Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study
JS Bell, IMMPACT, University of Aberdeen, 2nd Floor, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZL, Scotland, UK. Email email@example.com
Objective To explore prospectively women’s decision making regarding mode of delivery after a previous caesarean section.
Main outcome measures The evolution of decision making, women’s participation in decision making, and factors affecting decision making.
Design and methods A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.
Setting An antenatal unit in a large teaching hospital in Scotland and participants’ homes.
Sample Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.
Results Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section.
Conclusion Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.
Across the UK, one in four first babies is born by caesarean section1 and rates in Scotland have increased from 5% in 1970 to 23.4% in 2003.1,2 Secondary caesarean section rates have also risen as attempts to deliver vaginally are unsuccessful, or avoided by women who are concerned about a possible emergency caesarean section.3 Repeat elective caesarean section is considered the most significant factor influencing Scottish caesarean section rates.4
Between 60 and 93% of women undergoing trial of labour (TOL) in Britain and the USA succeed in giving birth vaginally.5–7 An Expert Advisory Group4 advocates that clinicians and women consider a TOL as the preferred option following one previous caesarean section. Data show an overall UK vaginal delivery rate of 33% following previous caesarean section, varying between regions from 27 to 38% and between units from 6 to 64%. One recent study suggested that 60% of women having repeat caesarean section may be unaware of alternative delivery options.8
Several studies suggest that around 7% of women who have a caesarean section may have requested one,9,10 and this percentage is likely to be higher for women with a previous caesarean section.11,12 A recent UK report, placing significant emphasis on the impact that women’s requests may have on increasing caesarean section rates,13 may have contributed to the public perception that women are ‘demanding’ caesarean section for reasons related to convenience or vanity.14,15 There is little evidence, however, of women stating a preference for caesarean section, even after an instrumental vaginal delivery or an emergency caesarean section.16,17 Those who ‘demand’ a caesarean section often have overriding fears for their own or their child’s safety or have experienced a traumatic birth.12,18
Recent government and National Health Service policies have encouraged women to participate more actively in individual care planning and decision making.19,20 The Royal Colleges of Midwives and Obstetricians and Gynaecologists emphasise patient choice and involvement in decision making,21,22 which may be difficult in an emergency situation. Whereas 30% of women having emergency caesarean section may have had no input into the decision, only 7% of those having elective caesarean section23 had none. In contrast, women who have previously had a caesarean section for a nonrecurrent cause may make decisions about delivery prior to labour, and have the opportunity to be fully involved.
The aim of this study was to explore prospectively the decision-making process regarding mode of delivery for women who had previously given birth by caesarean section; in particular, to understand when and how this decision is made.
The setting for the study was Aberdeen Maternity Hospital, which acts as a secondary, as well as a tertiary referral centre for the Grampian region. Qualitative methods were used to follow women from recruitment at 20 weeks of gestation through pregnancy and the immediate postnatal period. We aimed to recruit a sample of 30 women, as we believed this number would allow us to achieve a saturation of relevant themes allowing for losses to follow up. The specific eligibility criteria were that women should be locally resident, older than 16 years, have had a first delivery by caesarean section for a nonrecurrent cause and be planning their second delivery.
After approval by the Grampian Research Ethics Committee, eligible women were identified from their case records by clinic staff at their first antenatal visit, and permission for future contact sought from all of them. Sixty eligible women gave permission for future contact over a period of 2 months, from October until December 2003. The researcher (M.M.) made at least two attempts to contact each woman at 20 weeks of gestation, unless their care provider indicated they were unsuitable for the study. Women who consented to all aspects of the data collection were then recruited into the study until the target number was achieved. The most common reasons for nonparticipation were: (i) the woman was assessed as unsuitable by her healthcare provider, e.g. a non-English-speaking woman, carrying twins; (ii) no contact was made and (iii) she refused to take part.
The following data sources were used:
- • diaries completed by participants;
- • observations of the clinical consultation in the third trimester at which it was expected the final decision regarding mode of delivery would be made or confirmed;
- • interviews with participants at 6 weeks postdelivery and
- • relevant field notes made by the researcher.
The methods were chosen to provide insight into different aspects of the decision-making process. Diaries were used because they allowed participants to keep a personal account of events, feelings and interactions with others as they occurred, rather than relying on recall.24 They have also been identified as particularly useful in recording life changing events.25 The consultation was observed to gain insight into how the final decision was made, and to watch the interaction between the woman and clinician. From the postnatal interview, a detailed portrayal of the woman’s thoughts and feelings was expected to emerge, with the limitation that these would be retrospective. Observations, memos and field notes provided an alternative perspective, that of the researcher, on the mother’s experience of interaction with health service staff, that together with in-depth interviews, form part of the stock of methods available to qualitative researchers.26 Rather than test preconceived hypotheses, these methods encourage the generation of theoretically informed hypotheses from the data collected. The use of three different methods enabled a more detailed exploration of the decision-making process.
Women made diary entries whenever they had a significant discussion or reflection on the decision about mode of delivery. The diary was specifically designed for the study and included open questions about decision making and was piloted on three women. Postal prompts were used to remind participants to record their reflections at 28 weeks of gestation and at 2 weeks postpartum. Women were encouraged to keep their diary with them and to record their feelings soon after delivery and postnatal debriefing.
The observations were performed by M.M. and took place during routine clinic consultations in a tertiary hospital in Aberdeen during the women’s third trimester; a time when decisions about mode of delivery are finalised. Consultations were tape-recorded, and field notes were taken by M.M. Transcriptions of the observations and diary data were used to facilitate discussion at the postnatal interviews that were carried out by M.M. in women’s homes 6 weeks postdelivery to elicit their views of the entire process of decision making (last interview: September 2004). Interviews were semi-structured using individualised schedules based on diary entries, observations and field notes; they were tape-recorded with the women’s consent.
Data from the observations, interviews, diaries and field notes were entered into N-VIVO and analysed using an inductive approach. Complete data from a selection of participants (chosen to reflect diversity) were analysed for themes and categories that were then discussed and agreed upon by a subgroup of the research team with experience in qualitative data analysis (M.M., M.P., S.L., V.H.). Data were then coded using the agreed themes, summarised and synthesised into framework charts to facilitate longitudinal analysis for each participant and cross-sectional analysis between participants.27
Thirty women were recruited into the study and four later withdrew. All women, except one, were Caucasian with ages ranging from 29 to 43 years (mean: 33.6). Most participants were affluent, with 22 classified by postcode in the two most affluent groups according to the Carstairs deprivation index.28 Geographical locations included urban, suburban and rural. Data were complete for 18 participants:
Summary of the data collected
Number of consultations observed: 23
Number of diaries received: 22
Number of postdelivery interviews: 21
Number with complete information: 18
Information was incomplete because some women did not attend hospital appointments, did not return diaries, or were unavailable for interview. Participants’ actual modes of delivery are shown in Table 1.
Table 1. Early intentions regarding delivery by mode of delivery experienced
|Unassisted Vaginal Delivery||2||0||1||0||3 (11.5)|
|Assisted Vaginal Delivery||3||0||3||0||6 (23.1)|
|Elective caesarean section||1||2||2||3||8 (30.8)|
|Emergency caesarean section||6||0||1||2||9 (34.6)|
Data on decision making were analysed from both a longitudinal and a cross-sectional perspective, and three dominant themes emerged:
- • the evolution of decision making
- • women’s participation and involvement in decision making
- • factors affecting decision making.
The evolution of decision making
Early thoughts on mode of delivery
Initial thoughts on preferred delivery method at 20 weeks are available for 21 women taken from the diaries and field notes when available (Table 1). The majority mentioned vaginal delivery or TOL, six had already decided on this method and six others expressed a preference for it. Two women had decided on caesarean section, and maintained this position throughout pregnancy. Seven women were undecided at this early point. One of the latter said that it was easier ‘not to think’ about the delivery (Px1, diary 24 and 37 weeks). In all cases, women’s early thoughts about the delivery were strongly influenced by their experience of their previous delivery (see section Factors affecting decision making: Previous delivery for quotes).
Development of the decision during pregnancy
Most women acknowledged that a decision could never be final because medical and social circumstances might change. Indeed, a number of those who were undecided or hoped for a TOL were presented with medical evidence that made them change their minds during the course of the pregnancy. For example, one woman changed her decision from TOL to elective caesarean section after a routine fetal scan showed ventricular cysts (which subsequently resolved), and she did not feel able to cope with the uncertainty of a TOL (Px14). Another woman opted for an elective caesarean section because her baby was very large for dates, making a caesarean section more likely. Prior to labour, a total of eight women had booked an elective caesarean section, including two initially undecided, three who had not given an early view on delivery and one who had expressed a preference for TOL. Contrariwise, five women who were undecided at the midpoint of pregnancy finally opted for a TOL. In some cases, medical staff made strong recommendations for particular kinds of delivery, and some women described how the decision kept changing during the course of the pregnancy. One wrote that the decision ‘appeared to be changing from week to week’ (Px28 postnatal interview), and none was comfortable with this. Because of uncertainty, several women expressed a wish that doctors should make the decision and not involve them at all.
In contrast, at least one woman was definite about her choice from the start (Px11), but she was in the minority and many expressed varying degrees of uncertainty.
Two examples of the evolution of the decision are given in Box 1.
Table Box 1. . Interview guide
|Extracts from diary and interview of Px14 who had an elective caesarean section|
|‘I have decided to go for a trial vaginal delivery…’ (diary 18 weeks)|
|‘My thoughts have taken a definite change. I am now considering requesting a C-section. The question mark over the baby’s health is enough uncertainty to deal with without going into labour and hitting complications’ (diary 21 weeks)|
|‘No decision reached … Need to go back at 38 weeks. Left with ‘undecided’ in my notes…’ (diary 34 weeks)|
|‘Have decided on a C-section…’ (diary 38 weeks)|
|‘I feel so relieved that the whole experience is over. I found my consultations really quite nerve wracking … I found reaching both my 1st and 2nd decision a big responsibility. I often wished that the final decision rested on the consultant as I wrestled with indecision at time.’ (postnatal interview)|
|Extracts from diary of Px30 who had a normal vaginal delivery|
|‘… still undecided and changing my mind from day to day…’ (diary 13 weeks)|
|‘Undecided although veering towards VBAC’ (diary 20 weeks)|
|‘… decided that no medical reason not to try VBAC … so will give it a go’ (diary 34 weeks)|
|‘Wondering if I should ask for an elective section …’ (diary 39 weeks)|
|‘I had been thinking about it (the decision making process) … from the day I found out I was pregnant’ (postnatal interview)|
Women’s participation and involvement in decision making
In their diaries all the women expressed a desire to be involved in the process of decision making, but not all of them actively participated. Some only became aware that a decision about how to deliver needed to be made during the course of the pregnancy, while others were fully aware of the decision and choices available from the start. At the beginning of her pregnancy, one participant wrote that she would like to be involved ‘as much as possible’ but nevertheless felt pressurised by her degree of involvement ‘I feel that too much choice was given to me when medically I have no idea … too much pressure on the day. Why is final decision mine?’ (Px28 diary postnatal). At her postnatal interview, the same woman described herself as ‘gobsmacked’ by the process, as she had not expected to have a choice. This view was reflected by others who expressed concern at the degree to which they were expected to take responsibility for the decision: ‘I felt quite shocked that ultimately it was me who had the final say’ (Px14 diary 18 weeks).
Most women felt happy with their involvement and level of responsibility: ‘I feel I was fully informed and … my wishes were taken into account throughout the pregnancy’ (Px18 postnatal interview). A woman who expected to have to ‘fight’ (Px21—diary preliminary questions) for an elective section found her request met with little resistance. Others felt that their choice was illusory as medical events dictated what would happen in the end: ‘it was essentially up to me until anything went wrong during the delivery, when it would be taken out of my hands’ (Px30 postnatal interview). Some did not feel they were ever given much choice: ‘It has never really been ‘discussed’ I was basically told they would prefer for me to try vaginal delivery but I could have a section if I really wanted’ (Px19 diary 34–38 week appointment); ‘… at the end of the day I guess it’s really up to me but I did feel my mind was made up for me’ (Px19 postnatal interview).
Women varied in the level of confidence they felt about decisions they had made. An extreme example involved a participant who was so adamant that she wanted a TOL that she decided not to meet her obstetrician to discuss other options (Px11). However, many of the women displayed uncertainty or anxiety about the decision and whether it was the ‘right’ one: ‘I was glad at the end of the day that the decision was kind of taken out of my hands’ (Px2 postnatal interview). One woman made a decision but later found herself needing ‘expert’ reassurance: ‘I would like my thoughts and feelings to be heard and respected but not being a medical person am relying and looking to my consultant for a final say’ (Px14 diary 18 weeks).
Factors affecting decision making
Women’s decisions about their delivery were influenced by their previous experience. For example, both women who expressed an early preference for caesarean section said that it was a quick method of delivery and they knew what to expect: ‘It means a long (+painful) recovery, but I believe this process would be much worse if I attempted a vaginal birth—and failed’ (Px21 diary 20 weeks). Their decision and that of several others was strongly influenced by the possibility of an emergency caesarean section if they opted for TOL. Eight women had not found their previous caesarean section distressing, but six said that it was unpleasant and had raised concerns about themselves or the wellbeing of their baby: ‘last time I felt so incapacitated and I hated it’ (Px4 interview); ‘It had quite an influence in that … it always made me question going for another natural delivery, just in case the same thing happened again’ (Px30 interview).
Having a ‘normal’ delivery
The desire to have a ‘normal’ delivery was expressed in different ways; as the wish to experience a natural birth: ‘I would like to experience the feeling of a natural delivery; I feel as if I have missed out on a unique feminine experience’ (Px18 diary 20 weeks); being able to say that they did it themselves was also important: ‘I would like to say that I have managed myself, or just be able to say that I gave it my best’ (Px29 diary 22 weeks); as was the hope of achieving the type of birth they had wanted in their first confinement. One woman noted she would ‘feel like a failure’ if she opted for a caesarean section (Px19) and several felt that caesarean section was seen as ‘taking the easy option’ (Px2, Px24). Others worried that they might not cope with the pain of labour, or would be unable to deliver a baby ‘on their own’. For example, one respondent was concerned that her uterine scar might rupture if she attempted labour, while another said the idea of labour pain ‘freaked her out’ (Px19 diary 32 weeks). Three women, who had not experienced labour, said this was like a first birth and expressed what one described as ‘fear of the unknown’.
Women seriously considered the practical implications of the different modes of delivery for their recovery. Temporary inability to drive and the disruption to family life caused by a longer recovery period after caesarean section were major considerations, as were the need for assistance from family members, childcare difficulties, missing important events and financial implications.
A few women felt they had received little information regarding mode of delivery and one woman explained how she overcame this by reading and searching on the Internet. Another participant was content that the health professionals had not gone into too much detail. Other women felt that they had been given a lot of information: ‘we were given every piece of information, maybe not what we wanted to hear but certainly we were told everything good and bad that could happen’ (Px7 postnatal interview). One woman felt ‘quite laden down with a lot of information and facts’ (Px2 diary, 34-week visit) and another found it ‘worrying’. Several women highlighted the need for information specific to their particular situation, rather than general information regarding different modes of delivery. Some wished to know what the doctor would do in their situation: ‘I was really wanting good sound advice, you know, ‘If I was in your shoes I would do this’, and I wasn’t, I was just given the facts there and then on that day … but those facts weren’t nothing to do with what my current pregnancy/baby … It was all, you know, this is the scenario that could happen if you went down this route, these are the risks involved with option A or option B kind of thing.” (Px2 postnatal interview).
Sources of influence
Information about health and practical issues associated with the different delivery options, tended to come from health professionals. Many women believed that their health professionals favoured them attempting a ‘normal’ delivery: ‘They say that usually they try the natural way. It’s recommended for the recovery’ (Px1 postnatal interview); ‘Although I still feel very open minded, I do feel a sense from differing health professionals that going for an elective section is considered unnecessary option and that a trial of labour should at be ‘given a go’ in most circumstances’ (Px2 diary 28 weeks); ‘It seems to me like the doctor has already had his decision, you know. He [Dr] just push me to go to natural delivery first and then if it is impossible to another decision’ (Px9 postnatal interview); ‘I was basically told they would prefer for me to try vaginal delivery but I could have a section if I really wanted.’ (Px19 diary 34–38 week consultation). Despite this, one woman reported no resistance to her request for a caesarean section ‘I was surprised that [Dr] said that if I wanted an elective section, I could have one.’ (Px24 postnatal interview). There was a perception that professional groups viewed the merits of each mode of delivery differently. A woman who had agreed an elective caesarean section with her consultant felt she had to hide this decision from her midwives lest it affected future interaction: ‘midwives particularly quite pro [TOL] … how is it going to affect my treatment in hospital?’ (Px14 postnatal interview).
Other sources of information and influence included partners, family members, friends and work colleagues. Women saw health professionals and partners as most influential, with family members, friends and colleagues usually providing supplementary information. Television programmes and the Internet (peer support networks and medical journals) were also seen as useful.
This study shows that the decision about mode of delivery often evolves during the course of pregnancy and is influenced by events in the previous delivery as well as the current pregnancy. While keen to be involved in the decision-making process, women were less confident about taking responsibility for the final decision. They also wanted information specific to their clinical circumstances and tailored to meet their individual needs.
The strengths of this study are its prospective nature and the element of triangulation provided by the three sources of qualitative data, which combine to give a more complete picture. This diversity of method proved fortunate, as the observations in the third trimester provided less insight into the decision-making process than had been hoped because in many cases the risks and benefits of TOL and elective caesarean section had been discussed in previous meetings, and the decision already made. Although the understanding of the decision-making process was less useful than anticipated, the observations were valuable in building the researcher–participant relationship, which in turn facilitated the interview process and diary completion. The diaries, in particular, provided an opportunity for women to document their perceptions of events and issues relevant to decision making soon after they occurred, thus reducing the likelihood of recall bias.29,30 This benefit was apparent in several interviews where the women had difficulty recalling their thoughts during the pregnancy, and the diary proved a useful memory prompt.
The results of such a small study may not be generalisable to all women making decisions after a primary caesarean section, but the concordance with published studies in this area suggests that they are not unrepresentative.31–35 Also, the study hospital had a vaginal birth after caesarean section (VBAC) rate of 31% in 2005 among women presenting with one previous caesarean section (P. Danielian, pers. comm.), which places it midrange with respect to the national figures of VBAC by unit (6–64%) and close to the national average.
In the present study, relatively few women held a firm opinion regarding the proposed mode of delivery at the beginning of pregnancy, and many still saw it as a ‘work in progress’ at the midpoint. Recognising that any decision made had to be provisional, women nevertheless found it hard to cope with the uncertainty this engendered. This finding is complemented by results from another study that examines the same decision-making process from the perspective of health professionals.31 In it, obstetricians and midwives expressed uncertainty about the optimal delivery strategy for women who had a previous caesarean section, reflecting the lack of a robust evidence base. There was also a perception among health professionals that women are confused by poor quality and conflicting information acquired from peers and other professionals.
In contrast to the impression created in the media,15 we found no evidence of clear preferences in terms of mode of delivery or demand for elective caesarean section; in fact, a high proportion of our respondents were uncertain about mode of delivery at 20 weeks. This finding appears to conflict with a recent Australian study in which most women expressed a preference for either repeat caesarean section or vaginal birth 6 months after caesarean section,32 but this may be explained by the difference in the timing of the follow up.
Women reported feeling that the cultural milieu among both medical and nursing staff favoured a TOL in the absence of contrary medical indications. There is already evidence that doctors are reluctant to perform a caesarean section when not medically indicated,36 and most health professionals prefer vaginal birth because it poses fewer risks to mother and child and improves maternal functioning in the weeks after birth.31 In contrast, obstetricians in the USA appear increasingly reluctant to encourage VBAC.37
Women expressed the desire to be involved in decision making, but the amount of involvement they envisaged varied widely from total (no wish to engage with professionals regarding the decision) to minimal (wanting the decision taken out of their hands). Some were reluctant to take on the responsibility for the decision, and most wished for more information and clinical input tailored to their own situation. Despite doctors’ attempts to involve them in decision making, women did not always welcome the opportunity, feeling that they lacked the necessary skills. Women’s need for more guidance by health professionals confirms the conclusion by Graham et al. that health professionals need to gauge varying levels of involvement required by individual women and to respond accordingly.9
In a study by Kamal et al.,31 doctors and midwives emphasised that decisions about mode of delivery were joint decisions, negotiated between women and professionals; however, the way in which consultations about these decisions were managed varied widely. Although we did not observe such differences in clinical style at the 34-week consultation, they may have existed and may explain the observed differences in women’s perception of the decision-making process in the present study. These ranged from lack of awareness that there was a decision to be made (possibly the result of a paternalist approach) to a sense of being overburdened by having responsibility for decision making (maybe a reflection of a more consumerist approach).
The factors women identified as influences on their choice of delivery method are similar to those found in previous reports. TOL was often favoured because of the ease of recovery and childcare considerations.33 A study of women opting for elective caesarean section, found fear to be an important factor, and health professionals to be less influential than friends and family.34 Ridley et al.35 found that women opting for VBAC are influenced by their sense of control in the decision making process as well as doctors’ encouragement. The overriding importance of a safe delivery of a healthy infant was universally acknowledged among women in the present study, whereas Eden et al.33 found this to be the case in only 4 of the 11 studies reviewed.
Implications for practice stem from the finding that most women wish to participate in the decision-making process about mode of delivery, but some would like more guidance from professionals. Standard information on risks and benefits did not always help, as women seemed unable to relate it to their own, sometimes changing, circumstances. Women’s need for more individualised care and targeted information is a challenge for providers of care in practice. A more thorough debriefing following the primary caesarean section may be helpful in providing women with specific information about their delivery options in future pregnancies, and encouraging them to start thinking about the issue before it becomes an immediate concern. Eliciting women’s preferences early in the subsequent pregnancy will allow time for detailed discussions; and continuity of care both within the clinic and in primary care could do much to reduce conflicting messages and reinforce consistent advice.
The decision about mode of delivery following previous caesarean section evolves during the course of pregnancy. Women wish to be involved in decision making, but some may be unhappy with the added responsibility this brings. There is a need for more individualised care in terms of information provided and decisions made.
Contribution to authorship
M.M. undertook recruitment, all the data collection, process, analysis, reporting and the design of the interview schedules. J.B. was the principal investigator and contributed to study development, analysis and reporting of the study. M.P. was a co-applicant on the study funding proposal and contributed to each stage of study development, analysis and reporting. S.B. and P.D. were co-applicants on the study funding proposal and contributed to process, reporting and HCP involvement. V.H. and S.L. were co-applicants and contributed to the study and tool design, analysis, process and reporting.
Ethics approval was granted by the Grampian Research Ethics Committee on 12th June 2003 prior to any recruitment or data collection.
The study was entirely funded by Chief Scientist Office, Scottish Executive.