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

Abstract

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.

Introduction

Rising caesarean section rate is a characteristic feature of modern obstetrics in most Western countries of the world, which is of concern for both professionals and the public. In Australia and the US almost every third woman has a caesarean birth (Laws et al., 2007, MacDorman et al., 2008a). Generally, in the developed world an incidence of 21.1% is reported (Betran et al., 2007). The same authors conclude that caesarean section rates substantially above 15% may imply that risks to women’s reproductive health have begun to outweigh the benefits. Risks of short- and long-term maternal and fetal morbidity associated with planned caesarean section are higher than those associated with vaginal birth (Gilliam, 2006, Liu et al., 2007, MacDorman et al., 2008b).

Women’s requests for caesarean sections have, to a great extent, attributed to the escalating rate. Caesarean section on maternal request is planned surgery performed without medical indication, where the wish of the woman compensates for the lack of medical reasons. The concept of ‘patient’s choice’ is well accepted among obstetricians (Habiba et al., 2006, Bettes et al., 2007). Habiba et al. (2006) report further that when confronted with a hypothetical woman’s request, 15–79% of European obstetricians would agree to perform a caesarean section.

The extent of women’s requests for a caesarean section is ambiguous, and the reported rates of caesarean section on maternal request vary considerably. A UK study reports prevalence rates up to 18% of all caesarean sections (NICE, 2004) whereas Childbirth Connection in the US (Declercq et al., 2007) describes a range from <1% to 48%. Other studies claim that the number of women requesting a caesarean section is small (Gamble and Creedy, 2001, Walker et al., 2004, Lavender et al., 2006, Weaver et al., 2007). Several factors affect the estimates such as the timing and method of the data collection, the influence of the caregiver and societal norms. When assessing women’s preferences for mode of childbirth, another important factor is the information provided about ways of giving birth (Gamble and Creedy, 2000). Childbirth related fear is a common reason for requesting a caesarean section (Saisto and Halmesmäki, 2003, Wax et al., 2004, Waldenström et al., 2006). Another reason described in the literature is a woman’s need to plan her birth and to be able to schedule a caesarean section (Minkoff and Chervenak, 2003). Research on socio-economic aspects of women’s preferences for caesarean sections is inconclusive. A relationship between affluence and elective caesarean sections in the UK has been reported (Alves and Sheikh, 2005) while a Canadian study showed that women living in the lowest-income areas were significantly more likely to have a caesarean birth (Leeb et al., 2005).

In a national Swedish study, 3061 women were asked in early pregnancy about their preferences regarding the mode of birth (Hildingsson et al., 2002). Eight per cent of the women stated that they preferred a caesarean section; among first time mothers and women with previous vaginal births the prevalence was lower, 3–4%. Women who wished for a caesarean section were more often older than 35 years, single, smokers, less well educated, lived in small cities, had more often considered abortion, and were more depressed and worried during pregnancy, not only about the birth but about many other things as well.

A caesarean section is not an option Swedish women can choose for themselves; still, women’s antenatal preferences are of importance. It has been shown that nearly half of the women who preferred a caesarean section in early pregnancy also had an operative birth. The strongest association for the preference was childbirth related fear, previous experience of caesarean section or a previous negative birth experience (Hildingsson, 2008).

Prenatal care in Sweden reaches almost 100% of pregnant women. Midwives are the primary caregivers for uncomplicated pregnancies, prenatal care, and care during labour and birth. In complicated cases, midwives co-operate with obstetricians. In Sweden the caesarean section rate increased from 5.3% in 1973 to 17.2% in 2008 and varies between 10% and 23% in different units. In this mid-Sweden region the caesarean section rate in 2007 was 18.8% (National Board of Health and Welfare, 2010).

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