesarean section | 384 (76.2%) | 322 (63.9%) | 481 (95.4%) | 43 (8.5%) | 111 (22.0%) | 36 (7.1%) |
Emergency cesarean section | 199 (58.5%) | 98 (28.8%) | 311 (91.5%) | 20 (5.9%) | 126 (37.1%) | 13 (3.8%) |
Forceps or vacuum birth | 213 (30.7%) | 143 (20.6%) | 616 (88.9%) | 22 (3.2%) | 114 (16.5%) | 27 (3.9%) |
Induction of labor | 1136 (74.2%) | 1122 (73.3%) | 1384 (90.5%) | 152 (9.9%) | 407 (26.6%) | 151 (9.9%) |
Amniotomy | 713 (52.5%) | 754 (55.5%) | 1277 (94.0%) | 32 (2.4%) | 59 (4.3%) | 50 (3.7%) |
Episiotomy | 208 (30.0%) | 119 (17.2%) | 530 (76.5%) | 45 (6.5%) | 89 (12.8%) | 38 (5.5%) |
Pairwise associations between informal coercion and medical indications as reported by the women can be found in Additional file
3: Table S3. Overall, women reported higher levels of informal coercion when they did not understand the reason for the intervention. All other interventions (e.g., fundal pressure, vaginal examinations, medication) were associated with a higher risk of informal coercion. In contrast, the risk was lower for women who had the opportunity to discuss the birth afterwards with the HCP involved.
Using imputed and weighted data, the estimated probability of experiencing any form of informal coercion was 26.7%. Furthermore, 16.3% of women reported pressure to consent and 9.5% reported being treated in a derogatory or insulting manner at least once. Risk ratios and 95% confidence intervals (CI) for factors associated with informal coercion are shown in Table
4 (left column). Women from a non-neighboring state were at greater risk of informal coercion (RR 1.45, 95% CI [1.26,1.66]), as were women living in more urban cantons (RR 1.16 [1.09,1.23]). A preference for autonomy in decision-making during childbirth (RR 1.15 [1.10,1.21]) and for vaginal birth (RR 1.15 [1.06,1.24]) increased the risk of informal coercion, as did high-risk pregnancy (RR 1.25 [1.10,1.41]). In contrast, for women who gave birth at a birthing center (an independent birth facility run by midwives), the risk was three times lower (RR 0.35 [0.21,0.59]). Women who did not give birth where they had initially planned because they had to be transferred from a birthing center or a different hospital were also at greater risk of informal coercion (RR 1.47 [1.25,1.73]). In addition, instrumental vaginal birth and all types of CS were associated with a higher risk of informal coercion (all RRs > 1.5). Interestingly, women reported informal coercion more often where more time had elapsed since the birth (RR 1.17 [1.06,1.29]).
Table 4
Estimated risks associated with informal coercion, postpartum depression, and satisfaction with childbirth
MATERNAL SOCIODEMOGRAPHIC CHARACTERISTICS |
Maternal age (years): |
18–23 | Ref. | | Ref. | | Ref. | |
24–27 | 1.06 | [0.77,1.47] | 1.25 | [0.91,1.72] | 1.47 | [−1.29,4.22] |
28–31 | 1.03 | [0.76,1.41] | 1.10 | [0.80,1.51] | 1.71 | [−0.90,4.32] |
32–35 | 0.88 | [0.63,1.22] | 1.03 | [0.75,1.43] | 0.30 | [−2.35,2.95] |
36–39 | 0.91 | [0.65,1.28] | 0.97 | [0.69,1.36] | 1.06 | [−1.71,3.82] |
40+ | 0.94 | [0.64,1.39] | 0.95 | [0.64,1.43] | 1.67 | [−1.52,4.86] |
Nationality: |
Swiss | Ref. | | Ref. | | Ref. | |
Neighboring state | 1.06 | [0.91,1.25] | 1.50 | [1.29,1.74] | −0.99 | [−2.24,0.26] |
Other | 1.45 | [1.26,1.66] | 1.57 | [1.36,1.82] | 0.01 | [−1.22,1.24] |
Socioeconomic status (+ 1 SD) | 1.02 | [0.96,1.09] | 0.90 | [0.85,0.96] | −0.02 | [−0.52,0.49] |
Urban (+ 1 SD) | 1.16 | [1.09,1.23] | 1.07 | [1.00,1.14] | −0.24 | [− 0.64,0.16] |
MOTHERS’ PREFERENCE AND EXPECTATIONS |
Preference for autonomous decision (+ 1 SD) | 1.15 | [1.10,1.21] | 1.02 | [0.96,1.08] | 0.37 | [−0.08,0.82] |
Preference for vaginal birth (+ 1 SD) | 1.15 | [1.06,1.24] | 1.02 | [0.95,1.09] | −0.74 | [−1.25,-0.23] |
Birth preparation (+ 1 SD) | 1.06 | [1.00,1.13] | 0.98 | [0.92,1.05] | 0.16 | [−0.31,0.63] |
PREGNANCY CHARACTERISTICS |
Parity: |
Nulliparous | Ref. | | Ref. | | Ref. | |
Multiparous - no previous CS | 0.94 | [0.79,1.13] | 0.90 | [0.76,1.06] | 1.35 | [0.21,2.49] |
Multiparous - previous CS | 1.00 | [0.81,1.23] | 0.92 | [0.74,1.14] | 1.50 | [−0.04,3.05] |
Multiple birth | 1.68 | [1.20,2.35] | 0.87 | [0.59,1.29] | 1.27 | [−2.03,4.56] |
High-risk pregnancy | 1.25 | [1.10,1.41] | 1.04 | [0.92,1.19] | −1.76 | [−2.73,-0.79] |
Main caregiver: |
Physician | Ref. | | Ref. | | Ref. | |
Midwife | 1.11 | [0.93,1.32] | 0.88 | [0.73,1.07] | −0.17 | [−1.49,1.16] |
Both | 0.95 | [0.82,1.10] | 0.82 | [0.69,0.97] | 0.99 | [−0.08,2.06] |
Other | 1.58 | [0.77,3.27] | 0.89 | [0.37,2.11] | −6.12 | [−13.55,1.3] |
BIRTH SETTING |
Knew at least one of the care providers | 1.00 | [0.88,1.14] | 0.98 | [0.86,1.12] | 1.05 | [0.09,2.00] |
Place of birth: |
Public hospital | Ref. | | Ref. | | Ref. | |
Private hospital | 1.01 | [0.86,1.19] | 1.05 | [0.89,1.24] | 0.19 | [−0.95,1.34] |
Birthing center | 0.35 | [0.21,0.59] | 0.65 | [0.46,0.93] | 3.54 | [1.96,5.13] |
At home | 0.72 | [0.44,1.20] | 0.88 | [0.56,1.37] | 7.55 | [5.84,9.27] |
Unplanned place of birth | 1.47 | [1.25,1.73] | 1.33 | [1.11,1.60] | −3.25 | [−5.19,-1.31] |
BIRTH CHARACTERISTICS |
Mode of birth: |
Non-instrumental vaginal birth | Ref. | | Ref. | | Ref. | |
Forceps or vacuum birth | 2.17 | [1.85,2.55] | 1.00 | [0.84,1.20] | −6.94 | [−8.41,-5.48] |
Planned cesarean section | 1.52 | [1.18,1.96] | 1.00 | [0.79,1.26] | −2.31 | [−4.08,-0.54] |
Unplanned cesarean section | 1.92 | [1.61,2.28] | 0.90 | [0.72,1.13] | −9.35 | [−11.14,-7.56] |
Emergency cesarean section | 2.10 | [1.71,2.58] | 1.32 | [1.08,1.62] | − 12.12 | [− 14.28,-9.96] |
Duration of birth (+ 10 h) | 1.07 | [1.01,1.13] | 1.02 | [0.96,1.09] | −2.68 | [−3.27,-2.09] |
Child’s weight (+ 1000 g) | 1.10 | [0.96,1.26] | 1.02 | [0.90,1.16] | 0.23 | [−0.74,1.20] |
Child’s age (+ 6 Mt.) | 1.17 | [1.06,1.29] | 0.89 | [0.81,0.99] | 0.09 | [−0.61,0.79] |
EXPERIENCE OF INFORMAL COERCION | – | – | 1.35 | [1.19,1.54] | −7.52 | [−8.63,-6.41] |
Postpartum depression
Responses to the Whooley questions used for depression screening indicated that 27.0% of the women were at risk of postpartum depression or another mental health disorder. Several demographic and birth-related factors were associated with increased risk of possible mental health problems. Women living in urban cantons (RR 1.07 [1.00,1.14]) and migrant women were at greater risk (both RRs > 1.5). Women who gave birth at a birthing center were at lower risk (RR 0.65 [0.46,0.93]), but women who were transferred to a (different) hospital were at higher risk (RR 1.33 [1.11,1.60]). Of all modes of delivery, only emergency CS was associated with increased risk (RR 1.32 [1.08,1.62]). Experiencing informal coercion also increased the risk of postpartum mental health disorders (RR 1.35 [1.19,1.54]).
Satisfaction
Satisfaction with childbirth was measured as total SIL score; higher values indicated higher satisfaction. The main factors influencing satisfaction were informal coercion, place of birth, and mode of delivery. Experiencing informal coercion had a negative effect on reported childbirth experience (− 7.52 [− 8.63,-6.41]). Women who gave birth at home or at a birthing center were generally more satisfied than women who gave birth at a hospital (birthing center + 3.54 [1.96,5.13]; at home + 7.55 [5.84,9.27]). Women who did not give birth where they had planned to were less satisfied (− 3.25 [− 5.19,-1.31]). Finally, women who had an unplanned or an emergency CS returned the lowest satisfaction ratings (unplanned CS -9.35 [− 11.14,-7.56]; emergency CS -12.12 [− 14.28,-9.96]).
Discussion
The goals of the current study were to estimate the prevalence of informal coercion during childbirth in Switzerland and to assess the risk associated with a number of individual and contextual factors. To that end, we developed a comprehensive questionnaire addressing various aspects of informal coercion, satisfaction with childbirth, and postpartum depression, as well as a range of demographic, pregnancy, and birth-related characteristics. Women aged 18 years or older who had given birth in Switzerland within the previous 12 months were recruited through online and offline channels; a majority accessed the questionnaire by clicking on a Facebook ad. An estimated 27% of women experienced informal coercion during childbirth, and about 16% reported feeling pressured to consent to an intervention. In addition, the present data demonstrate that informal coercion negatively affects satisfaction with childbirth and is associated with increased risk of postpartum depression.
The observed association between informal coercion and depression does not support conclusions regarding any causal relationship. While experiencing informal coercion may increase the risk of postpartum depression, another possibility is that women who are already suffering from depression may be more likely to experience informal coercion. Nevertheless, these results highlight the importance of safeguarding against informal coercion to prevent post-partum depression. Longitudinal studies have reported that CS may negatively affect women’s delivery experience and increase their subsequent risk of postpartum depression, especially among those with a strong preference for vaginal delivery [
68,
69]. Our data suggest that the relationship between mode of delivery and postpartum depression may be mediated by informal coercion, and this seems a worthwhile avenue for future research.
Although their scope and methodology differ, other studies report similar rates of informal coercion in high-income countries. For instance, Vedam et al. [
24] found that about 28% of women who gave birth at a hospital in the US experienced mistreatment—most commonly, violations of physical privacy, being shouted at or scolded, and requests for help that were unanswered. In another US study, about 15% of women reported feeling pressured to consent to a medical intervention [
1]. In general, the risk of experiencing mistreatment during childbirth seems to be lower for women who are multiparous, older than 30, white, and speak the same language as the HCP. That risk is higher if women have to be transferred to hospital from a different location during childbirth [
24,
70]. In line with previous research, the present study indicates that migrant women are at greater risk of experiencing informal coercion than Swiss nationals. The risk is also higher for women living in more urban regions than for those living in more rural regions. In urban regions, the known higher rate of CS [
71] and the increased risk of informal coercion identified here suggest that many interventions in urban areas are performed without explicit consent, but this requires further exploration.
Another important unresolved question is how the relationship between birth setting and a woman’s childbirth preferences and expectations impacts the experience of informal coercion. Our data show that women who express a strong preference for a vaginal and self-determined birth tend to report informal coercion more often than women for whom these issues are less important. Expectations related to self-determined birth may reflect different conceptions of a “good” birth [
72] that are not always realistic. In institutional settings, women and HCP share the responsibility for the health of both mother and child. Additionally, the birth process in institutional settings is likely to be standardized for reasons of quality and effectiveness, and HCP are required to follow specific guidelines. At first glance, birthing centers may seem to allow for greater self-determination, but any direct comparison between hospitals and birthing centers must be drawn with caution for a number of reasons. First, only women with low-risk pregnancies can give birth at a birthing center. Second, birthing centers are not authorized to carry out the most debated obstetric interventions that incur a higher risk of informal coercion. Finally, the observed association between informal coercion and transfer to hospital does not necessarily imply any misconduct by HCP at the hospital; it might equally reflect a woman’s disappointment—even if she understands the reasons—that her preference for a vaginal birth with minimal medical intervention could not be met. In short, while women’s preferences and expectations clearly impact the experience of informal coercion, the role of the birth setting and associated preferences and expectations require further investigation.
In addition, informal coercion does not necessarily imply HCP intent. While organizational or working conditions can never justify the use of informal coercion, a number of circumstances may explain why it nevertheless occurs (and suggest how it might be prevented). First, economic pressures, incentive systems, or fear of legal liability may cause HCP to feel compelled to intervene when in doubt [
18]. Second, most of the interventions performed by HCP are routine operations, and HCP may not always be sensitive to the possible consequences for the mother. Third, women differ in their perception of such suggestions as “support”, “nudge” [
73,
74], or outright pressure, and that perception may also change over time [
75]. Finally, HCP encounter a wide range of patient attitudes, preferences, and needs, and some may not know how best to respond if a woman rejects a treatment suggestion, even (or especially) if it is based on current best practice [
29]. Nevertheless, our findings indicate that informal coercion is a common feature of childbirth, with potentially traumatizing consequences that are likely to affect both the woman and her family. In general, as obstetric interventions seem to have a negative impact on women’s birth experience [
56], HCP must take account of potentially harmful outcomes that include both the immediate physical circumstances and longer-term psychological consequences for the mother when contemplating any such intervention.
In the present study, about one in four women reported feeling intimidated during childbirth. This number increased to one in three among women who underwent a CS or induction of labor. While many women favor vaginal birth, concerns about the child’s health tend to overrule other arguments when discussing possible interventions [
76]. This explains why “playing the dead baby card” is so effective, as none of those involved—mother or HCP—want to be responsible for a negative outcome [
77]. HCP have the power to modulate women’s fears, either frightening them by stressing the possible risks or empowering them to play an active role in childbirth. Clearly, some women also hold false beliefs because of their lack of knowledge about certain interventions. In the present case, women who did not understand the reasons for an intervention were more likely to feel coerced. Women who were afforded the opportunity of a childbirth debriefing to discuss the birth with the HCP involved reported lower rates of informal coercion than those who had no such opportunity. These findings highlight the need for HCP to explain any intervention and the reasons for it [
1,
76]. Informing women about procedures and seeking their active participation is not only a legal requirement but a sign of respect for the mother and her child.
Strengths and limitations
To our knowledge, this is the first in-depth investigation of the prevalence of informal coercion in a large nationwide sample. As well as controlling for multiple characteristics of pregnancy and birth, we controlled for birth preparation and attitudes and expectations regarding patient involvement. The questionnaire design ensured a relatively low dropout rate, yielding a more representative sample.
One significant limitation of the study is the possibility of self-selection bias, which is typically more problematic in non-probability samples. The survey sample was not representative in terms of variables like place of birth, nationality, mode of delivery, and other potentially relevant characteristics that were not assessed. For example, the proportion of women who gave birth at a birthing center was higher than in the census data, which may indicate that the participants were more actively engaged with the topic of childbirth and therefore more interested in responding to the survey. In addition, while the recruitment material was carefully selected, we had no control over or insight into Facebook’s algorithms for delivering ads [
33]. On the other hand, we did follow recommended practice to reduce bias in non-probability samples by combining various offline and online recruitment channels [
31]. Women recruited through Facebook did not differ significantly from women recruited through other channels in terms of reported informal coercion, postpartum depression, or satisfaction with childbirth.
It is reasonable to assume that the reported prevalence is a fairly conservative estimate, as more satisfied patients are generally more inclined to respond to questionnaires measuring patient satisfaction [
78]. In the present case, for example, women were more likely to drop out of the study if they had had an unwanted CS than if the CS was their own preference. Although we used multiple items to assess informal coercion, the rate of covert coercion (i.e., coercion that the women themselves did not recognize) remains completely unknown. These micro-interactions are subtle, and women who are overwhelmed and focused on the birth itself may be unaware of what is going on around them [
79]. These feelings may continue for several months, which would explain why women were less likely to report informal coercion in the first few months after birth than around 6 months to a year after.
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