Swedish caregivers’ attitudes towards caesarean section on maternal request

Article Outline

• Summary
• The context of Swedish maternity care
• Method
  • Participants
  • Data analysis
• Results
  • Women's characteristics
    • To control, plan, and demand
    • Fear of giving birth
  • Hindrance in care
    • Stress in intrapartum care
    • Fear among staff
  • Change of attitudes
  • Methods of prevention
    • Birth preparation and counselling
    • Presence of midwives
    • Postpartum talk
  • The role of the professional
    • Encouraging normal birth
    • Balance evidence and autonomy
• Discussion
  • Methodological considerations
  • Women's characteristics
  • Hindrance in care
  • Change of attitudes
  • Methods of prevention
  • The role of the professionals
• Conclusions and implications
• Acknowledgements
• References
• Copyright

Summary 

Background

Caesarean section (CS) is not an option that women in Sweden can chose themselves, although the rise in CS rate has been attributed to women. This study describes obstetricians’ and midwives’ attitudes towards CS on maternal request.

Methods

A qualitative descriptive study, with content analysis of 5 focus group discussions where 16 midwives and 9 obstetricians participated.

Results

The overarching theme was identified as “Caesarean section on maternal request—a balance between resistance and respect”. On the one hand, CS was viewed as a risky project; on the other hand, request for a CS was understood and respected when women had had a previous traumatic birth experience. Still, a CS was not really seen as a solution for childbirth related fear. Five categories were related to the theme. Overall, our findings indicate that caregivers blamed the women for the increase, they considered the management of CS on maternal request difficult, and they suggested preventive methods to reduce CS and means to strengthen their professional roles.

Key conclusions and implication for practice

Both midwives and obstetricians considered the management of CS on maternal request difficult, and the result showed that they balanced between resistance and respect. The result also showed that the participants stressed the importance of professionals advocating natural birth with evidence-based knowledge and methods to prevent maternal requests. Ongoing discussions among health professionals on attitudes and practice would strengthen their professional roles and lead to a decrease in CS rates in Sweden.

Keywords: Caesarean section, Content analysis, Focus groups interviews, Maternal request, Attitudes, Caregivers

The caesarean section (CS) rate in Sweden was 17.7% in 2006, with regional variations between 11 and 27%.¹ For term pregnancies, the percentage increased from 9.2% in 1990 to 16.4% in 2006.¹ The increase has to some extent been explained by changes in the pregnant population, such as the increase in Body Mass Index, higher maternal age at first baby and lower parity (more primiparas).² Similar results have been showed by Joseph et al.³ where the increase in primary caesarean rate was explained by changes in maternal characteristics like age, parity, weight and obstetric practice. The highest increase in CS in Sweden has been among full term pregnancies with singleton babies in vertex position², ⁴ and in this group the increase was 50% during the years 1990–2001.²

Another rationale for the increasing CS rate, given much publicity in both the lay and medical press, is women's request for CS in the absence of clinical indication. International estimates on maternal request range from 4 to 18% of all CS⁵ but these figures have been questioned.⁶ Recent research has shown that the numbers of women requesting a CS are small.⁷, ⁸ However, in the Swedish Medical Birth Register, CS on maternal request has no explicit diagnosis, but is covered in the diagnose code for CS on psychosocial indication. Psychosocial indication was the diagnose code that increased the most from 1990 to 2001² suggesting that women's preferences do have an impact on the CS rates in Sweden. In a national Swedish cohort, 3061 women were asked in early pregnancy about their preferences regarding mode of delivery.⁹ Eight percent of these women preferred to have a caesarean section, but among first time mothers and women with previous vaginal births the prevalence was lower, 3–4%. The strongest risk factors for the preference were fear of giving birth and previous caesarean sections.⁹ This is supported by Weaver et al.⁸ who reported psychological issues such as women's fear of giving birth and concerns about the safety of the baby as factors behind request for CS.

In addition to reports of prevalence and causes of the rise in CS on maternal request, caregivers attitudes are assumed to have an impact on the way women's requests are met. Previous research has shown that obstetricians offer several explanations for why women's inquiries about CS are rising. Bettes et al.¹⁰ reported that obstetricians-gynaecologists perceived an increase in patients’ inquiries regarding caesarean births attributed to the information of the media and to convenience. In a Swedish survey, 41% of the responses from 166 obstetricians and 69 midwives attributed the rising CS rate to factors related to the woman herself.¹¹ Another Swedish study reported that experienced (>10 years) obstetricians had a more positive attitude towards performing CS and were more likely to view CS as a safe alternative compared to younger and less experienced doctors.¹² Habiba et al.¹³ concluded that obstetricians attitudes in European countries are influenced by cultural factors, legal liability and variables linked to the specific perinatal care organization.

It is likely that the attitudes and beliefs of the caregivers will affect the way women's request for caesarean birth is received and handled. Thus, it is important to elucidate the views of obstetricians and midwives in order to understand what appears to be a growing international issue. This study seeks to do just that by describing obstetricians’ and midwives’ attitudes about caesarean section on maternal request.

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The context of Swedish maternity care 

Antenatal care in Sweden is organized within the public primary health care system with the midwife as the primary caregiver, taking care of all pregnant women in a certain geographical area during pregnancy. Care during labour, birth and the postnatal period occurs in hospitals with midwives as the independent caregiver for uncomplicated cases. Midwives work in collaboration with obstetricians if complications occur. There are no alternative birth settings in Sweden and continuity of caregiver between episodes of care is rare. Formally, caesarean section is not an option women can choose themselves. The obstetrician has to be convinced about the need to perform surgery without a medical indication. The majority of obstetric departments in hospitals have established qualified teams who provide support for women who suffer from childbirth related fear. If a woman wishes to have a CS she is referred to such a team before she meets the obstetrician for the final decision.

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Method 

Participants 

The study used a purposive sample of midwives and obstetricians from three county hospitals and antenatal clinics in the middle of Sweden. Sixteen midwives (all women) and nine obstetricians (five women and four men) participated in five focus group discussions (FGDs) with four to six participants in each group. A focus group is an organized discussion with a group of individuals to gain information about their views and experiences of a topic presented to them in advance.¹⁴, ¹⁵ Focus groups are often used to examine people's experience of health care and to investigate the attitudes and needs of caregivers.¹⁶ In order to get a range of variation, the focus groups differed in composition: two groups were composed of both obstetricians and midwives, one focus group included obstetricians only, and two groups midwives only. The intention was to study attitudes in a professional group co-working in the clinical practice, not to study differences in attitudes between groups of professionals (midwives and obstetricians). Five groups were chosen to be relevant based on results from previous focus groups studies.¹⁶ The first author was moderator and an observer (last author) took detailed notes. The opening question was worded “Please tell us about your opinion regarding the rise in CS on maternal request”. The discussions proceeded for 1.5–2h and were open and lively. The observer provided a brief summary of each group discussion at the end of the session and the participants confirmed that the discussion was correctly understood. All focus group discussions were audiotaped.

Data analysis 

The first author transcribed the FGDs verbatim. Each interview was read through several times to gain a sense of meaning, focusing on the manifest content. All significant text units were coded using the computer programme N-Vivo.¹⁷ This step required coding the transcript line by line and implied words or clauses being coded and labelled close to the text with words or phrases from the transcript. Next, all the codes were examined and compared to clarify relationships. The various codes were sorted into subcategories (n=9). In accordance with similarities and differences in the sub-categories, five categories were created all related to the manifest content.¹⁸ An example of the coding process is presented in Table 1. The intention during this process of categorization was to stay close to the words through a constant movement between the whole and the parts of the text. The accuracy of how to sort codes with similar content into categories was confirmed in discussions in which all co-authors participated and agreed. In a final step, a theme was formulated to represent the latent content of data. During the process of analysis a consensus was reached on categories and theme. A theme can be described as regularity within categories.¹⁹ The description of the underlying meaning of the categories was on an interpretive level since no description is free of interpretation. However, qualitative description is less interpretive than other qualitative approaches aiming at a comprehensive summary of events, concerns or perceptions in the everyday terms of these phenomena.²⁰

Table 1. Examples of codes, sub-categories, categories and theme from content analysis about caregivers’ attitudes towards CS on maternal request.

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Results 

“Caesarean section on maternal request—a balance between resistance and respect” was the theme formulated to illustrate the central interpreted meaning of the focus groups discussions. Five categories comprised the content areas found in the FGs and were all related to this main theme. The theme reflected the complex and somewhat contradictory nature of caregivers’ attitudes towards CS on maternal request, which was of concern for the participants in the FGs and was described on a personal, organizational and a societal level.

Women's characteristics 

The participants were convinced that the characteristics and experiences of women were of importance to the rise in CS on maternal request. A previous negative birth experience was respected and accepted as reason for elective CS. Primiparaes requesting CS without medical reasons, however, caused strong reactions and met resistance.

Midwives and doctors described the modern birthing woman as being different compared to women in earlier generations, in part because they tend to be older at the time of their first pregnancy. Women at a higher age were presumed to need more control and to want to plan their lives and reproduction. The respondents described women as being well informed but lacking knowledge about the risks with surgical delivery.

R8: I think there is a need to be in control. The woman wants to be in control and decide about her body. Not losing control but have it planned, I know what's going to happen. Being spared the unpredictable, this vague thing a (vaginal) birth can be.

R4: I think, women are being ignorant (of complications related to CS) and think CS is the easiest way.

Women with childbirth related fear were described in all FGs as a major group among women requesting elective CS. There was a consensus among the participants about the complexity of childbirth fear. Fear of pain and injuries to the mother and child during labour and birth were described as reasons for CS on maternal request. The fear of being badly treated, of being naked and being at the mercy of somebody were other experiences the participants felt influenced women's attitudes towards birth. Women with childbirth related fear were described in the FGDs as having less confidence in their bodies and birthing abilities.

R 17: My experience is that there are a lot of women today afraid of everything. They have no trust in their bodily functions or that we are made to give birth.

The importance of sexual assaults and traumatic birth stories told by others were pointed out as reasonable reasons for tocophobia. However, the participants in the FGs viewed first-time mothers requesting a CS as provocative and difficult to understand.

R1: But its strange when young women without any birthing experience come and the first thing they say is, yes I want a CS. What does that fear stand for? They cannot put it in words, I think, it's just something there. I don’t know if it is the personality or type of person you are, it's just like that.

R22: But this primipara who just declares “I’ll have a CS” and I do not understand why … you get provoked and make a stand.

Hindrance in care 

FG participants believed that the needs of birthing women are not always met in hospitals. Working conditions were identified as a hindrance to provide high quality care. Obstetricians and midwives concluded that a heavy workload made it difficult to provide a supportive and safe environment. The participants also discussed the link between dissatisfaction with intrapartum care, negative birth experiences and a request for CS.

There was a general opinion in the FGs that a strained situation in the delivery units had an impact on the birth outcome. When midwives had to be responsible for several women in active labour and doctors felt the stress of heavy workload, they found it difficult to provide high quality care. Such stress in the intrapartum care was perceived to complicate births, leave the woman with a negative birth experience and be the cause of maternal request in a subsequent pregnancy.

R15: The major rise in the CS rate in Sweden is due to stress in the delivery units. The women get worried and the doctors are inexperienced with what's normal and abnormal and intervene too early though it's a normal process. That's the major reason, not the maternal request.

The risk of litigation was of concern for professionals in the intrapartum care. Fear of complications due to vaginal birth was discussed in the FGs and was considered to be a reason for a reluctant acceptance of a CS without a medical indication. Further more, the obstetricians noted that they were more likely now than before to accept women's request for CS rather than dealing with a “worse case scenario” if they promoted a vaginal birth. The authority of doctors was described as diminishing and questioned by well-prepared women arguing for their right to a caesarean birth.

R8: It's more about us and our fear of complications.

R10: That's so, sometimes you feel fearful about the outcome, like the old primipara with her fifth IVF treatment. You feel nothing must go wrong and wouldn’t it be better with a CS just in case.

Change of attitudes 

Factors in modern society were discussed in all FGs and connected to women's request for CS. Migration, a general shift towards individualism, the influence of the media, and less traditional female values were described as overarching phenomena affecting women's preferences on mode of delivery. The participants perceived that knowledge and attitudes are more influenced by media and friends of the same age than before. They also discussed that experiences of birth are not communicated between generations of women to the same extent as before. The participants viewed the media as having contributed to the changes in attitudes towards CS. Reports on celebrities and women's right to a CS have influenced people's views on birthing and mode of delivery.

R7: There have been a lot of writings in the papers and women demand their right to CS. There have been a lot in the media. In a way it is something you are entitled to, so I believe it's a lot influenced from there.

R9: But it seems to be common knowledge in society that if you want a CS you will have one.

Methods of prevention 

In all focus groups, the importance of preventing maternal requests for CS was discussed and several suggestions were made. Participants believed that information at an early stage and to a sufficient degree could change women's preferences towards vaginal birth. The midwife's role was highlighted and the participants believed that various methods of support before, during and after birth would enhance and strengthen women's abilities to give birth, and reduce the request.

The participants perceived birth preparation and antenatal classes as important tools in reducing the rate of CS. It was argued that giving birth is a natural process and a strong but painful experience that women must prepare for.

R3: Then I’m a little bit old-fashioned being brought up with prophylaxis. That has helped throughout my working life and I’ve worked with it a lot in the antenatal care. But when I meet women on the delivery unit, not all of them know what it's about; they haven’t had the opportunity to practice relaxation. Nobody told them about it.

There was a strong support in the FGs for special consultations for women who experience fear and anxiety when facing birth. The woman with tocophobia should be met with respect and understanding. Requests for CS should be respected but alternatives must always be discussed.

R16: My attitude is that the most important is to take away the focus on the birth right then and to understand why this mother has these thoughts. What's behind her request for a CS? Then there's time for the special consultation.

It was made clear in the FGDs that a midwife, present in the room and attentive to the woman's wishes, could enhance a positive birth experience and thereby reduce the request for CS in a subsequent pregnancy. The participants discussed that epidural anaesthesia should not be a midwife substitute and the woman should not be left alone.

R24: Yes, 11–12% of the elective CS have a psychosocial indication and 75% of these women are multiparae. That's something we really should consider. What can we do about it? It's very much about how we take care of patients during birth, our attitudes and how they are being met and so on.

Since the birth experience is strongly related to request for CS in the next pregnancy, the FG participants generally considered a postpartum discussion important. This discussion can be used to confirm the experience of the woman, explain the course of labour, and answer questions. The participants stressed that, particularly after a complicated birth, women need to discuss and process their experiences, thoughts, and feelings in order to understand what has happened and why.

R8: Well, taking care of the woman after birth is far more important, when it's an emergency CS. The woman needs to be seen by and have their talk with the obstetrician. Maybe they need another follow-up to understand what happened so they don’t leave us with a negative experience.

The role of the professional 

Participants also discussed the responsibility of both the caregivers and the expecting parents to consider the medical implications on an increasing CS rate. Being a professional was to make a stand against CS without medical reasons, by clarifying the risks with an operative delivery, and emphasizing the advantages of vaginal birth.

There was a strong conviction in the FGs that a vaginal birth is the natural mode of delivery after a normal pregnancy. The participants claimed that the professional starting point in discussions with women about mode of delivery should be that CS without medical indication is connected with more risks for both mother and child, today and in the future. The obstetricians described an obligation to clarify the medical risks with a surgical delivery and to influence the woman to have a vaginal birth, without violating her integrity. It was however, considered difficult to inform women about risks as the participants did not want to frighten them. The doctors were also concerned about the medical consequences of a high CS rate in terms of more complicated births in the future.

R24: Still the purpose must be as good as possible for the woman and then in some way it is up to us to sell it, the best is a normal birth.

FGs participants believed that the maternal request for CS was caused by women's misunderstandings about the pros and cons of the operation. It was considered important to give evidence-based knowledge about vaginal birth and CS. Midwives and obstetricians in all FGs emphasized that to be professional implied commitment and authority without getting into conflicts with the patients. The respondents also stressed the importance of having a dialogue with the woman. The question of autonomy, when it came to mode of delivery, was most frequently discussed in the FGs where obstetricians took part.

R18: But I still don’t think that it (women's demand) can force me to perform a CS. Then we all know, when you are sitting there with that individual woman you try to find some mutual understanding because that's important… It's not an end in its self to refrain from surgery if that's what you want but I think it's important to have tried other alternatives and have had a good dialogue.

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Discussion 

The main finding of this study revealed that CS on maternal request was of concern for both obstetricians and midwives in this Swedish setting and was described in the theme “Caesarean section on maternal request—a balance between resistance and respect”. CS on maternal request was viewed as a risky project, where women exposed themselves and their babies to danger and it should be prevented. On the other hand, request for a CS was understood and respected when women have had a previous traumatic birth experience. The caregivers’ ascribed blame to the women for the increase, they considered the management of CS on maternal request difficult, and they suggested preventive methods to reduce CS and to strengthen their professional roles.

Methodological considerations 

The findings are limited to the data collected during five focus groups in a Swedish setting. The great majority of informants were experienced professionals from antenatal, intrapartum and postpartum care who regularly meet women requesting CS. It is not possible to generalize the findings, but there are reasons to believe that the results of this study are transferable to other settings where midwives and obstetricians are meeting women requesting CS. The researchers are experienced midwives, which could impact the analysis, as their clinical pre-understanding might affect the interpretation of the findings. Several strategies were used to reduce the impact of this potential bias. A summary of the results was sent to all participants and a few clarifications were made. Choosing participants with various and extensive experience was another way to deal with credibility issues. Representative quotations from the transcribed text have been used to show the reader how categories and theme reflect data. The result of the analysis was constantly validated through the dialogue among the authors. Caregivers and independent researchers taking part in a seminar where the project was reported and discussed also verified the results.

Women's characteristics 

A majority of the FGs participants believed that fear of giving birth, caused by a previous negative birth experience was the major reason for women requesting CS. However, the reported prevalence of childbirth fear has not changed over the last 20 years despite the fact that the proportion of women requesting CS for this reason has doubled.²¹ It has also been shown that childbirth fear is difficult to communicate.²² Still, midwives and obstetricians taking part in the FGDs agreed that counselling was an important complement to antenatal care and current programs were functioning well. It has, however, been argued that counselling for childbirth fear actually increases the number of CS.²³ The results of this study correspond with other reports¹¹, ²⁴ that ascribed the increasing CS rate to a substantial extent, to the woman. It is possible that women's requests for CS are exaggerated to reduce the attention on the medical professional's role in the continually increasing CS rate.²⁵ If this is the case, it is important to see beyond the way women's birthing preferences are discussed today in the medical press and focus instead on women's actual experiences and choices from a normal birth perspective. CS on maternal request has increased but is not a major reason behind rising CS rate.²⁵, ²⁶

Hindrance in care 

There was a general understanding in the FGs that a women's first birth experience will affect her attitude towards future mode of delivery. Limited hospital resources produce stress, which would have an impact on the quality of care as well as on birth outcomes. This finding is supported by a Cochrane Review that showed that continuous support during labour could reduce the rate of caesarean births.²⁷ Intrapartum care characterized by emotional support, information, and comfort measures from a present midwife could also enhance the possibility of a positive birth experience. Fear of litigation was another reported reason for the rise in CS and was related to both elective and emergency CS (doing CS “just in case”). A similar finding was shown in a British survey of obstetricians, who ranked fear of litigation as the main reason for the rise in CS in the UK, followed by maternal request.²⁴

Change of attitudes 

There was a belief in all FGs that changes in society affects women's attitudes towards giving birth. Traditions have less importance today on human choices and actions.²⁸ In the media, the increase of CS has often been ascribed to women themselves, which was also the case in most FGs since, to a certain degree; they held women responsible for the increase. All FGs confirmed that media and the Internet are great sources of information for expecting parents. In a recent review Gamble and co-workers²⁹ discussed a publication pattern in newspaper articles and medical journals, where women's choice of CS is considered to be the main reason for rising CS rates. In addition, York et al.³⁰ described women choosing CS after a previous CS as relying more on relatives, friends or women with similar experiences than on information from caregivers.

Methods of prevention 

In all FGDs several methods of prevention were brought up in order to reduce maternal requests for CS. Birth preparation, counselling and midwife presence were all seen as being helpful in reducing requests. In Sweden, the return to psychoprophylaxis is once more a focus in antenatal classes after being replaced with more general information about birth issues during the past decade.³¹ The participants stressed the importance of the postpartum talk in order to discuss a negative birth experience and subsequent request for CS. York et al.³⁰ showed that a decision about CS is often made shortly after the birth, or at early stages in the next pregnancy. Olin and Faxelid³² reported that many new parents want to discuss the birth with their midwife.

The role of the professionals 

The FGs participants did not favor women having the right to decide about mode of delivery themselves. The concept of informed choice that is common in other countries is not relevant in the Swedish context. By law³³ the obstetricians always makes the decisions, but the law also states that patients should be involved in the decision making process. Kamal et al.³⁴ described decision-making about mode of delivery as a social practice where interpretation of medical evidence, judgements of individual cases, negotiations with women, and external influences such as the organization of care were important. Strategies for discussions with women were perceived as “consumerist, mutualistic or paternalistic”. The results of the present study showed that the attitudes towards women requesting CS were composed of similar strategies. A more joint approach to decision-making, the “mutualistic” strategy, was the alternative preferred among the FG participants. The “consumerist” option, that is to transfer the responsibility of decision making to the woman, was not favoured. A professional's argument for a vaginal birth could be considered as paternalistic, lacking a respectful attitude, in spite of a solid medical grounding. Combining these strategies results in a contradictory policy towards request for CS. The professionals in the FGs understood this as problematic.

The attitude of the professions towards CS without medical indication was balanced between the consideration for the woman and the obligation to practice evidence-based medicine. The somewhat contradictory attitude of the providers can be understood as a way to respond both to the women's demands, the expectations from society, and professional standards.

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Conclusions and implications 

The result of this study suggests that the management of CS on maternal request was a balance between resistance and respect. Both midwives and obstetricians considered handling CS on maternal request difficult.

The clinical implications revealed that women with childbirth related fear should be taken seriously and counselling must be available. A positive birth experience is likely to reduce the need of elective CS due to fear of giving birth. Health professionals should advocate natural births with evidence-based knowledge and preventive tools. Ongoing discussions among professionals on attitudes and practice would strengthen their professional roles, benefit and lead to a decreasing CS rate in most maternity settings.

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Acknowledgements 

Funding: The study has been supported by grants from the County Council of Västernorrland, Sweden and the Swedish Research Council.

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