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Keywords:

  • Caesarean section;
  • vaginal delivery

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Objective  To quantify the risk of morbidity from vaginal delivery (VD) that pregnant women would be prepared to accept before requesting an elective caesarean section and to compare these views with those of clinicians.

Design  Cross-sectional survey.

Setting  Major teaching hospital (nulliparas and midwives) and national samples of medical specialists.

Sample  Nulliparas (n = 122), midwives (n = 84), obstetricians (n = 166), urogynaecologists (n = 12) and colorectal surgeons (n = 79).

Methods  Face-to-face interviews (nulliparas) and mailed questionnaire (clinicians).

Main outcome measures  Maximum level of risk participants would be prepared to accept before opting for an elective caesarean section for each of 17 potential complications of VD. Utility scores for each complication were calculated with higher scores (closer to 1) indicating a greater acceptance of risk.

Results  Pregnant women were willing to accept higher risks than clinicians for all 17 potential complications. They were least accepting of the risks of severe anal incontinence (mean utility score 0.32), emergency caesarean section (0.51), moderate anal incontinence (0.56), severe urinary incontinence (0.56), fourth-degree tears (0.59) and third-degree tears (0.72). The views of midwives were closest to those of pregnant women. Urogynaecologists and colorectal surgeons were the most risk averse, with 42 and 41%, respectively, stating that they would request an elective caesarean for themselves or their partners.

Conclusions  Pregnant women were willing to accept significantly higher risks of potential complications of VD than clinicians involved in their care. Pregnant women’s views were more closely aligned to midwives than to medical specialists.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Increasing rates of caesarean sections are a continuing concern for the obstetric and public health communites.1,2 Fears of maternal and neonatal morbidity from vaginal delivery (VD) may be encouraging this trend.

Although VD is the physiological mode of childbirth, it may be associated with significant short- and long-term complications, including neuropraxia of the pudendal nerves and direct trauma to pelvic floor and the anal sphincter.3–5

Pelvic floor injuries may cause pelvic organ prolapse and urinary and anal incontinence. There may be other maternal and neonatal complications associated with VD that can be costly and devastating for the woman and/or infant. In addition, there may be medico-legal implications for the obstetrician involved.6–13 Legally and ethically, women have the right to choose their management; however, caesarean section is not without morbidity and mortality.14 Hence, these factors need to be considered when discussing elective caesarean section as an option for childbirth.15

Instrumental VD, vacuum extraction and forceps-assisted delivery, and emergency caesarean section are all potential consequences from an attempted VD but are often omitted from studies evaluating VD outcomes.16

Various studies have canvassed a range of obstetricians’ opinions regarding their personal choice of mode of delivery and their willingness to perform caesarean section at patient request in the absence of an obstetric indication.14,17–20 Seventeen percent of London obstetricians (31% of female obstetricians) said that they would have an elective caesarean section in the absence of obstetric indications; their main concern was the risk of pelvic floor injuries.19 A more recent English survey found that 33% of obstetricians (19% of female obstetricians) would choose an elective caesarean section for themselves or their partner.21 In contrast to this, the same study showed that only 7% of midwives would choose an elective caesarean section. Clinicians in other countries may be less inclined to choose elective caesarean section for themselves, but many would perform it at patient request.14,17,18,20,22 Furthermore, 53% of obstetricians in Vancouver, Canada, felt that it was the woman’s right to elect for a caesarean section with no medical indication,23 and 62% of urogynaecologists in the USA24 support elective caesarean section to prevent the long-term consequences of urinary incontinence.

Thus, there are diverging views among different clinicians involved in childbirth with regard to performance of elective caesarean section and VD.21,23 In contrast, there is a paucity of information about the views of pregnant women on VD and elective caesarean section. This study was undertaken to ascertain which potential complications were important to and to measure the maximum level of risk of complications that pregnant women would be prepared to accept before opting for an elective caesarean section, knowing the potential risks of elective caesarean section. These views are compared with those of midwives and obstetricians as well as with two groups of surgeons who deal with the complications that may occur. As there is evidence that rates of elective caesarean section vary among women from differing socio-economic backgrounds,25 a further aim of this study was to determine whether risk acceptance was associated with personal characteristics of women.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Development of questionnaire for pregnant women

Following an extensive literature review and examination of local data on the rates of complications from VD, verbal scripts were developed to describe the following clinical scenarios and their consequences to the mother: pain during labour, delivery and postpartum; prolonged labour (first stage>12 hours and second stage >3 hours); instrumental delivery; emergency caesarean section; perineal pain; superficial (first and second degree) and deep tears (third and fourth degree); sexual dysfunction (lasting longer than 6 months); and long-term urinary incontinence, vaginal prolapse and faecal incontinence. A detailed explanation of caesarean section and its possible complications (major abdominal surgery, anaesthesia requirements, wound pain and need for more analgesia, decreased mobility, longer hospital stay, inability to drive for 6 weeks; increased risk of uterine, pelvic and bladder infection, wound breakdown, blood loss, transfusion, thrombosis; potential risks in future pregnancies, placenta accreta, uterine scar rupture; and neonatal respiratory problems with potential neonatal intensive care unit admission, jaundice, and temporary feeding difficulties) were also developed to closely reflect the information that would be provided by a clinician when obtaining informed consent. Scripts were reviewed by an obstetrician, a midwife, a colorectal surgeon and an urogynaecologist to ensure that appropriate correct and standardised information was given to all women.

The scripts were incorporated into an interviewer-administered questionnaire for pregnant women that elicited the maximum level of risk of each complication that participants would accept from VD before opting for an elective caesarean section, knowing the risks of a caesarean section. The values were recorded on a scale from 0 to 100%. This was based on a validated prospective measure of preference method described in previous trials.26–28

The questionnaire also elicited demographic data, type of antenatal care, obstetric history (miscarriages, ectopics and terminations) and the mode of delivery the pregnant woman planned to have if her pregnancy was uncomplicated. Questions pertaining to the willingness of pregnant women to be involved in a hypothetical randomised controlled trial (RCT) of VD versus elective caesarean section were also asked but will be reported separately.

Research assistants (RAs) were trained by a clinical research psychologist and an obstetrician to explain the scenarios, to assess whether women had adequate understanding of the issues, to respond to patients’ questions and to administer the questionnaire in a standardised, reliable manner. Prior to the main study, the study methodology and questionnaire was pilot tested with a small sample. These pilot interviews were audiotaped and reviewed by a panel of obstetricians, midwives and a medical psychologist to ensure that the information provided to women was consistent with current evidence and clinical advice and that the quantification of acceptable risk was conducted in a reproducible manner.

Nulliparous women with a singleton uncomplicated pregnancy, within the first 26 weeks of their pregnancy were eligible to participate. Those who had a high-risk pregnancy (hypertension, high body mass index, diabetes or pre-existing medical conditions), did not speak fluent English, were illiterate, under 16 years of age or cognitively impaired were excluded from the study. To minimise selection bias, we recruited consecutive women, on specified study days, from antenatal clinics (public hospital clinics and private obstetrician rooms) based at one major teaching centre in Sydney, Australia. All obstetricians with private admitting rights to the hospital were approached requesting permission to enlist their patients.

A self-administered questionnaire for clinicians, including the same 17 potential complications of VD was developed from the patient questionnaire. In this, clinicians were asked to respond as if they themselves or their partner were pregnant.

Specialists were identified from the membership lists of their respective professional bodies. All urogynaecologists throughout Australia and New Zealand were identified from the membership register of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG); all colorectal surgeons in Australia and New Zealand were identified from the membership list of the Colorectal Surgical Society of Australia and New Zealand; due to their larger numbers, only the obstetricians in New South Wales (NSW) were identified from the RANZCOG register (NSW branch). Doctors were mailed a copy of the questionnaire and received up to three reminders according to a standardised follow-up protocol.

Information needed to contact midwives was not available secondary to privacy concerns so questionnaires were distributed directly to midwives on the wards within Royal Prince Alfred Hospital, Sydney.

Sample size

We calculated that 49 participants would be needed in each group to detect a moderate effect size of 0.25 between groups, with 80% power and a 5% significance level. The sample size for women (n = 100) was determined to provide adequate power to achieve the second aim of this study addressing RCT participation (reported separately).

Statistical analysis

Proportions for categorical data and means for age were used to describe demographic data. Participants’ responses indicating the maximal level of risk (from 0 to 100%) that they would accept before opting for an elective caesarean section were converted to utility scores that ranged from 0 to 1. A number close to 1 represents a high threshold for that particular complication or outcome occurring, whereas a number closer to 0 represents a low threshold for that risk. Thus, the utility scores reflect participants’ strength of preference to avoid the particular outcome. The group mean utility scores were calculated for each potential complication of VD. Associations between utility scores and demographic and personal characteristics of respondents (age, marital status, level of education, employment status, type of antenatal care chosen, public/private insurance status and preferred mode of delivery) were investigated using Wilcoxon rank-sum tests for nonparametric data. Kruskal–Wallis tests were used to compare utilities between groups. A separate analysis of utilities for female respondents only also was undertaken.

Ethics approval

Approval was obtained from the ethics committees of the University of Sydney and of the Sydney South West Area Health Service prior to commencing the study.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Of 193 pregnant women who attended the clinics on study days, 33 were not eligible (30 had insufficient spoken English, two were multiparas and one had a high-risk pregnancy) and 58 were not willing to participate leaving a sample of 102. Two of 12 obstetricians with private admitting rights to the hospital allowed the RAs to be present in their rooms to approach women for recruitment, and the other women were recruited in the public antenatal clinics. The consent rate for pregnant women was 64% in the public clinic and 60% in the private rooms. The mean age of participants was 31 years, 82% had tertiary education and 37% were privately insured. Eighty-four of 165 midwives (51%), 166 of 319 (52%) obstetricians, 12 of 22 urogynaecologists (55%) and 79 of 142 (61%) colorectal surgeons completed the questionnaire.

The mean gestational age of the women at time of participation was 22 weeks, 93% of whom were planning to have a VD, 2% were considering an elective caesarean section and 5% were undecided at the time of participation. Characteristics of pregnant women and clinicians are shown in Table 1. Many clinicians had previously had more than one delivery, and as these were often different types, the total number of deliveries may exceed the number of subjects.

Table 1.  Characteristics of pregnant women
 Pregnant women (n = 102), n (%)Midwives (n = 84), n (%)Obstetricians (n = 166), n (%)Urogynaecologists (n = 12), n (%)Colorectal surgeons (n = 87), n (%)
  1. GP, general practitioner/family physician; SVD, spontaneous vaginal delivery.

Sex
Male3 (5)126 (76)9 (75)80 (92)
Female102 (100)80 (95)39 (23)3 (25)7 (8)
Marital status
Single3 (3)25 (30)16 (10)01 (1)
Married/de facto98 (96)50 (60)139 (84)11 (92)76 (87)
Divorced 6 (7)9 (5)02 (2)
Widowed 3 (4)2 (1)02 (2)
Education level
Up to secondary17 (17) 
Tertiary84 (82) 
Employment
Full time72 (71) 
Part time13 (13) 
Unemployed2 (2) 
Home duties10 (10) 
Student5 (5) 
Insurance status
Public65 (64) 
Private37 (37) 
Type of antenatal care
Midwife clinic36 (35) 
Shared GP care50 (49) 
Obstetrician only15 (14) 
Undecided1 (1) 
Type of previous delivery(ies)
SVD 34 (40)101 (61)6 (50)48 (55)
Instrumental vaginal 12 (14)49 (30)6 (50)65 (75)
Elective caesarean section 6 (7)18 (11)2 (17)21 (24)
Emergency caesarean section 8 (10)29 (17)011 (13)
No deliveries 35 (42)20 (12)1 (8)9 (10)
Mean gestational age (range)22 
Mean age (range)31 (21–43)42 (25–65)50 (33–78)50 (42–64)47 (33–69)
Mean years in practice (range)14 (0–35)19 (1–54)20 (3–35)12 (1–42)

Midwives and obstetricians were more likely to aim for a spontaneous vaginal delivery compared with colorectal surgeons and urogynaecologists (Table 2). There was a statistically significant difference in the proportion of each group who would opt for an elective caesarean section in a future pregnancy: pregnant women (2/102, 2%, 95% CI 0.3–7.6), midwives (9/84, 11%, 95% CI 5.3–19.8), obstetricians (35/166, 21%, 95% CI 15.3–28.2), colorectal surgeons (36/87, 41%, 95% CI 31.1–52.4) and urogynaecologists (5/12, 42%, 95% CI 16.5–71.4) (χ2= 55.1, df = 4, P < 0.0001).

Table 2.  Type of delivery participants would aim for
 Pregnant women, n (%)Midwives, n (%)Obstetricians, n (%)Urogynaecologists, n (%)Colorectal surgeons, n (%)
  1. SVD, spontaneous vaginal delivery.

SVD95 (93)71 (86)120 (78)4 (50)38 (48)
Labour ward, SVD87 (85)30 (36)108 (69)4 (50)38 (48)
Birth centre, SVD8 (8)40 (48)11 (7)00
Home birth1 (1)1 (1)
Elective caesarean section2 (2)8 (10)32 (21)4 (50)35 (44)

Utilities of pregnant women

The ranking of mean utility scores for pregnant women is presented in Table 3. These women were most concerned with severe anal incontinence; a low score (0.32) indicating that they were willing to take the least risk of this outcome occurring before they would opt for an elective caesarean section. In contrast, the high scores for perineal discomfort (0.94), pain during labour (0.92), superficial tears (0.92) and prolonged labour (0.87) indicated that pregnant women would accept an extremely high risk of these outcomes.

Table 3.  Comparison between groups of mean utility scores (ranking)
ScenarioPregnant womenMidwivesObstetriciansUrogynaecologistsColorectal surgeonsP value
  • AI, anal incontinence; UI, urinary incontinence.

  • *

    Deeper tears: third and fourth degree.

  • **

    Superficial tears: first and second degree.

Severe AI0.32 (1)0.15 (1)0.03 (1)0.05 (1)0.02 (1)<0.001
Severe UI0.51 (2)0.23 (2)0.10 (2)0.08 (2)0.04 (2)<0.001
Moderate AI0.56 (3)0.24 (3)0.10 (2)0.07 (2)0.09 (3)<0.001
Emergency caesarean section0.59 (4)0.62 (9)0.49 (11)0.49 (10)0.33 (10)<0.001
Vaginal prolapse0.71 (5)0.36 (4)0.34 (7)0.28 (7)0.24 (6)<0.001
Deeper tears*0.72 (6)0.39 (5)0.21 (4)0.21 (6)0.14 (4)<0.001
Forceps delivery0.73 (7)0.63 (11)0.41 (12)0.48 (12)0.41 (8)<0.001
Moderate UI0.75 (8)0.39 (5)0.22 (4)0.17 (4)0.14 (5)<0.001
Vacuum extraction0.79 (9)0.72 (13)0.66 (17)0.65 (13)0.40 (12)<0.001
Mild AI0.81 (10)0.42 (7)0.24 (6)0.15 (4)0.24 (7)<0.001
Sexual dissatisfaction0.82 (11)0.63 (9)0.41 (8)0.39 (9)0.40 (11)<0.001
Episiotomy0.84 (12)0.77 (14)0.71 (16)0.74 (14)0.46 (13)<0.001
Mild UI0.84 (12)0.56 (8)0.44 (9)0.37 (7)0.28 (9)<0.001
Prolonged labour0.87 (14)0.68 (12)0.44 (10)0.49 (11)0.47 (13)<0.001
Superficial tears**0.92 (15)0.89 (17)0.83 (17)0.79 (17)0.53 (15)<0.001
Pain during labour0.92 (15)0.86 (15)0.63 (13)0.71 (15)0.60 (16)<0.001
Perineal discomfort0.94 (17)0.86 (16)0.66 (14)0.66 (16)0.68 (17)<0.001

Concern about prolonged labour was an outcome associated with level of employment and the type of antenatal care chosen. Women who were in paid employment had a greater mean utility score for prolonged labour compared with those who were not in paid employment (0.89 versus 0.77, t = 2.10, 100df, P = 0.04). Women who were seeing a private obstetrician had a mean utility score of 0.94 for prolonged labour compared with 0.85 for women attending the public clinic (t = 2.35, 35.5df, P = 0.02). There were no significant associations between education level or medical insurance status and mean utility scores.

Women who elected to have a caesarean section or were still undecided accepted significantly lower levels of risk in 7 of the 17 variables assessed (Table 4).

Table 4.  Comparison of mean utility scores of pregnant women by mode of delivery aimed for SVD or other
ScenarioSVD (n = 95)Elective caesarean section or undecided (n = 7)P value
  1. AI, anal incontinence; SVD, spontaneous vaginal delivery; UI, urinary incontinence. Bold values show statistically significant P values (< 0.05).

Perineal discomfort0.960.820.003
Pain during labour0.920.820.2
Prolonged labour0.890.610.01
Superficial tears0.940.660.006
Deeper tears0.740.440.04
Episiotomy0.850.670.3
Vacuum extraction0.810.520.05
Forceps delivery0.750.440.09
Emergency caesarean section0.600.410.1
Sexual dissatisfaction0.830.690.09
Vaginal prolapse0.740.280.003
Mild UI0.870.540.01
Moderate UI0.770.500.08
Severe UI0.530.300.08
Mild AI0.820.640.04
Moderate AI0.570.440.4
Severe AI0.330.190.2

Comparison of utilities of pregnant women with those of clinicians

When the distributions of utility scores in each of the four clinician groups were compared, there were statistically significantly differences for all risks assessed. Midwives were always prepared to take the greatest risks and colorectal surgeons the least (Table 3). Severe anal incontinence was ranked first by all groups, but the mean utilities for obstetricians, urogynaecologists and colorectal surgeons were 0.05 or less compared with 0.15 for midwives and 0.32 for pregnant women. Emergency caesarean section was ranked fourth by the pregnant women but was ranked at least ninth by clinicians, with mean utilities ranging from 0.33 for colorectal surgeons to 0.62 for midwives and 0.59 for pregnant women.

Associations with clinician utilities

Clinicians who were married or living as married had a significantly lower mean utility scores than the non-married for emergency caesarean section (P = 0.03), superficial tears (P = 0.03) and severe anal incontinence (P = 0.04), but there were no other significant associations between marital status and study outcomes. Compared with those with no children, clinicians who had had children had a significantly higher mean utility score for vaginal prolapse (P = 0.02). Female clinicians had significantly higher utility scores than males for 15 of the 17 scenarios (data available from authors). The rank order of utility scores for female participants in each group is compared in Table 5. Actual utility scores are not reported to preserve the confidentiality of responses in small groups.

Table 5.  Rank order of mean utility scores, by group, for female participants
ScenarioPregnant womenMidwivesObstetriciansUrogynaecologistsColorectal surgeonsSignificance of difference in mean scores P value
  1. AI, anal incontinence; UI, urinary incontinence; (=), equal ranking. Bold values show statistically significant P values (< 0.05).

Severe AI11111<0.001
Severe UI22332<0.001
Moderate AI33224<0.001
Emergency caesarean section411119 (=)90.06
Vaginal prolapse54776<0.001
Deeper tears65443<0.001
Forceps delivery7912105<0.001
Moderate UI86567 (=)<0.001
Vacuum extraction9131711 (=)130.3
Mild AI107657 (=)<0.001
Sexual dissatisfaction1110811 (=)14<0.001
Episiotomy12 (=)141511 (=)11<0.001
Mild UI12 (=)8109 (=)10<0.001
Prolonged labour14129812<0.001
Superficial tears15 (=)171611 (=)150.002
Pain during labour15 (=)151411 (=)16<0.001
Perineal discomfort17161311 (=)17<0.001

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Our findings demonstrate that women are able to quantify the risks of VD they would be prepared to accept before they would request an elective caesarean section. Compared with clinicians, pregnant women tend to have a much higher threshold for the potential complications of VD, especially those associated with the pelvic floor. Anal incontinence was the potential complication with the lowest utility score for pregnant women. All groups ranked pelvic floor problems fourth of the top five reasons for preferring an elective caesarean section over VD. Pregnant women’s views more closely resembled those of midwives than those of other clinicians.

Most published papers have surveyed a variety of clinicians on their opinions about request for primary elective caesarean section, why they would agree to or refuse such a request and their practice patterns.14,17–24,29,30 There has been a questionnaire-based survey of women’s views on elective caesarean section,31 a longitudinal observational study to establish whether preference for elective caesarean section changes as gestation advances32 and a critical review of the literature on request for caesarean section.33 To our knowledge, this study is the first published paper to evaluate utility scores for the potential risks of VD, to compare women’s and clinicians’ views and to quantify the particular factors that would prompt a woman to request a primary elective caesarean section.

Only 2% of the pregnant women in our study were considering elective caesarean section with no obstetric indication. This rate is similar to the rate of 0.3–14% reported in a recent review regarding women’s preferences and request for caesarean section.33 By comparison, in our study, 10% of midwives and 21% of obstetricians would request an elective caesarean section where they (or their partners) to have a future delivery, results not dissimilar to those of midwives and obstetricians in surveys performed in the UK.19,21 Colorectal surgeons and urogynaecologists were much more likely to request an elective caesarean section, 44 and 50%, respectively. Similarly, a survey of American urogynaecologists found that 80.4% supported performing elective caesarean section for long-term prevention of urinary incontinence.24 Perhaps, this is because there is some evidence suggesting that elective caesarean section may be protective in preventing stress urinary incontinence,34,35 although others suggest that this evidence is weak.36 By comparison, in the same American survey, Materno–Fetal Medicine (MFM) specialists were 3.4 times less likely to agree to perform a primary elective caesarean section.24 MFM and general obstetricians are more involved in direct obstetric care and regard elective caesarean section as having a higher rate of maternal morbidity and mortality than VD,37 and the incidence of pelvic floor complications is low.

In general, nulliparous pregnant women in this study were least willing to accept severe urinary incontinence and moderate and severe anal incontinence. Interestingly, however, the level of risk they were willing to accept was higher than the reported prevalence of such outcomes, for example the 0.3–6% reported rate of third- and fourth-degree tears38–40 versus the 72% risk women in our study were willing to accept. When the women were informed of these rates at the end of the interview, they felt generally relieved.

Many participating nulliparous women did not know that anal incontinence was a possible outcome of VD unlike urinary incontinence, which is generally recognised as a potential complication of childbirth. Whereas the latter is discussed in antenatal classes and in the general community, anal incontinence is not.41 In addition, one survey from the UK found most trainee doctors and midwives were unaware that anal incontinence was a possible consequence of VD.42 However, notwithstanding the catastrophic consequences of such a complication, the incidence is extremely low and the evidence for caesarean section preventing anal incontinence is weak.43 Nelson found that 198 caesarean sections would need to be performed to prevent one case of anal incontinence and that such incontinence is more likely to be caused by pregnancy than by mode of delivery.

Among clinicians, midwives had the highest mean utility scores and colorectal surgeons the lowest. This could be due to the predominance of female fellows among midwives, as female clinicians would accept significantly higher risks of all outcomes except for vaginal prolapse. Gender also appears to play a role in the willingness of clinicians to perform elective caesarean section. An American College of Obstetricians and Gynaecologists survey found that female fellows were more negative towards caesarean section on request than male fellows, stating that caesarean section involved more risks and fewer benefits. In contrast, among a Dutch cohort of obstetricians and gynaecologists, there was no gender difference in willingness to perform a primary elective caesarean section.30

Pregnant women had low utility scores for emergency caesarean section as an outcome of VD and were more likely to request an elective caesarean section to prevent having an emergency caesarean section. However, they were prepared to accept a much higher likelihood of emergency caesarean section than the participating clinicians. This may be because the experience of labour is important, even if it is unsuccessful.44 The women ranked emergency caesarean section as the 4th most important reason for requesting caesarean section, whereas clinicians ranked emergency caesarean section from 9th to 11th in their scoring.

Although numbers were small, there was a statistically significant association found between the mode of delivery planned and the type of antenatal care women were receiving. Women seeing a private obstetrician during their antenatal period were more willing to have a prolonged labour than those attending public antenatal clinics. The clinical significance of this finding is uncertain, but it may be that the women attending a private obstetrician trust their obstetrician to make an appropriate decision while managing their delivery. This may be a similar scenario to that discussed by Beechler and Steinmetz45 in the care of the critically ill. They argued that patients would trust and take notice of the primary physician whom they have known for more than 1–2 days and with whom they have previously established a relationship of trust.

There were no significant associations between mean utility scores and the level of education, employment or private medical insurance. Other studies have also shown that these variables do not affect the women’s choice for caesarean section instead of VD.46

The caesarean section rate has risen in most developed countries over the past 10–15 years partially because of maternal request and lower thresholds among physicians to perform the operation due to increasing levels of litigation. Florica et al.47 found an increase in caesarean section over a 5-year period to be due to suspected fetal distress, maternal request and labour dystocia. Our study demonstrates that low-risk obstetric women are more accepting of many of the risks of VD than clinicians. However, when faced with the alternative choices of potential severe complications either for themselves or for their baby from VD, many will preferentially choose delivery by caesarean section.48

Strengths of our study include the identification of representative samples of a broad group of specialists who are involved with the management of labour and its complications, as well as the involvement of consecutive pregnant women attending routine antenatal visits. However, we acknowledge a number of limitations. The response rates for the surveys (although this is similar to the response rates of other studies) leave potential for selection bias. The nonresponders may be a different group. Some clinicians may have declined to allow their patients to be approached as they may have thought that introducing some of the rare complications from VD and presenting them in this way to nulliparous women could precipitate requests for elective caesarean section and also introduce the ‘fear’ factor, which may even hinder and slow down the progress of labour. Furthermore, as the samples of midwives and pregnant women were derived from a single maternity unit at a tertiary centre, the views of these participants may not be representative of the broader community. Although our statistical analyses addressed only a priori hypotheses, we also acknowledge the potential for false-positive findings with the use of multiple tests of statistical significance.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

We have shown that both pregnant women and clinicians are able to quantify the different levels of potential risks (utility scores) they would be prepared to accept before requesting an elective caesarean section, while being aware of the potential complications of elective caesarean section.

All groups were most risk averse for severe anal and urinary incontinence. Acceptance of other risks varied among clinician groups. A study to assess whether women’s views change following delivery is currently underway.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

C.E.T., J.M.Y. and M.J.S. were the main contributors to the conception, design, analysis, interpretation of data and preparation of manuscript. J.L., H.P. and C.B. advised on the original design and carrying out of the study and reviewed the manuscript.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Approval was obtained from the ethics committees of the Sydney South West Area Health Service (Ref. No. X06-0097, 14 June 2006) and of the University of Sydney (Ref. No. 9434, 28 July 2006) prior to commencing the study.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Funding from the University of Sydney and the Colorectal Training Board of Colorectal Surgical Society of Australia and New Zealand and RACS by the award of the Notaras scholarship.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

The authors would like to thank all the pregnant women and clinicians who participated in the study. Dr Anthony Frumar and Dr Karuna Raja who provided patients. Christine Merlino, Rachael Roberts and Pauline Byrne for helping with interviews and data collection. Funding from the University of Sydney and the Training Board of the Colorectal Surgical Society of Australia and New Zealand and Royal Australasian College of Surgeons (RACS) by the award of the Notaras Scholarship to C.E.T.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  14. Supporting Information

Additional Supporting Information may be found in the online version of this article.

Appendix S1. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. Clinician questionnaires.

Appendix S2. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. Antenatal questionnaires completed by participating women during face-to-face interview with a research assistant.

Please note: Blackwell Publishing is not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

FilenameFormatSizeDescription
BJO_1892_sm_AppendixS1.doc88KSupporting info item
BJO_1892_sm_AppendixS2.doc98KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.