Womens' attitudes and beliefs of childbirth and association with birth preference: A comparison of a Swedish and an Australian sample in mid-pregnancy
Introduction
Depending upon where a woman lives, the ‘management’ of her pregnancy and birth varies considerably. Pregnant women with complications in low income countries who desperately need specialised intervention such as caesarean often cannot access it (Betrán et al., 2007, Gibbons et al., 2010). On the contrary, the rate of caesarean for low risk women, in high income nations continues to cause concern among many clinicians, researchers and policy makers.
The caesarean rate reported in the Australian population is almost double that of Sweden—31% and 17%, respectively (Socialstyrelsen, 2007, Laws and Sullivan, 2009). Neither demographics nor medical indications alone explain this variance. Efforts focused on standardising the classification of principal medical indications for caesarean such as the ‘ten group’ system (Robson, 2001) are contributing to some stabilisation in caesarean rates (Laws and Sullivan, 2009). Despite this, the disparity in caesarean rate between and within countries persists. Cultural beliefs, attitudes and the context of birthing services are important potential contributors to explore when attempting to understand why so many more women have an operative birth in Australia compared to Sweden.
In a 2009 Australian study of childbirth related fear and birth outcome, the researchers put forward a view that the cultural conception of childbirth is different between Australia and Sweden and that this is translated into the policy and practice of maternity care (Fenwick et al., 2009). The reverse is also as likely to be true. The policy and practice of maternity care creates a cultural conception of pregnancy and childbirth.
In the Australian setting of this current study, prenatal care is provided both by General Practitioners (GPs) in primary care clinics and in a public hospital based clinic by a mixture of junior and senior doctors and midwives. This system is known as ‘shared care’. Some women have continuity of midwifery care but this is limited. Prenatal care in Sweden on the other hand has the midwife as the primary caregiver in a community setting for all uncomplicated pregnancies. If complications occur the midwives work in collaboration with obstetricians. Intra partum care in both countries is almost completely hospital based. In Sweden midwives are the primary caregiver in the normal labour. In Australia a mixed system of public and privately insured care has the effect of a greater involvement from doctors in the conduct of the normal labour.
The social/cultural context of maternity care matters in whether a particular phenomenon, such as escalating caesarean rates, is recognised as a societal concern in the first instance (Bryant et al., 2007). The corollary being that in countries such as Australia where the prevalence of caesarean is high, the cultural context and system of care may influence women's attitudes and beliefs making intervention in childbirth socially acceptable (Klein et al., 2006, Green and Baston, 2007). This trend was seen in a 2004 Australian study, which reported the existence of wider cultural norms of acceptance of caesarean. The women who were questioned specifically about caesarean at 7 weeks post partum indicated a belief that the wider community perceived caesarean as easy and convenient (Walker et al., 2004).
A persistent media view is that women are actively seeking caesarean section without clear medical indication and this is what is driving the rate of caesarean upwards. The evidence however is that very few women are actually doing this (Gamble and Creedy, 2000, Hildingsson et al., 2002, Kingdon et al., 2006, McCourt et al., 2007, Weaver et al., 2007, Bourgeault et al., 2008, Mazzoni et al., 2010, Karlström et al., 2011). Of the few women who really do request a caesarean without clear medical indication, worries for the well-being of the child, a previous negative birth experience and fear of childbirth have a strong association with such a request (Gamble and Creedy, 2001, Hildingsson et al., 2002, Robson et al., 2008).
Separate from actual requests by women for caesarean, a preference for caesarean in early pregnancy can increase a woman’s odds of actually having one (Hildingsson, 2008). Likewise a willingness to accept intervention in pregnancy increases the odds of actually getting intervention (Green and Baston, 2007). Further, Green and Baston report that in a ten year period from when they first surveyed women regarding their attitudes and preferences towards birth in the UK, women have become more willing to accept medical intervention. While these women may not be actively requesting medical intervention in general, and caesarean in particular, they have become more accepting to its suggestion (Green and Baston, 2007). The same authors put forward a view that there is an ‘attitude spectrum’ among women in their willingness to accept intervention (Green and Baston, 2007).
There is some evidence showing that women who do not subscribe to a belief system that views birth as a normal event are more likely to prefer a caesarean (Thomas and Paranjothy, 2001, Fenwick et al., 2010). What is not clear yet from the literature is if there are other attitudinal profiles of women that can be associated with particular birthing preferences and indeed actualised outcomes.
The question of whether women hold beliefs and attitudes to birth, irrespective of the system of care, or whether they adopt beliefs and attitudes that render them accepting of the dominant culture of the system, is largely unknown. Underpinning this current study was the view that in countries such as Australia with its high caesarean rate relative to Sweden, there exist cultural norms of an attitudinal acceptance of highly medicalised birth.
The aim of this work was to conduct a cross cultural study assessing attitudes and beliefs towards childbirth and the association with preference for caesarean in a sample of Swedish and Australian women in mid-pregnancy.
Section snippets
Method
This work is part of a broader investigation of aspects of the pregnancy, birth and early parenting experiences of rural and regional women in Sweden and Australia undertaken during the years 2007–2009, some results of which have been reported previously (Haines et al., 2011).
Response rates
Of the 530 women who were eligible from the Swedish sample, 519 were recruited (98% eligible), 386 women returned the questionnaire giving a response rate of 74.37%. The Australian sample had 413 women eligible, 168 recruited (41% of those eligible) and 123 returns making a response rate of 74%.
Sample characteristics
The socio demographic characteristics of both samples were well matched with no significant differences in age, marital status, parity and education. The Australian sample had significantly more women
Discussion
In this cross cultural cohort study the aim was to compare attitudes and beliefs about birth between Swedish and Australian women. There are three major findings. Firstly, the results support the formation of an integrated set of items, consisting of four subscales, adapted from the Thomas and Paranjothy (2001) attitudes and beliefs inventory. This is a potentially important tool in progressing our understanding of how women think about birth, and the relationship that attitudes have with birth
Conclusion
The context of care may be important in shaping women's attitudes to birth. Using a set of attitudinal subscales developed for this study, the results suggest a systematic difference in the attitudes held by Australian and Swedish women. The Australian women were less likely, than the Swedish women, to subscribe to a belief system that valued the natural process of birth, and generally were more ambivalent in their attitudes. In countries such as Australia the cultural context and system of
Acknowledgements
The study has been supported by grants from the County council of Vasternorrland, Sweden, the Swedish Research Council, Stockholm, Sweden, Mid Sweden University, Sundsvall, Sweden and The University of Melbourne, Shepparton, Australia.
References (42)
- et al.
Caesarean birth: consumption, safety, order, and good mothering
Social Science and Medicine
(2007) - et al.
Explaining obstetric interventionism: technical skills, common conceptualisations, or collective countertransference?
Women's Studies International Forum
(2008) - et al.
Why do women request caesarean section in a normal, healthy first pregnancy?
Midwifery
(2010) - et al.
Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample
Midwifery
(2011) How much influence do women in Sweden have on caesarean section? A follow-up study of women's preferences in early pregnancy
Midwifery
(2008)- et al.
Few women wish to be delivered by caesarean section
BJOG: An International Journal of Obstetrics and Gynaecology
(2002) - et al.
An empirical comparison of alternative methods for principal component extraction
Journal of Business Research
(1987) - et al.
Behind the myth—few women prefer caesarean section in the absence of medical or obstetrical factors
Midwifery
(2011) Consumerism, reflexivity and the medical encounter
Social Science and Medicine
(1997)Can we reduce the caesarean section rate?
Best Practice and Research Clinical Obstetrics and Gynaecology
(2001)