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Clinician’s attitudes towards caesarean section: A cross-sectional survey in two tertiary level maternity units in Ireland

Open AccessPublished:August 19, 2021DOI:https://doi.org/10.1016/j.wombi.2021.08.004

      Abstract

      Background

      Although caesarean section (CS) is a life-saving intervention when medically indicated, the growth in CS rates is causing concern. In reducing unnecessary CS, it is important to understand clinicians’ attitudes towards CS so that these might be understood contextually.

      Objective

      To explore clinicians’ attitudes towards CS in Ireland.

      Methods

      A cross sectional survey involving maternity care professionals in two urban maternity hospitals in Ireland. Descriptive statistics were used to analyse the data. Ethical approval was granted by the Research Ethics Committees of the University and the two study sites.

      Findings

      One hundred and fifty-two maternity care professionals responded to the survey. Most (97%) indicated that the CS rate in their unit was ‘high’, although 81% believed there was a shift in culture towards a lower threshold for performing CS. Most participants (85%) considered birth a natural process that should not be interfered with unless necessary and that elective CS is not the safest option for the mother (74%) or baby (71%), yet 45% believed that a woman should be able to have a CS if she wants a CS. Just over half the participants considered a previous 3rd or 4th degree tear an indication for an elective CS. Offering vaginal birth after a previous CS for fetal distress and failure to progress increased with clinical experience.

      Conclusion

      The findings of this survey can be considered contextually in addressing high CS rates and will be of wider relevance in understanding maternity care providers’ beliefs about CS in general.

      Keywords

      Statement of significance

      Issue

      Understanding clinicians’ attitudes towards caesarean section (CS) is necessary so that these might be understood contextually in addressing high CS rates.

      What is already known

      Trends in mode of birth have altered globally over the past 20 years with increases in CS observed in all areas. Multiple contributory factors, beyond medical necessity, have been described in explaining the rising CS rates.

      What this paper adds

      Information related to the attitudes and beliefs of maternity care professionals towards CS. This information can be considered contextually in addressing high CS rates and in understanding beliefs held by maternity care providers about CS in general.

      1. Introduction

      Trends in mode of birth have altered globally over the past 20 years with increases in caesarean section (CS) observed in all areas. In East Asia and the Pacific, for example, CS has increased from 13.4% of livebirths in 2000 to 28.8% in 2015 [
      • Boerma T.
      • Ronsmans C.
      • Melesse D.Y.
      • Barros A.J.D.
      • Barros F.C.
      • Juan L.
      • et al.
      Optimising caesarean section use 1 global epidemiology of use of and disparities in caesarean sections.
      ]. Similar increases have been observed in Eastern Europe and Central Asia with CS rates rising from 11.9% in 2000 to 27.3% in 2015 [
      • Boerma T.
      • Ronsmans C.
      • Melesse D.Y.
      • Barros A.J.D.
      • Barros F.C.
      • Juan L.
      • et al.
      Optimising caesarean section use 1 global epidemiology of use of and disparities in caesarean sections.
      ]. Although CS is a life-saving intervention when medically indicated, the growth in CS rates are a cause for concern, especially given the associated risks for women and babies. Such risks include a three-fold [
      • Mascarello K.C.
      • Horta B.L.
      • Silveira M.F.
      Maternal complications and cesarean section without indication: systematic review and meta-analysis.
      ] or higher [
      • Fahmy W.M.
      • Crispim C.A.
      • Cliffe S.
      Association between maternal death and cesarean section in Latin America: a systematic literature review.
      ] increased risk of maternal mortality, an increased risk of postpartum infection [
      • Mascarello K.C.
      • Horta B.L.
      • Silveira M.F.
      Maternal complications and cesarean section without indication: systematic review and meta-analysis.
      ,
      • Keag O.E.
      • Norman J.E.
      • Stock S.J.
      Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis.
      ] and an increased risk of haemorrhage [
      • Liu S.
      • Liston R.M.
      • Joseph K.S.
      • Heaman M.
      • Sauve R.
      • Kramer M.S.
      Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term.
      ]. CS also confers risks in subsequent pregnancies. These include an increased risk for miscarriage, placenta previa, placenta accreta and placental abruption [
      • Keag O.E.
      • Norman J.E.
      • Stock S.J.
      Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis.
      ]. An increased risk of stillbirth in subsequent pregnancy following CS has also been reported although no difference in perinatal mortality has been observed [
      • Keag O.E.
      • Norman J.E.
      • Stock S.J.
      Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis.
      ]. In addition, the cost of birth to maternity services is greater in countries with higher CS rates [
      • Moran P.
      • Normand C.
      • Gillen P.
      • Wuytack F.
      • Turner M.
      • Begley C.
      • Daly D.
      Economic implications of reducing caesarean section rates — analysis of two health systems.
      ].
      Multiple contributory factors, beyond medical necessity, have been described in explaining the rising CS rates. Declining vaginal birth after CS with a concomitant increase in elective repeat CS dominates as a factor, with a previous CS cited as the primary indication in approximately 30% of CS [
      • Ryan G.A.
      • Nicholson S.M.
      • Morrison J.J.
      Vaginal birth after caesarean section: current status and where to from here?.
      ]. Women’s preference has also been cited, although evidence to support this as a major factor is minimal [
      • Panda S.
      • Begley C.
      • Daly D.
      Influence of women’s request and preference on the rising rate of caesarean section — a comparison of reviews.
      ]. Reported preference for CS rates across studies include 3.5%–8% for nulliparous women [
      • Mazzoni A.
      • Althabe F.
      • Gutierrez L.
      • Gibbons L.
      • Liu N.H.
      • Bonotti A.M.
      • et al.
      Women’s preferences and mode of delivery in public and private hospitals: a prospective cohort study.
      ,
      • Lindstad Løvåsmoen E.M.
      • Nyland Bjørgo M.
      • Lukasse M.
      • Schei B.
      • Henriksen L.
      Women’s preference for caesarean section and the actual mode of delivery — comparing five sites in Norway.
      ], 9% for multiparous women [
      • Lindstad Løvåsmoen E.M.
      • Nyland Bjørgo M.
      • Lukasse M.
      • Schei B.
      • Henriksen L.
      Women’s preference for caesarean section and the actual mode of delivery — comparing five sites in Norway.
      ], and an overall pooled preference rate, based on 38 studies involving 19,403 women, of 15.6% [
      • Mazzoni A.
      • Althabe F.
      • Liu N.H.
      • Bonotti A.M.
      • Gibbons L.
      • Sanchez A.J.
      • et al.
      Women’s preference for caesarean section: a systematic review and meta-analysis of observational studies.
      ]. Litigation and the perception that CS is less risky and safer (or as safe as) vaginal birth also dominate as explanatory factors [
      • Fuglenes D.
      • Oian P.
      • Kristiansen I.S.
      Obstetricians’ choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation?.
      ,
      • Zwecker P.
      • Azoulay L.
      • Abenhaim H.A.
      Effect of fear of litigation on obstetric care: a nationwide analysis on obstetric practice.
      ,
      • Panda S.
      • Begley C.
      • Daly D.
      Clinicians’ views of factors influencing decision making for caesarean section: a systematic review and meta-synthesis of qualitative, quantitative and mixed methods studies.
      ].
      Interventions for reducing unnecessary CS have been widely studied [
      • Lundgren I.
      • Smith V.
      • Nilsson C.
      • Vehvilainen-Julkunen K.
      • Nicoletti J.
      • Devane D.
      • et al.
      Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.
      ,
      • Nilsson C.
      • Lundgren I.
      • Smith V.
      • Vehvilainen-Julkunen K.
      • Nicoletti J.
      • Devane D.
      • et al.
      Women-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.
      ,
      • Betran A.P.
      • Temmerman M.
      • Kingdon C.
      • Mohiddin A.
      • Opiyo N.
      • Torloni M.R.
      • et al.
      Interventions to reduce unnecessary caesarean sections in healthy women and babies.
      ,
      • Chen I.
      • Opiyo N.
      • Tavender E.
      • Mortazhejri S.
      • Radar T.
      • Petkovic J.
      • et al.
      Non-clinical interventions for reducing unnecessary caesarean section.
      ]. An overview of systematic reviews that explored antenatal and intrapartum interventions identified 25 interventions that were shown to reduce CS [
      • Smith V.
      • Gallagher L.
      • Carroll M.
      • Hannon K.
      • Begley C.
      Antenatal and intrapartum interventions for reducing caesarean section, promoting vaginal birth, and reducing fear of childbirth: an overview of systematic reviews.
      ]. Examples of these interventions include various methods for labour induction, continuous and one-to-one support during labour, external cephalic version, and hypnosis and acupressure during labour. Interventions that increased CS were also described (n = 9). Examples of these are continuous cardiotocography (CTG) during labour, intermittent auscultation of the fetal heart with a Doppler or intermittent CTG compared to a Pinard, and incentives linked directly with initiation and frequency of antenatal care [
      • Smith V.
      • Gallagher L.
      • Carroll M.
      • Hannon K.
      • Begley C.
      Antenatal and intrapartum interventions for reducing caesarean section, promoting vaginal birth, and reducing fear of childbirth: an overview of systematic reviews.
      ]. Valuable empirical evidence on practices and methods that could help reduce CS, however, becomes less consequential if there is an inability or reluctance on the part of an organisation and the clinicians therein to implement this evidence. Similarly, reducing unnecessary CS will be difficult where an organisational culture of accepting high CS activity exists or where clinicians’ perceptions and beliefs towards CS, including litigious fear, dominate as the main drivers.
      In planning an intervention targeted towards reducing CS it would be important foremostly to understand the environment within which that intervention might be implemented. This should include an assessment of clinicians’ attitudes or opinions towards CS so that these might be understood contextually. As part of a larger project that planned to develop, and pilot-feasibility test, an intervention to reduce unnecessary CS we surveyed clinicians in two maternity hospitals in Ireland to explore their attitudes towards CS.

      2. Methods

      2.1 Design

      A cross sectional survey designed to explore attitudes towards CS was performed. The survey, which consisted of 16 items and a free-text option to add additional comments, was adapted with permission from The RCOG National Sentinel Caesarean Section Audit [
      • Thomas J.
      • Paranjothy S.
      • Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit
      National Sentinel Caesarean Section Audit Report.
      ].

      2.2 Setting and sample

      The study setting was two urban, tertiary maternity hospitals each with birth rates of >8000 per annum, in Ireland. The CS rate at the time of the survey at both study sites was around 34%. The target population for the survey included midwives, nurses, obstetricians, and allied healthcare professionals involved in providing care to women during pregnancy, childbirth and postpartum (n = 900 approx. based on local annual report data). As this was a cross-sectional survey, we aimed to achieve as high a response rate as possible from the sample population. As such we did not determine an a priori sample size estimate.

      2.3 Data collection

      To provide participants with options for how they might wish to complete the survey, and to help maximise on response rates, the survey was made available in both hardcopy and online. Online surveys were made available to the sites via SurveyMonkey. The link to the survey was posted on the site’s internal network (intranet). Hardcopy surveys were distributed to key areas throughout the sites (e.g. antenatal wards, labour wards, staff locker rooms) and with assistance from onsite midwifery staff (local practice development and research departments). Secure locked boxes were positioned beside the boxes of hardcopy surveys for participants to return their completed survey. The boxes for returned surveys were accessed by the study research assistant 1–2 times per week for the duration of the study, and completed surveys were collected. Survey distribution opened in February 2018 and closed in May 2018.

      2.4 Data analysis

      Descriptive statistics (counts and proportions) were used to analyse the data, with p-values for differences between groups (e.g. professions, study sites) calculated using the z-test for differences in proportions, where appropriate, with alpha set at 0.05. Participants were also offered a free-text option to add any further comments they might have regarding CS at the end of the survey. The comments provided were insufficient in depth to provide a basis for a rigorous thematic analysis of these data. Instead we present free-text quotes alongside survey results, where relevant, to further support the quantitative findings with participant’s subjective views.

      2.5 Ethics

      Ethical approval for the study was granted by the University Faculty of Health Sciences Research Ethics Committee (Ref: 170501, December 2017), and by the Research Ethics Committees of the two participating hospitals (Ref: study 21-2017 and Ref: REC-2017-026). Consent was implied by completing and returning a hardcopy survey or by ticking ‘I agree to take part in the study’ and the ‘submit’ buttons if completing the survey online. The survey was anonymous and participant names were not collected on either the hardcopy or electronic survey formats.

      3. Results

      A total of 152 maternity care professionals participated in the survey, providing an approximate 17% representative response rate. The majority of participants were midwives (72%) and most had been working for more than 10 years in maternity care at the time of the survey. Table 1 presents the participants’ demographic details, overall and by site.
      Table 1Participant demographic details.
      ProfessionTotal; N = 152Site A; N = 71Site B; N = 81
      n (%)n (%)n (%)
       Midwife109 (72%)45 (63%)64 (79%)
       Neonatal nurse2 (1%)2 (3%)
       Obstetrician22 (14%)18 (25%)4 (5%)
       Neonatologist1 (1%)1 (1%)
       Physiotherapist7 (5%)1 (1%)6 (7%)
       Anaesthetist4 (2%)4 (5%)
       Other
      Health care assistant (n = 4); student midwife (n = 1); manager (n = 1); staff nurse (n = 1).
      7 (5%)5 (7%)2 (3%)
      Length of time working in maternity care
       Less than 2 years26 (17%)10 (14%)16 (20%)
       2–5 years40 (26%)21 (30%)19 (23%)
       >5 to 10 years30 (20%)13 (18%)17 (21%)
       More than 10 years56 (39%)27 (38%)29 (36%)
      Gender
       Female142 (93%)67 (94%)75 (93%)
       Male10 (7%)4 (6%)6 (7%)
       Prefer not to answer
      Age
       18–2528 (18%)14 (20%)14 (17%)
       26–3555 (36%)28 (39%)27 (33%)
       36–4535 (23%)18 (25%)17 (21%)
       ≥4633 (22%)11 (16%)22 (27%)
       Prefer not to say1 (1%)1 (1%)
      a Health care assistant (n = 4); student midwife (n = 1); manager (n = 1); staff nurse (n = 1).

      3.1 Views on caesarean section

      Ninety-seven percent (146/151) of participants, when asked if they thought the CS rate in their unit was ‘high’, responded yes to this question. Table 2 presents the ‘yes’ responses by profession, with minimal variation observed between groups.
      Table 2Proportions indicating that the CS rate was ‘high’ in their unit by professional group.
      Professionn/N (%)
      Midwife107/109 (98%)
      Neonatal nurse5/6 (83%)
      Obstetrician17/18 (94%)
      Physiotherapist7/7 (100%)
      Neonatologist1/1 (100%)
      Anaesthetist3/4 (75%)
      Other7/7 (100%)
      Participants who responded ‘yes’ to this question were also asked to offer a CS rate that they considered ‘too high’. Responses ranged from 15% (n = 3) to 100% (n = 1). Most offered a rate of 25% as being ‘too high’ (36/146, 25%) followed by rates of 30% (34/146, 23%) and 40% (20/146, 14%). Free-text comments from some participants highlighted a view that induction of labour leads to an increased CS rate“Reducing the number of unnecessary inductions would have a huge impact on reducing the number of unnecessary sections…” (Midwife)
      Participants were asked if they discussed CS rates with women in the antenatal clinic. Twenty (17%) of 124 participants indicated that they discussed CS with women only when clinically indicated, whereas eleven (9%) of the 124 participants discussed CS only when brought up by a woman. Seventeen (14%) discussed CS with women even when it was not clinically indicated. The majority indicated that they discussed CS with women when it was both raised by the woman and when clinically indicated (59/124, 48%). Participants were also asked if they believed there was a shift in obstetric culture towards a lower threshold for performing CS. Of the 145 that answered this question, 81% responded ‘yes’, with rates in both sites equivalent (82% and 81%, respectively). Fewer midwives (84/107, 78%) than obstetricians (20/22, 91%) believed there was a shift towards a lower threshold, although this difference was not significant (p = 0.18).
      To gain further insights into clinicians’ views of CS, participants were presented with a series of statements and asked to rate these on a 5-point Likert scale from strongly disagree to strongly agree. Seven statements related to elective CS and three were general statements about birth. Table 3 presents the results.
      Table 3Views on elective CS and birth.
      SDDNASA
      ‘Elective caesarean section……’
      Is not the safest option for the mother (n = 151)72588031
      Is not the safest option for the baby (n = 151)92698027
      Will least affect the mother’s future sexual function (n = 152)156929327
      Will reduce the chances of stress incontinence (n = 152)106217585
      Will increase the chances of urge incontinence (n = 151)97437310
      Will reduce the chances of faecal incontinence (n = 152)44824679
      Is more painful than vaginal birth (n = 151)1720176631
      Giving birth is a natural process that should not be interfered with unless necessary (n = 150)18135870
      If a woman wants to have a vaginal birth, she should be able to attempt one (n = 148)10557454
      If a woman wants to have a CS, she should be able to have one (n = 150)106013607
      SD: strongly disagree; D: disagree; N: neutral; A: agree; SA: strongly agree.
      When asked if a previous 3rd or 4th degree tear was an indication for an elective CS, 53% of participants overall responded ‘yes’, although fewer midwives than obstetricians indicated this (50% versus 64%; p < 0.0001).

      3.2 Advising women

      In general, for women in labour who have had a previous CS, 7% (10/148) of participants advise against an epidural, 39% advise against induction of labour and 74% advise continuous fetal monitoring. For women with an uncomplicated singleton pregnancy with cephalic presentation, 88% (127/145) of participants would offer vaginal birth where there was one previous CS for breech presentation, 81% would offer vaginal birth for one previous CS for fetal distress, and 74% would offer vaginal birth for one previous CS due to failure to progress. Respective proportions that would offer both elective CS and vaginal birth were 1%, 18% and 20%. Differences in offering vaginal birth were observed between participants with less than two years’ experience compared to those with greater than 10 years’ experience for women who had a previous CS for fetal distress and failure to progress but not for women who had a previous CS for breech (Table 4).
      Table 4Offering vaginal birth by years of experience.
      <2 years (n = 23)2−5 years (n = 40)>5 to 10 years (n = 27)>10 years (n = 55)<2 years vs >10 years p-value
      Previous CS for breech19 (83%)34 (85%)23 (85%)51 (93%)0.180
      Previous CS for fetal distress16 (70%)27 (68%)22 (81%)52 (95%)0.002
      Previous CS for failure to progress17 (74%)24 (60%)20 (74%)47 (85%)0.043
      The p-values in bold indicate a significantly different result.

      3.3 Care of women requesting CS in the absence of medical indication

      Participants were asked, when counselling women about elective CS in the absence of any maternal medical, obstetric or fetal complications, what risks for mother and baby associated with CS would they discuss with women. The most common risk offered was haemorrhage (90/106; 85%), followed by infection 86/106 (81%), and visceral injury 61/106 (58%). Other risks commonly mentioned were deep venous thrombosis, recovery post-CS (e.g. pain), uterine injury, hysterectomy, and death.
      Participants were also asked, when counselling women about elective CS in the absence of any maternal medical, fetal or obstetric complications, whether they discussed risks associated with vaginal birth with women. Of those that responded, half (61/121; 50%) indicated that they did. The most common risk discussed was perineal trauma (49/59; 83%), followed by haemorrhage (33/59; 56%), instrumental birth (17/59: 29%); shoulder dystocia (11/59; 19%) and infection (8/59; 14%). Other risks that might be discussed included pain, induction of labour, failure to progress and uterine rupture. Aligned with these data were free-text comments regarding concerns held by some participants that a lack of information on the risks associated with CS could lead to an increased CS rate:I believe in a mother’s choice but only once fully informed about all the risks and benefits. I feel that a full medical and social history is important before deciding if a mother can request an elective CS.” (Obstetrician)Working in private postnatal, I feel women usually elect for LSCS due to lack of education, many not prepared for pain and recovery time, some women not aware they will bleed post LSCS etc. Education sessions with a midwife would reduce amount electing for LSCS/Prepare women more for recovery from LSCS.” (Midwife)
      Participants were also presented with two scenarios; (i) a 25-year-old woman with no previous pregnancies and (ii) 25-year-old multiparous woman with no previous CS or complicated pregnancies, and were asked how they might respond to women matching these scenarios if they requested a CS in the absence of any medical indications. Table 5 presents the results.
      Table 5Requests for CS in the absence of medical indication (scenarios).
      25-year-old woman with no previous pregnancies; N = 13225-year-old multiparous woman with no previous CS or complicated pregnancies; N = 127
      Agree to book an elective CS
      Recommend vaginal birth but accept maternal choice as to vaginal birth or elective CS21 (16%)20 (16%)
      Recommend vaginal birth, and refer to colleague for second opinion23 (17%)20 (16%)
      Recommend vaginal birth64 (49%)65 (51%)
      Note24 (18%) participants chose more than one option; of these, 7 (29%) indicated they would agree to book an elective CS22 (17%) participants chose more than one option, of these 6 (22%) indicated they would agree to book an elective CS
      In considering requests for CS in the absence of medical indication, free-text comments from several participants, predominantly midwives, highlighted the importance of meeting the needs of each individual woman and upholding and supporting maternal choice.In the absence of medical contraindications, mothers should be offered the birth they feel most safe and comfortable with, with backup supports to intervene rapidly if needed.” (Midwife)I believe that maternal choice also needs to be respected and if a woman is requesting an elective CS or a vaginal birth under any circumstances then her choice should be respected + supported.” (Midwife)

      4. Discussion

      This survey offers insight into clinicians’ attitudes towards CS in Ireland. The findings both reflect and contrast attitudes towards CS internationally, and evidence-based information. For example, there was strong agreement that the CS rates in the participating units are high; however, rates that are considered ‘too high’ by the majority of participants (25%–40%) are considerably beyond the 10% level which the World Health Organization (WHO) has noted that there is no associated reduction in maternal or neonatal mortality rates []. Although participants largely believed there was a change in obstetric culture towards lower CS, these ‘too high’ rates appear to indicate that clinicians remain accepting of considerably high CS activity.
      Almost three-quarters of survey participants agreed or strongly agreed that elective CS was not the safest option for the mother or baby. This appears contradictory to 45% of clinicians indicating that they agreed or strongly agreed that a woman should be able to have a CS if she wants to have one. Not withstanding choice in maternity care, supporting an option that is considered less safe appears clinically conflicting. It does align in-part however, with international guidance that recommends offering planned CS to women requesting a CS if, after discussion and support, a vaginal birth remains unacceptable to them [
      • National Institute of Health and Care Excellence (NICE)
      ].
      Clinicians’ responses to the statements as to how CS might affect women were generally reflective of current research findings; however, some disparities are noted. For example, 39 (26%) participants believed that CS would ‘…least affect future sexual function’. This belief contrasts with recent evidence that describes an increase in one or more sexual health issues (defined as reduced desire, difficulty in obtaining an orgasm, lack of lubrication, or dyspareunia) in women who had a CS compared to women who had spontaneous vaginal birth (OR 1.18, 95% CI 1.09–1.28), including in women who had a CS after a previous vaginal birth (OR 1.10, 95% CI 1.01–1.19) [
      • Hjorth S.
      • Kirkegaard H.
      • Olsen J.
      • Thornton J.G.
      • Nohr E.A.
      Mode of birth and long-term sexual health: a follow-up study of mothers in the Danish National Birth Cohort.
      ]. Seventy-six (50%) participants also believed that elective CS ‘…reduces the chances of faecal incontinence’, which, based on large population cohort studies [
      • MacArthur C.
      • Wilson D.
      • Herbison P.
      • Lancashire R.J.
      • Hagen S.
      • Toozs-Hobson P.
      • Dean N.
      • Glazener C.
      • ProLong Study Group
      Faecal incontinence persisting after childbirth: a 12 year longitudinal study.
      ,
      • Schei B.
      • Johannessen H.H.
      • Rydning A.
      • Sultan A.
      • Mørkved S.
      Anal incontinence after vaginal delivery or cesarean section.
      ] is not supported in the literature. Similarly, a meta-analysis of 13 high quality studies found no difference in faecal incontinence in women who had CS compared to women who had vaginal birth (OR 0.93, 95% CI 0.77–1.13) [
      • Nelson R.L.
      • Furner S.E.
      • Westercamp M.
      • Farquhar C.
      Cesarean delivery for the prevention of anal incontinence.
      ]. As regards urinary incontinence, clinicians had mixed views, but the international literature also shows differing results which, in general, appear to indicate that CS does reduce the likelihood of urinary incontinence [
      • Tähtinen R.M.
      • Cartwright R.
      • Tsui J.F.
      • Aaltonen R.L.
      • Aoki Y.
      • Cárdenas J.L.
      • et al.
      Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis.
      ]. Most clinicians (64%), in their belief that CS was more painful than vaginal birth, were concurrent with the findings of a recent systematic review involving 17 studies which reported an incidence of chronic post-CS pain between two and six months postpartum of between 4% and 42% [
      • Yimer H.
      • Woldie H.
      Incidence and associated factors of chronic pain after caesarean section: a systematic review.
      ].
      Despite the lower incidence of some morbidities following CS, a comparative study in the UK found that a group of 122 first-time pregnant women were willing to accept significantly higher risks of complications described as potentially likely to follow vaginal birth (such as anal incontinence and fourth degree perineal tears) than 341 clinicians involved in giving maternity care [
      • Turner C.E.
      • Young J.M.
      • Solomon M.J.
      • Ludlow J.
      • Benness C.
      • Phipps H.
      Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians.
      ]. Clinicians may thus erroneously assume that it is in the women’s best interests to recommend a CS when the woman herself may not wish to make that choice.
      The majority of clinicians (84%) in our survey agreed or strongly agreed that ‘giving birth is a natural process that should not be interfered with unless necessary.’ This aligns with opinions offered by the WHO whereby the WHO has spoken out against the increasing medicalisation of normal childbirth processes, saying that it is “undermining a woman’s own capability to give birth and negatively impacting her birth experience” [
      • World Health Organization
      Making Childbirth a Positive Experience: New WHO Guideline on Intrapartum Care.
      ]. An interesting finding in this study were differences in the proportions of clinicians offering vaginal birth after previous CS according to years of experience. Those with less than two years’ experience compared to those with greater than ten years’ experience were less likely to offer vaginal birth. This is in direct contrast to findings from other studies which reported trends towards higher CS rate with increasing seniority and experience [
      • Kabakian-Khasholian T.
      • Kaddour A.
      • Dejong J.
      • Shayboub R.
      • Nassar A.
      The policy environment encouraging C-section in Lebanon.
      ,
      • Kwee A.
      • Cohlen B.J.
      • Kanhai H.H.
      • Bruinse H.W.
      • Visser G.H.
      Caesarean section on request: a survey in the Netherlands.
      ]. Although speculative, it may indicate that those with greater experience in clinical care have more confidence in vaginal birth success after previous CS, having witnessed such success over the years.

      4.1 Strengths & limitations

      The survey is limited by the relatively low response rate (17%) compared to the numbers of clinicians working in the involved maternity units, reducing the generalisability of the findings. Additionally, the majority of participants were midwives. While midwives may reflect the clinician group that are more likely to discuss CS as a birthing option with women, obstetricians represent the clinician group that are most likely to make the decision regarding the need for or performance of a CS. Having more obstetricians participate in the survey would likely have enhanced the generalisability of the findings further. Nonetheless, the survey findings are informative for gaining insight into the views and thoughts about CS in the context of maternity care in Ireland, for developing and targeting interventions for View Commentsreducing unnecessary CS within this context and for addressing views that conflict with the current evidence base.

      5. Conclusion

      This survey offers insight into clinicians’ attitudes towards CS in Ireland. The findings are both consistent with and contrasting towards evidence-based information on CS internationally. One-third of all births in the study sites are currently by CS. The findings of this study can be considered contextually in addressing these high CS rates. They additionally have wider relevance in understanding the beliefs held about CS by maternity professionals in general.

      Conflict of interest

      None declared.

      Ethical statement

      Ethical approval for the study was granted by Trinity College Dublin University’s Faculty of Health Sciences Research Ethics Committee (Ref: 170501, 19-Dec-2017), and by the Research Ethics Committees of the two participating hospitals (Ref: study 21-2 017 and Ref: REC-2017-026).

      Funding

      The Health Research Board Ireland, as part of a wider research project, the REDUCE study, under the Definitive Intervention and Feasibility Awards (DIFA) 2017 (Grant No: DIFA-2017-011). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

      Author contributions

      CB and VS conceived the study design and methodology. VS and KH collected the data. KH analysed the data. VS drafted the manuscript. CB and KH contributed intellectual content. VS, CB and KH read and approved the manuscript prior to submission.

      Acknowledgements

      We wish to thank the participants for giving their valuable time in completing the survey, and the staff of the Health Research Board Mother and Baby Clinical Trials Network, Ireland, for their assistance with recruitment.

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