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Keywords:

  • Caesarean section on maternal request;
  • experience of childbirth;
  • fear of delivery

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Objective  The aim of this study was to examine the expectations and experiences in women undergoing a caesarean section on maternal request and compare these with women undergoing caesarean section with breech presentation as the indication and women who intended to have vaginal delivery acting as a control group. A second aim was to study whether assisted delivery and emergency caesarean section in the control group affected the birth experience.

Design  A prospective group-comparison cohort study.

Setting  Danderyd Hospital, Stockholm, Sweden.

Sample  First-time mothers (n= 496) were recruited to the study in week 37–39 of gestation and follow up was carried out 3 months after delivery. Comparisons were made between ‘caesarean section on maternal request’, ‘caesarean section due to breech presentation’ and ‘controls planning a vaginal delivery’.

Methods  The instrument used was the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ).

Main outcome measures  Expectations prior to delivery and experiences at 3 months after birth.

Results  Mothers requesting a caesarean section had more negative expectations of a vaginal delivery (P < 0.001) and 43.4% in this group showed a clinically significant fear of delivery. Mothers in the two groups expecting a vaginal delivery, but having an emergency caesarean section or an assisted vaginal delivery had more negative experiences of childbirth (P < 0.001).

Conclusions  Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasises the importance of postnatal support.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Caesarean section on maternal request without obstetric indication is common in many countries.1–3 In a Norwegian study, researchers found that 7.6% of the caesarean section was made on maternal request.2 In some countries there have been reports published that may have influenced this development.3 A UK report4 encouraged women to decide for themselves what type of care they would like, the place of delivery and the degree of intervention. The Audit Commission Report from UK announced that maternity care needed to be more women centred.5 A shift towards greater willingness to accept obstetric interventions appears to have occurred since the 1980s.6 Worry about labour pain has been found to be an important predictor for a first-time mother’s experience of pain.7

Whether or not a caesarean section should be carried out on maternal request is a controversial issue.8,9 Some researchers have stated that elective caesarean section is a safe and a psychologically well-tolerated procedure. The results are ‘comparable with an uncomplicated vaginal delivery and far superior to secondary interventions such as vacuum delivery or emergency CS’.10 Others express concerns of risk for increased maternal mortality and neonatal respiratory distress11,12 as compared with vaginal delivery.

Extreme fear of delivery affects the daily life of about 6% of pregnant women13 and approximately 10% of pregnant women in Sweden suffer from pathological fear of childbirth.14 The reasons mentioned for fear of childbirth are fear of pain, of pelvic floor injuries, of losing the baby, of losing one’s own life, of losing self-control and of being left without assistance during labour.15 Traumatic stress in relation to childbirth is defined as post-traumatic stress experienced before the expected event (childbirth). Traumatic stress related to a threatening forthcoming event and fear of childbirth correlate. High trait anxiety, depressive symptomatology, psychological/psychiatric counselling related to childbirth and self-rated psychological problems measured in early pregnancy have all been described as risk factors for traumatic stress and fear of childbirth in late pregnancy.16

Whether fear of childbirth and emergency caesarean section are related is unclear,14,17,18 but emergency caesarean section increases the risk of a negative birth experience.19 This could lead to a request for an elective caesarean section in future pregnancies or affect women’s willingness to have more children.

Maternal request for an elective caesarean section and fear of delivery are associated,2,3 but to our knowledge no report has been published that describes the prevalence of childbirth fear among women requesting a caesarean section. Hildingsson showed that a preference for caesarean section (in early pregnancy) was associated with medical diagnosis, age, parity, previous elective caesarean section and previous emergency caesarean section.20 An association between a negative experience during the first labour and fear of delivery in the next pregnancy and subsequent maternal requests for caesarean section has also been described19,21 in addition to a lower desire for more children.22

First-time mothers requesting a caesarean section are of special interest since they have no experience of childbirth. Reasons for childbirth fear in this group could be a history of abuse or stories of complicated deliveries among female relatives and friends. This group also differs from women planning vaginal deliveries; their personality is slightly different23 and they are older.20 Whether or not they have postponed their pregnancy due to fear of delivery has not been confirmed.

Evidence from a range of studies suggests that maternal psychosocial health can have a significant effect on the mother–infant relationship and that this in turn can have consequences for both the short- and long-term psychological health of the child.24–26 The suggestion that psychological factors might be associated with pregnancy outcome is of great interest, because it emphasises that midwives and obstetricians may be able to identify the risk of complications during labour through prenatal screening instruments, thereby, potentially reducing the incidence of complications during birth. The primary outcome of care during delivery is a physically healthy mother and infant, but psychosocial outcomes are also important. These include maternal satisfaction with birth, the mother–infant interaction, breastfeeding and feelings about future births.

There were two aims of the present study: to investigate if expectations of vaginal delivery differs between first-time mothers with a normal pregnancy requesting a caesarean section, first-time mothers with an elective caesarean section due to breech presentation and first-time mothers planning a vaginal delivery and to study the birth experience in the above-mentioned groups;

To study whether emergency caesarean section or delivery with vacuum extraction (VE) or forceps among women planning a vaginal birth affect the birth experience.

Material and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Study population

In a prospective cohort study design, 496 healthy first-time mothers with a normal pregnancy were recruited at gestational ages of between 37 and 39 weeks. In this paper, we will report data concerning expectations and experience of childbirth.

The women planning and giving birth with elective caesarean section were divided into two groups; caesarean section on ‘mother’s request’ (n= 104) and caesarean section for breech presentation (n= 128). Women who requested a caesarean section without any medical indication took part in a 1-h counselling session with an experienced obstetrician to discuss the advantages and disadvantages of vaginal birth versus caesarean section. Both groups were compared with women planning a vaginal birth (n= 264). In order to be able to measure differences in fear of childbirth and experience of birth related to the mode of delivery, the women planning a vaginal birth were divided into three subgroups depending on outcome: women who had a spontaneous vaginal delivery; women who underwent assisted vaginal delivery and women who had an emergency caesarean section.

Fourteen percent of the women in the group planning vaginal delivery (control group) underwent an emergency caesarean section and are referred to as ‘emergency caesarean section’ and 16% had an assisted delivery [vacuum extraction (VE)/forceps] and are referred to as ‘assisted vaginal delivery’.

The study was carried out between January 2003 and June 2005. Twice a week, during the study period, one of the researchers identified possible participants from the surgical schedule at the operating theatre. Exclusion criteria were women with a body mass index >30 or having psychiatric illness or who experienced complications during pregnancy. Two questionnaires revealing expectations and experiences of delivery were used. The participants answered the questionnaire late in their pregnancy and 3 months after birth.

The study was approved by the Research Ethics Committee of Karolinska Institutet and informed consent was obtained from all participants.

Assessments

After recruitment (i.e. when the elective caesarean section was already scheduled), each subject completed the first questionnaire. Women were instructed to rate their personal feelings and cognitions when thinking about a vaginal delivery on a six-point Likert scale with the end points ‘not at all… and extremely…’. The instrument used for this purpose was Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), an instrument measuring the degree of fear of childbirth or negative experience of delivery.27 Versions W-DEQ A and B were used. Both full versions have 33 items, each with a scoring range of 0–5. The minimum score is thus 0 and the maximum score is 165. The higher the score, the greater the fear of childbirth manifested. The questionnaires have been developed to measure a construct of fear related to childbirth during pregnancy and after delivery by asking the woman about her expectations before the delivery (version A) and experience after delivery (version B). In questionnaire B, measuring experience after birth, we used a modified version with 20 items that included only questions that were suitable both for women who had a caesarean section or who had a vaginal delivery.18 The minimum score on the 20-item modified version was thus 0, and the maximum was 100.

Statistical analysis

In W-DEQ A before the delivery (Expectations), the groups were compared using the 33-item version, namely mothers who expected a vaginal delivery; mothers with an elective caesarean section on request and mothers with an elective caesarean section due to breech presentation. In the analysis of experiences (W-DEQ B), five groups were compared: mothers who had a spontaneous vaginal delivery; mothers who expected a vaginal delivery but had an emergency caesarean section; mothers who expected a vaginal delivery but had an assisted vaginal delivery; mothers with an elective caesarean section on request and mothers with an elective caesarean section due to breech presentation.

All variables were summarised using standard descriptive statistics, for example, frequencies, means and SD. Differences between groups in expectations before and experiences of the delivery were analysed by one-way analysis of variance (ANOVA) with post hoc test using Tukey’s honestly significant difference correction. Relationships between expectations and experiences were expressed using Pearson’s product–moment correlation coefficients. The significance level was 5% (two-tailed) in all analyses.

A principal component analysis with Varimax rotation of the 33-item version of W-DEQ was performed. In accordance with Johnson and Slade,17 a four-factor solution was chosen. Four items with the highest factor loadings (i.e. correlations) in each factor were entered in an item analysis. Thus, the latent variables derived from the factor analysis were replaced by a manifest item, representing the factor. In the item analyses, differences in the scores were analysed with the chi-square test or Fisher’s exact test.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Dropouts

The total number of caesarean section among first-time mothers at the hospital during the study period on indication ‘maternal request’ was 204, of which 104 were included in the study. The total number of respondents can be seen in Figure 1. The chief reason for the large dropout before birth was the short time between the arrival of the posted questionnaire and the birth of the baby. There was; however, no significant difference in the proportion of dropouts between the groups (P < 0.36). The number of women answering both questionnaires A and B were 49 among those for the caesarean section on maternal request group, 69 for the caesarean section with breech presentation and 128 for controls. There were no statistically significant differences in dropouts between the groups in relation to age (P < 0.099), university education (P < 0.615), experience of poor health (P < 0.826) or smoking habits (P < 0.506). There was, however, a lower dropout rate among women who had undergone in vitro fertilisation (IVF) (P < 0.031).

image

Figure 1. Comparison between the groups on W-DEQ score in late pregnancy. ***P < 0.001.

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Socio-demographic background of the respondents

Women who requested caesarean section were more often born outside Sweden (P < 0.003) and they were older than women in the other groups (mean age 33.9 years versus 30.8 years, P < 0.001). The proportion of women with a university education did not differ between the groups (P < 0.6083). Fewer women requesting a caesarean section participated in parenthood education during pregnancy than women planning a vaginal birth (P < 0.001). These data have been published earlier.28

Factor analysis of the W-DEQ

The principal component analysis yielded a factor structure that was fairly invariant of the structure with the factor analysis by Johnson and Slade (Table 1) (15) explaining 57.4% of the total variance. The first component represents items measuring fear of childbirth; the second component, lack of positive anticipation of becoming a mother; the third component, losing control of oneself or behaving badly during the delivery; and the fourth component, the fantasies of injuring the child. Items with the highest factor loadings were called components. The four items with highest factor loadings (i.e. item 6 ‘I am very afraid of the delivery’; item 18 ‘I don’t feel happy at all’ item 25; ‘I am afraid of behaving badly’; and item 32 ‘I am afraid of losing the child’, were entered in the item analyses of expectations, while in the analysis of experiences item 25 was not included in the 20-item version of the W-DEQ B (24).

Table 1.  Factor analysis
Item numberItemComponenth2
IIIIIIIV
  • Factor labels: I, fear; II, lack of positive anticipation; III, isolation; IV, riskiness.

  • *

    Highest factor loadings are in bold, and factor loadings above 0.35 are underlined.

6Afraid0.73*0.18−0.270.100.65
4Not strong0.730.30−0.130.090.65
5Not confident0.720.15−0.290.160.65
17Not relaxed0.680.08−0.280.080.55
29Not natural0.650.370.290.040.64
22Not self-confident0.640.30−0.210.130.55
30Not obvious0.630.470.180.010.64
8Weak0.610.32−0.350.020.59
12Tense0.600.02−0.260.200.47
9Not safe0.600.39−0.160.170.57
26Not let happen0.590.14−0.150.210.43
10Dependent0.580.12−0.040.040.35
19Panic0.570.22−0.510.130.65
16Not composed0.570.17−0.40−0.010.51
2Frightful0.520.39−0.430.040.61
7Deserted0.510.21−0.380.010.44
31Dangerous0.490.31−0.220.290.47
18Not happy0.200.81−0.210.070.75
14Not proud0.130.78−0.160.020.66
13Not glad0.190.76−0.290.020.71
21Not longing for child0.040.74−0.01−0.080.55
1Not fantastic0.420.61−0.170.060.58
28Not funny0.430.570.010.040.51
23No trust0.380.54−0.130.180.49
15Abandoned0.370.49−0.440.170.60
3Lonely0.360.45−0.330.110.45
25Behave badly−0.08−0.150.67−0.180.51
24Pain−0.08−0.070.650.110.44
27Lose control−0.17−0.040.63−0.100.44
20Hopelessness−0.39−0.350.55−0.110.58
11Desolate−0.46−0.330.52−0.030.59
32Child die0.160.05−0.040.900.83
33Child injured0.230.02−0.100.890.85

Expectations of delivery

Expectations of delivery refer to vaginal delivery for all women independent of whether they were scheduled for caesarean section. In the ANOVA analysis there was a highly significant difference in negative expectations of delivery (F(2, 282) = 21.71, P < 0.001). The post hoc test revealed that women requesting a caesarean section had a significantly higher total score than those of the other four groups and more negative expectations than compared with the women in the other groups (Figure 1). The rate of women with a W-DEQ A score above 84, which has been used as a cutoff level for clinically significant fear of childbirth (24), was 13.2% in the vaginal group, 6% in the group with a caesarean section due to breech presentation and 43.4% in the caesarean section on maternal request group. Few mothers both in the vaginal group and in the group with a caesarean section due to breech presentation had total scores above 100, which is the cutoff level for very severe fear of childbirth (n= 8 or 5% and n= 2 or 3%, respectively). The corresponding frequency in the group requesting caesarean section was 28%, which was significantly higher (n= 15; χ2= 31.36, df= 2; P < 0.001) than the other two groups.

In the item analysis (Figure 2), mothers of the caesarean section group on maternal request were more afraid than the other groups (χ2= 34.45, df= 2; P < 0.001). They also felt less happy before the delivery (χ2= 6.18, df= 2; P= 0.046) and were more afraid that the child would die (χ2= 12.19, df= 2; P= 0.002). Mothers with a caesarean section due to breech presentation were more afraid of behaving badly during the delivery (χ2= 15.36, df= 2; P < 0.0016) than women in the other two groups.

image

Figure 2. Item analysis in late pregnancy. P < 0.001.

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Experiences of delivery

Experiences of delivery refer to the actual mode of delivery for all groups. Mothers of the two groups that expected a vaginal delivery, but who had an emergency caesarean section or assisted vaginal delivery, had more negative experiences of the delivery (Figure 3). The difference was statistically significant (F(4, 367) = 6.24, P < 0.001).

image

Figure 3. Comparisons between scores on W-DEQ after birth. ***P < 0.001.

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In the item analysis (Figure 4), the vaginal group was less afraid than the other groups. Furthermore, the two vaginal groups with complications were less happy during the delivery and were more afraid that the child would be injured. However, none of the post hoc analyses was statistically significant.

image

Figure 4. Item analysis after birth.

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Relationships between expectations and experiences of delivery

In the total group (participants answering both questionnaire A and B, n= 246) there was a weak, but significant, relationship between the expectations and the experiences of delivery (rxy= 0.31, P < 0.001). However, when the relationships were calculated for the separate groups, there was a stronger positive correlation in all groups (rxy > 0.40), that is, mothers with a positive expectancy also had a more positive experience of the delivery except for the mothers with an elective caesarean section on request where there was no significant relationship between expectancy and experience (rxy= 0.04, P= 0.781).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Expectations of delivery

Our sample consisted of first-time mothers. They are a group of special interest since they have no previous experience of childbirth. We found that few mothers, both in the vaginal delivery group and in the group with a caesarean section due to breech presentation, had total scores above 100, which is the cutoff level for severe fear of childbirth.27 The corresponding frequency in the group requesting caesarean section was significantly higher. Twenty-eight percent of the women requesting a caesarean section compared with 5% among women undergoing caesarean section due to breech presentation and 3% planning a vaginal birth (control group) had a score above 100. When the cutoff score was set at 85.8 (which indicates clinically significant fear of childbirth) 43.2% in the group with caesarean section on maternal request, 13.2% in the vaginal group and 9.6% in caesarean section group with breech presentation showed what is defined as childbirth fear. This indicates that many but not all women requesting a caesarean section suffer from childbirth fear. Possible explanations for this finding could be either that the fear is not the issue for all women requesting a caesarean section, or that the scale is not picking up their particular fears. It is also possible that the cutoff level for the scale needs adjusting. However, the W-DEQ instrument was developed and tested in clinical practice and in treatment studies and its reliability and validity have been established,27 and the level of women with childbirth fear in the vaginal delivery group in the present study accords with previous studies undertaken in a Swedish population.14

In a UK study where the W-DEQ instrument was also used, researchers found four items measuring distinct domains within childbirth fear.17 As our factor analysis was fairly invariant, when compared with this study, this could support the assumption that certain domains such as being ‘afraid’, ‘not relaxed’, ‘not self-confident’, ‘not happy’, ‘not proud’ or ‘not longing for child’ and being afraid that the ‘child would die or be injured’ are expressed more as frightening than others among pregnant women. One of the items found to differ significantly in our study and in the Johnson and Slade study17 was ‘fear of behaving badly during labour’. In our study, there was no difference in mean scores in this item between the vaginal delivery group and the group requesting a caesarean section (3.07 versus 3.13), but the score was higher in caesarean section group with breech presentation compared with the other groups (3.76) (Figure 2). This is difficult to explain. As the group we studied were first-time mothers, ‘fear of behaving badly’ is a construct that is not based on their own experience. It is possible that this apprehension is acquired from friends or relatives describing their experience of labour and birth.

Another item of importance found in both our study and the UK study of Johnson and Slade17 was fear of the child dying. In that study the two items related to injury and death of the child appeared to be separate factors, whereas in our study this was not the case. This may be related to differences in national perception of risk of death of a child in or around labour. In Sweden, the perinatal mortality is very low,26 but fear of the event may be higher. Sweden has a smaller population than the UK and when a baby is injured or dies during labour, the Swedish media may be more likely to report these events. Other Swedish studies on childbirth anxiety show that fear of loss of control and fear of death or injury of the infant is often mentioned as an item that concerns women during pregnancy15,28.

Experience of birth

Women planning a vaginal delivery but experiencing an emergency caesarean section or an assisted vaginal delivery had more negative birth experiences than the other groups. Our results are in agreement with those previously presented18 and support the clinical impression of this group as more vulnerable and probably in need of extra support postnatally. Women with a spontaneous vaginal delivery scored in a similar way on W-DEQ B as the group undergoing caesarean section on maternal request 35.2 versus 34.9 and the group of women who underwent an elective caesarean section due to breech who scored 32.7 (Figure 3). Theses differences were not statistically significant.

Experience of birth after emergency caesarean section and assisted deliveries

The rate of emergency caesarean section (14%) and assisted deliveries (16%) are in accordance with average figures in Sweden.29 These intervention rates are likely be related to the number of first-time mothers, the number of epidurals and the threshold for acting on prolonged labour. The rate of epidurals among primiparae was 50% at the hospital at the time when the study was conducted. In a population-based cohort study of epidural analgesia among primiparae in Sweden, the rate of assisted delivery was 18.8% in delivery units with a 50–59% frequency of epidural block use.29

Mothers of the two groups that expected a vaginal delivery, but experienced an emergency caesarean section or assisted vaginal delivery, had more negative experiences of the delivery than other groups (Figure 3). A negative experience and fear of an emergency caesarean section or an assisted instrumental delivery may lead to a request for elective caesarean section in future.2,19 Counselling of such women after delivery and in the next pregnancy may be ineffective unless the impact of childbirth fear and strategies chosen by these women, their effects on perception of mode of delivery and later adaptation to the newborn child are understood.

Previous studies have shown that women undergoing counselling due to fear of childbirth have a three to six times higher rate of elective caesarean section,12 but the rate of emergency caesarean section or a negative birth experience may not be higher.17 Almost one-third of the women with a preference early in pregnancy for caesarean section had an elective caesarean section and another 15% had an emergency caesarean section.17 Whether the former figure reflects difficulties of providing relevant treatment for childbirth anxiety or whether it is a reflection of a shift in paradigm among obstetricians towards an acceptance of elective caesarean section on maternal request or a combination of both is not known.

Limitations

In our study, the participants in both caesarean section groups knew that they would be delivered by elective caesarean section when they answered the W-DEQ A questionnaire. Even if they were asked to describe how they felt when thinking about a vaginal delivery, it is possible that the knowledge that they would not experience a vaginal delivery could have affected their answers. Since they knew that they would have an elective caesarean section, they did not have to ‘fake bad’ in their answers in order to have their wish for a planned caesarean section fulfilled.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Our study demonstrates that women requesting an elective caesarean section appear to often suffer from clinically significant fear of childbirth, but in over half of such women we not able to demonstrate such fear. Women subjected to complicated deliveries had a more negative birth experience, which emphasises the importance of postnatal support.

Women suffering from childbirth fear seem to be in need of better counselling and support. There is need to study whether there are certain factors that are expressed more clearly as frightening than others and also to study how effective counselling and care during pregnancy and childbirth should be carried out. The characteristics of women not suffering from childbirth fear, but requesting an elective caesarean section, and reasons for their request, clearly needs further study. There is a need for women undergoing emergency caesarean section or assisted vaginal delivery to have better postnatal support. Her first birth may embody a woman’s feelings towards giving birth and affect family planning, future pregnancies and deliveries.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

We would like to thank the County Council of Stockholm and BB Stockholm AB who supported the study.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

Journal club

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Journal club

This prospective group comparison cohort study examines expectations and experiences in women undergoing a caesarean section on maternal request and compares these with women undergoing caesarean section with breech presentation as the indication, and with those who intended vaginal delivery acting a control group. They also examined whether assisted delivery and emergency caesarean section in the control group affected the birth experience.

Discussion points

  • 1
    Background: Is there evidence that an elective caesarean section carries more risk to the mother than a planned vaginal delivery? What are the clinical and psychological factors that are known to be associated with a request for caesarean section?
  • 2
    Technical: Do you think that this study has examined a group of women who are representative of pregnant women in Sweden? Do you think the methods used in the study are appropriate? How important is the factor analysis component of the analysis? Do you think the results can be applied to the UK population?
  • 3
    Clinical practice: Are the two main findings of the study surprising to you? Would they alter your management of: (a) a woman who asks you for an elective caesarean section in her first pregnancy without a clear medical indication, and (b) your postnatal assessment and management of a woman who has undergone an unexpected emergency caesarean section?
  • 4
    Future research: How would you go about further investigating the factors that influence the request of a woman for an elective caesarean section in her first continuing pregnancy?

Correspondence: Dr M Marsh, Denmark Hill, London SE5 9RS, UK. Email michael.s.marsh@kcl.ac.uk