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Keywords:

  • Caesarean;
  • elective caesarean;
  • mode of delivery;
  • patient preferences

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Objective  Caesarean section rates in Chile are reported to be as high as 60% in some populations. The purpose of this study was to determine pregnant Chilean women’s preferences towards mode of delivery.

Design  Interviewer-administered cross-sectional survey.

Setting  Prenatal clinics in Santiago, Chile.

Population  Pregnant women in Santiago, Chile.

Methods  Of 180 women completing the questionnaire, 90 were interviewed at a private clinic (caesarean delivery rate 60%) and 90 were interviewed at a public clinic (cesarean delivery rate 22%). Data collected included demographics, preferred mode of delivery, and women’s attitudes towards vaginal and caesarean deliveries.

Main outcome measures  Mode of delivery preferences, perceptions of mode of delivery measured on a 1–7 Likert scale.

Results  The majority of women (77.8%) preferred vaginal delivery, 9.4% preferred caesarean section, and 12.8% had no preference. There was no statistical difference in preference between the public clinic (11% preferred caesarean) and the private clinic (8% preferred caesarean, P= 0.74). Overall, women preferring caesarean birth were slightly older than other groups (31.6 years, versus 28.4 years for women who preferred vaginal and 27.3 years for women who had no preference, P= 0.05), but there were otherwise no differences in parity, income, or education. On a scale of 1–7, women preferring caesarean birth rated vaginal birth as more painful, while women preferring vaginal birth rated it as less painful (5.8 versus 3.7, P= 0.003). Whether vaginal or caesarean, each group felt that their preferred mode of delivery was safer for their baby (P < 0.001).

Conclusions  Chilean women do not prefer caesarean section to vaginal delivery, even in a practice setting where caesarean delivery is more prevalent. Thus, women’s preferences is unlikely to be the most significant factor driving the high caesarean rates in Chile.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

In 2004, the caesarean delivery rate in the USA reached 29.1%, its highest point yet.1 Despite recommendations by the World Health Organization to reach a caesarean rate of 15% by 2010,2 the caesarean rate has increased steadily over the past 7 years.1,3 Given the continually increasing caesarean section rate accompanied by a decreasing rate of vaginal birth after caesarean, it is questionable as to which mode of delivery is preferable both from a medical standpoint, as well as from a patient’s.

In response to the increase in caesarean section rates, a recent commentary specifically addressed the risks and benefits of elective caesarean delivery.4 Risks of a caesarean section include all potential operative complications, postoperative complications, and maternal death, although the numbers associated with these risks are being modified as surgical and post-op care improves. Of note, in the recent study of trial of labor versus elective repeat caesarean, there were two maternal deaths due to operative complications among the 15 801 women who underwent elective repeat caesarean delivery.5

Despite the potential risks, elective caesarean section may offer some substantial benefits. An elective caesarean would certainly avoid the dangers of emergency caesarean section and may protect the pelvic floor from the strain of vaginal delivery, perhaps reducing the incidence of incontinence and pelvic organ prolapse.6 Elective caesarean delivery may also avoid certain neonatal risks of vaginal delivery including shoulder dystocias, exposure to intrapartum infection, and intracranial injuries, as well as exposure to post-term pregnancy. Thus, from a medical standpoint it is unclear as to which mode of delivery is optimal. Further, from an economic standpoint, caesarean delivery is quite similar in cost to vaginal delivery and actually may be less expensive when comparing elective caesarean to a trial of labour in nulliparous women and only slightly more expensive than in multiparous women.7 In light of these views, it is important to determine the mode of delivery that is preferable to women.

In the USA, the practice of elective caesarean section is controversial. Around the world, however, there are a number of countries in which elective caesarean is widely available and routinely offered. For example, in a study done in 1997, Chile was found to have a caesarean section rate of 40%, more than twice the WHO recommendation.2 However, it is unclear whether women actually prefer elective caesarean delivery or whether it is physician preference that drives the high rate. Investigators have questioned whether high rates of caesarean section in other countries are physician or patient driven, and research conducted in Brazil suggested that women might be convinced by their physicians to have caesarean sections, even during labour when they are most vulnerable.8

The purpose of this study was to determine the attitudes toward mode of delivery among pregnant women in Chile, a country where elective caesarean delivery is acceptable. Our goals were to determine whether women prefer vaginal delivery or caesarean section, to describe the reasons for their preferences, and to compare the attitudes of women treated by private health clinics with those who are treated in the public health system.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

A questionnaire was adapted and elaborated from questionnaires used in other studies8,9 that focused on preference toward mode of delivery and the aetiology of these preferences. The questionnaire was pilot tested at the San Francisco General Hospital in San Francisco, California, and revisions were made to ensure coherent and culturally sensitive language. In November 2002, the questionnaire was administered to 90 women at a public health clinic in Chile where the caesarean section rate is 23% and the care is provided by midwives and obstetricians, and 90 women at a private health clinic in Chile where the caesarean section rate is 56% and the care is provided by obstetricians only. Ninety-eight women were recruited consecutively at the private clinic and eight declined to participate. Ninety-three were recruited consecutively at the public clinic and three declined to participate. Women who agreed to participate signed a consent form and filled out a questionnaire of approximately 10 minutes’ duration. None of the women had a medical condition that required a caesarean delivery.

All of the interviews were conducted by one of the authors (A.A.), a female resident in obstetrics and gynecology fluent in Spanish, in a private room in the clinic. She administered the demographic questions, asked about preferred mode of delivery and stayed in the room to answer any questions while the woman completed the rest of the form, which took about 10 minutes. Two qualitative approaches were used to determine why a particular mode of delivery had been chosen. The first was a series of 20 statements about perceptions regarding mode of delivery; the second, ten statements about the importance of certain factors in their decision to choose caesarean or vaginal delivery (see Appendix S1). Women were asked to indicate their degree of agreement or disagreement with each statement on a seven-point Likert scale. The use of the Likert scale allowed women to report the degree of intensity with which they agreed or disagreed with an item. The means of all results were compared with a Student’s t test and proportions were compared with a chi-square analysis. To control for potential confounders, multivariate linear regression models were used.

No personal identifying information was obtained. The interviewer was not involved in administering medical care to the women, and their treating physicians were not involved in the interview process. This research project was approved by the Institutional Review Boards at the University of California, San Francisco, and Sotero del Rio Hospital and Clinica Santa Maria in Santiago, Chile.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

We found that there were some demographic differences between women treated by private and public health clinics (Table 1). While there was no difference in gestational age between the two groups or the number of women in the third trimester (47% of women in the public clinic versus 48% of women in the private clinic, P= 0.46), the mean age of the private patients was greater. Public patients had less formal education, a lower median income, and were more likely to be multiparous. Among the multiparous women, the private patients were more likely to have had a previous caesarean delivery.

Table 1.  Characteristics of the study population, according to location of prenatal care
 Public (n= 90)Private (n= 90)P-value
  1. C/S, caesarean section; mo, month.

Age, years27.629.50.03
Gestational age, weeks25.124.90.85
Multiparous, %59380.005
Prior C/S, % (of 87 multips)21440.02
At least some college, %1488<0.001
Median income category (1–7)2 (US$100–200/mo)5 (US$1000–2000/mo)<0.0001

Despite these differences between the two groups, we found no difference between their preferences toward mode of delivery (Figure 1). Both public and private patients overwhelmingly preferred vaginal to caesarean delivery, with 77% of public and 79% of private patients preferring vaginal delivery (P= 0.74). Only 11% of public patients and 8% of private patients preferred caesarean delivery. Twelve percent of public and 13% of private patients had no preference for mode of delivery.

image

Figure 1. Women’s preference toward mode of delivery. Statistical comparisons are by the χ2 test. C/S, caesarean section; SVD, spontaneous vaginal delivery.

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Given the lack of differences between the private and public populations, we then compared women who preferred caesarean delivery to those who preferred vaginal delivery (Table 2). Women who preferred caesarean section were older, tended to be multiparous, and were more likely to have had previous caesarean delivery. There were no differences in mean gestational age, education level, or income category between women who desired caesarean versus women who desired vaginal delivery.

Table 2.  Characteristics of the study population, according to preferred mode of delivery
 Caesarean (n= 17)Vaginal (n= 140)P-value
  1. mo, month.

Age, years31.628.40.03
Gestational age, weeks27.524.80.23
Multiparous, %71480.08
Past caesarean delivery599<0.001
At least some college, %47510.73
Median income category (1–7)3 (US$200–500/mo)3 (US$200–500/mo)0.9

When questioned about their perceptions regarding mode of delivery differences appeared between the two groups preferring vaginal versus caesarean delivery (Figure 2). Women who preferred caesarean section agreed with the statement, ‘vaginal delivery is more painful than caesarean’, whereas women who preferred vaginal delivery slightly disagreed with that statement (P < 0.001). Women who preferred vaginal delivery agreed with the statement ‘my partner would prefer that I have a vaginal delivery;’ women who preferred caesarean section slightly disagreed with that statement (P < 0.001). Women who preferred caesarean section disagreed with the statement ‘I will recover my figure faster after vaginal delivery’ and disagreed with the statement that ‘vaginal delivery is safer for the baby than caesarean’ whereas women who preferred vaginal delivery agreed with both statements (P < 0.001). Of note, to the statement ‘caesarean delivery is safer for the mother than vaginal’ women seemed uncertain in their response, but there was a trend towards women preferring caesarean reporting higher scores (4.0 versus 3.1, P= 0.080). Women who desired caesarean section agreed that caesarean section was more convenient; women who preferred vaginal delivery disagreed (P < 0.001).

image

Figure 2. Women’s perceptions regarding mode of delivery by preference. The mean scores and 95% CI are shown. All statistical comparisons are by the Student’s t test. C/S, caesarean section; SVD, spontaneous vaginal delivery.

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When questioned regarding specific factors in their decision towards one mode of delivery, again there were differences between the two groups (Figure 3). Women who desired caesarean delivery indicated the importance of being able to schedule their delivery and the ease of recovery as factors influencing the decision to choose caesarean section. Both patients who desired caesarean delivery and those who desired vaginal delivery indicated the importance of enjoyment of sex and the ease of recovery as factors influencing their respective choices. Only the women who desired vaginal delivery indicated the importance of having a natural experience. Interestingly, both women desiring a vaginal birth and those desiring caesarean delivery felt strongly that their health (mean score 6.71 versus 6.94, P= 0.329) and the health of their baby (mean score 6.85 versus 7.00, P= 0.444) were important contributors to their decision. The overall mean scores of women’s health (6.73) and the baby’s health (6.87) were higher than the mean scores of the other factors influencing the decision towards mode of delivery (P < 0.001 for both).

image

Figure 3. Factors in decision regarding mode of delivery by delivery preference. The mean scores and 95% CI are shown. All statistical comparisons are by the Student’s t test. C/S, caesarean section; SVD, spontaneous vaginal delivery.

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The univariate findings above persisted in multivariate linear regression models used to control for potential confounders including maternal age, income, education, parity, gestational age, prior mode of delivery, and clinic type (data now shown).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

In our study of Chilean women’s preferences toward mode of delivery, we found that in a setting where the rate of caesarean delivery is 40% and elective caesarean delivery is an option, that the vast majority of women preferred vaginal delivery. Moreover, we found no difference in the rate of women who preferred vaginal delivery between the private and public clinics despite a large difference in the caesarean delivery rate in these two settings. Finally, when we compared women’s perceptions of mode of delivery and the factors they used to make their decision, we found some interesting differences and similarities between the women by preferred mode of delivery.

There was no difference between women who preferred vaginal delivery and women who preferred caesarean delivery concerning how important their safety and that of their baby was in their decision regarding the mode of delivery. Further, these two factors were scored higher than any of the others with regard to how important they were in influencing the participants’ decision. However, the women who preferred vaginal delivery generally felt it was the safer mode of delivery, while the women who preferred caesarean delivery felt that caesarean was safer. This difference was also noted regarding pain, recovery, and their partners’ preferences. Whether these differences were perceived by the women in our study prior to their decision, or whether making their decision then influenced their perception, cannot be answered by our cross-sectional survey. Regardless, these perceptions towards vaginal and caesarean deliveries are associated with stated preference towards mode of delivery and should be addressed with careful counselling and education by healthcare providers.

Epidemiological studies in Brazil and in Chile have demonstrated that caesarean section rates are higher among women of higher education level, higher income categories, and private insurance status.10 We suspected that since caesarean section rates were much higher in the private sector, private healthcare women might prefer caesarean section more often than public healthcare women. We were surprised to find that both public and private healthcare women overwhelmingly preferred vaginal delivery to the same extent, further supporting the hypothesis that preference of the woman is unlikely to be the most significant factor driving the high caesarean rates.

If patients are not demanding elective caesarean deliveries, physicians must shoulder some of the responsibility for inflated caesarean rates. It has been demonstrated that physicians influence intrapartum elective caesarean delivery; in one study, elective caesareans were offered before a clear medical indication in 13% of labours.4 Obstetrician age, maternal–fetal medicine specialists, and full-time faculty were all significantly associated with increased numbers of elective caesarean sections during labour. However, caesarean rates were not associated with maternal age, parity, stage or length of labour, epidural use, gestational age, insurance status, day of week, or time of delivery. Interestingly, this study concluded that physician characteristics (as opposed to patient characteristics or intrapartum factors) are a major determinant of whether labouring women are being offered caesarean delivery without clear medical indications. It is possible that some of these physician factors may be contribute to the high caesarean section rates in Chile as well.

Approximately 80% of the Chilean population is served by public health care and 20% by private health care. There are differences in the way that labour and delivery are conducted in these settings, with midwives performing the majority of the deliveries in the public sector. In the private sector, women still expect to be delivered by their own personal physician, who will be called to the hospital for each delivery. Prior evidence has suggested that physicians who are expected to attend each private patient’s delivery, regardless of time of day or exhaustion level, have both economic and schedule incentives to influence the time and method of delivery towards caesarean section.11,12,13

While our study may inform some of the questions surrounding elective caesarean delivery, it is not without limitations. As a cross-sectional survey, we cannot propose any causality between our findings and patients’ actual caesarean rates. Also, women were interviewed in the prenatal setting, and stated preferences may not anticipate actual preferences at the time of delivery. In our attempt to make the statements simple and short, some qualifying statements were removed. Thus, women may make their own assumptions about what is meant by ‘pain’, which could be pain during labour, at time of delivery, or in the postpartum period. Further, while our study was powered to examine the primary question of mode of delivery preference between the public and private patients, it was underpowered to examine several of the secondary questions. Despite this, the study was adequately powered for the majority of the comparisons between preferred mode of delivery and these findings persisted in both univariate and multivariate analyses. Additionally, we did not investigate how cost or price might influence women’s preferences, as women do not pay differentially by mode of delivery in Chile. Finally, the patients in Santiago, Chile, may not represent all women in Chile, let alone women in the USA. However, we believe this study was best performed in a culture where elective caesarean is an acceptable and a common occurrence.

In all likelihood, a combination of physician factors as well as patient perceptions likely contributes to increasing caesarean rates. If the goal is to reduce the rate of caesarean deliveries, then advocates for vaginal delivery should focus on identifying and modifying the physician factors and women’s perceptions that influence the decision to elect caesarean section. More importantly, we have a duty to perform prospective, long-term studies of caesarean delivery to fully determine the risks and benefits of a procedure that is performed more than one million times per year in the USA. Meanwhile, educating women as well as physicians about current information regarding the risks and benefits of caesarean will enable them to make a shared decision that will be in the best interest of the mother and her child.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Dr Caughey is supported by the National Institute of Child Health and Human Development, Grant # HD01262 as a Women’s Reproductive Health Research Scholar.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
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    Menacker F, Curtin SC. Trends in cesarean birth and vaginal birth after previous cesarean, 1991–99. Natl Vital Stat Rep 2001;49:116.
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    Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351:25819 [Epub 2004 Dec 14].
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    Bost BW. Cesarean delivery on demand: what will it cost? Am J Obstet Gynecol 2003;188:141821; discussion 1421–3.
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    Hopkins K. Are Brazilian women really choosing to deliver by cesarean? Soc Sci Med 2000;51:72540.
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    Osis MJ, Padua KS, Duarte GA, Souza TR, Faundes A. The opinion of Brazilian women regarding vaginal labor and cesarean section. Int J Gynaecol Obstet 2001;75(Suppl 1):S5966.
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    Behague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ 2002;324:9425.
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    Spetz J, Smith MW, Ennis SF. Physician incentives and the timing of cesarean sections: evidence from California. Med Care 2001;39:53650.
  • 12
    Ryan K, Schnatz P, Greene J, Curry S. Change in cesarean section rate as a reflection of the present malpractice crisis. Conn Med 2005;69:13941.
  • 13
    Grant D. Explaining source of payment differences in U.S. cesarean rates: why do privately insured mothers receive more cesareans than mothers who are not privately insured? Health Care Manag Sci 2005;8:517.