Choice and birth method: mixed-method study of caesarean delivery for maternal request

Authors


Dr C Kingdon, Research Fellow, Department Midwifery Studies, University of Central Lancashire, Preston PR1 2HE, UK. Email ckingdon@uclan.ac.uk

Abstract

Objective  To explore whether women view decision-making surrounding vaginal or caesarean birth as their choice.

Design  Longitudinal cohort study utilising quantitative (questionnaire, routinely collected data) and qualitative (in-depth interviews) methods simultaneously.

Setting  A large hospital providing National Health Service maternity care in the UK.

Sample  Four-hundred and fifty-four primigravid women.

Methods  Women completed up to three questionnaires between their antenatal booking appointment and delivery. Amongst these women, 153 were interviewed at least once during pregnancy (between 24 and 36 weeks) and/or after 12 moths after birth. Data were also obtained from women’s hospital delivery records. Descriptive statistical analysis was performed (survey and delivery data). Interview data were analysed using a seven-stage sequential form of qualitative analysis.

Results  Whilst many women supported the principle of choice, they identified how, in practice their autonomy was limited by individual circumstance and available care provision. All women felt that concerns about their baby’s or their own health should take precedence over personal preference. Moreover, expressing a preference for either vaginal or caesarean birth was inherently problematic as choice until the time of delivery was neither static nor final. Women did not have autonomous choice over their actual birth method, but neither did they necessarily want it.

Conclusions  The results of this large exploratory study suggest that choice may not be the best concept through which to approach the current arrangements for birth in the UK. Moreover, they challenge the notion of choice that currently prevails in international debates about caesarean delivery for maternal request.

Introduction

In the past, the relationship between healthcare professionals and their patients has been described as largely paternalistic.1 Today, the century old adage ‘doctor knows best’ has been superseded by the principle of ‘patient choice’ in public and private healthcare systems across the developed countries of the western world. In all medical specialties, the principle of patient autonomy has become aligned with a notion of choice, which aims to place doctor and patient in a consumerist relationship.2 In obstetrics however, whilst place of birth, presence of support person and types of pain relief are widely accepted as matters for the expectant mother’s choosing, her role in decision-making surrounding actual birth method is the source of ongoing, intense debate. Obstetricians worldwide have identified the idea of caesarean delivery on maternal request (CDMR) as a contemporary ethical controversy.3

Caesarean delivery on maternal request has been defined as a subset of elective caesarean section (CS), performed not by medical necessity or indication, but on the request of the pregnant woman.4 Since the mid-1990s, a succession of articles in peer-reviewed journals and the print media have reported women’s preference,5–13 clinician’s views,14–17 or estimated the contribution of CDMR to rising national CS rates.18,19 The convenience of being able to schedule a planned CS, avoidance of the pain associated with labour, alleviation of the risk of damage to the perineum during vaginal delivery, and a fear of vaginal birth, are suggested as reasons why this method of birth may be becoming more acceptable to women.20 Globally, reported rates of CDMR range from 48%9 to <1%13 depending on the definition of CDMR used, specific population studied, timing and method of data collection.7 In the United Kingdom (UK), prospective surveys of pregnant nulliparous women suggest between 3.3%11 and 12%10 would prefer CDMR. A recent survey of European obstetricians’ willingness to perform CDMR found that compliance with a hypothetical woman’s request simply because it was ‘her choice’ to be highest (79%) in the UK.17

In the UK, the vast majority of births take place within the National Health Service (NHS), with <0.5% occurring in the private sector.21 Choice has been an enduring theme in NHS maternity care policy since 1993.22 The present UK government aims to introduce choice across the NHS,23 as well as reinstating its centrality to maternity care.24 The national guideline for CS includes the practice recommendation that an individual clinician, when faced with a request for CDMR has the right to decline such a request, but out of respect for the woman’s decision, she should be offered referral for a second opinion.25 We aimed to explore the views and experiences of a cohort of women accessing NHS maternity care for the first time, to identify how they report decision-making surrounding birth method.

Methods

Study sample

We undertook this study with women accessing the largest single hospital providing NHS maternity care in England. The hospital is in Liverpool in the North West of England and has approximately 8000 births per annum. It has an on-site midwifery-led-unit and an obstetric consultant-led delivery suite. At the study outset the hospital’s spontaneous vaginal delivery rate was 67.5% and the CS rate was 20.9%,26 which was consistent with national figures at the time.11 Of the 1216 caesarean deliveries 59.2% were emergency procedures and 40.7% were elective operations. No figures were available for the incidence of CDMR. Women, who booked for antenatal care between November 2001 and February 2004, were sent a study information sheet with their routine antenatal clinic appointment letter. All potentially eligible women were identified by hand searching hospital records. The inclusion criteria was primigravid women accessing care at the study hospital, who were English speaking and aged over 16 years of age. Women were excluded if they had previously experienced a live birth after 24-week gestation or more than three spontaneous or medical abortions, if a multiple pregnancy was identified, they experienced a miscarriage or stillbirth, they booked late (>18 weeks), transferred care to another provider, had an acute psychiatric illness or were known substance abusers. A total of 619 women were approached to participate of whom 454 provided written informed consent. Research Ethics Committee and Research and Development approval was obtained.

Study design

We conducted a longitudinal cohort study, using quantitative (questionnaires, routinely collected data) and qualitative (in-depth interviews) mixed methods simultaneously. The study was designed to follow the same women from early pregnancy up to 12 months after their first experience of childbirth. Prospective survey and interview data were collected from women at a number of time-points during pregnancy and after birth (see Figure 1). Routinely collected data from hospital records were also accessed to provide information about actual birth method.

Figure 1.

 Algorithm for Longitudinal Study Cohort.

The questionnaires used were adapted for the study from a questionnaire used in a previous national study,11 which surveyed the views of 2475 women (1114 of whom were expecting their first baby). Questions included ‘How would you prefer to give birth to this baby?’ (Table 2 lists the six options available to women in response to this question) and how strongly do you agree or disagree with the statement ‘I would like a birth that will allow me to plan the date my baby is born’, for example (see Figures 2 and 3 for list of other statements). All questionnaires incorporated free-text boxes for additional comments. The first questionnaire was distributed when women attended their first antenatal hospital appointment (abbreviated hereafter as the ‘booking’ questionnaire). The rationale for distributing the questionnaire at this point was to ascertain women’s views prior to any regular contact with maternity services. Women completed this questionnaire whilst they waited in clinic or they took it home and returned it by post. All subsequent questionnaires were mailed to respondents’ homes and returned by post. The rationale for distributing further questionnaires in the second and third trimesters (hereafter the ‘24-week questionnaire’ and the ‘36-week questionnaire’) was to assess temporal changes. Prior to questionnaires being sent, medical records were checked to ensure questionnaires were not sent to women who had miscarried or experienced a stillbirth. Women who did not initially respond received a reminder 2 weeks later and a further questionnaire after another 2 weeks.

Table 2.   ‘How would you prefer to give birth to this baby?’ Responses of subset of women who returned all three antenatal questionnaires
 Booking (n = 209)
n (%)
20–24 weeks (n = 209)
n (%)
32–36 weeks (n = 207)
n (%)
I would prefer to give birth vaginally143 (68.4)154 (73.7)167 (80.7)
I would prefer to have a planned CS7 (3.3)2 (1.0)4 (1.9)
Haven’t thought about it7 (3.3)4 (1.9)0 (0)
I do not have a preference24 (11.5)22 (10.5)13 (6.3)
I don’t know14 (6.7)6 (2.9)2 (1.0)
My preference is dictated by medical reasons14 (6.7)21 (10.0)21 (10.1)
Figure 2.

 Maternal preferences at 36-week gestation: ‘I would like a birth that…’.

Figure 3.

 Maternal views on childbirth at 36-week gestation.

Women who participated in the quantitative components of the study were sent a postal invitation during the 16th week of their pregnancy to return if they were happy to participate in semi-structured interviews during the 24th and/or 36th week of their pregnancy. The rationale for interviewing women at 24-week gestation was that by this point they would have adjusted to their pregnancies and begun to form views about different birth methods. Interviews at 36 weeks were also considered important as by this gestation women would be preparing to give birth imminently. Moreover, the option of two antenatal interviews facilitated an in-depth exploration of how women’s views change as pregnancy progresses. The sampling strategy for the antenatal interviews was pragmatic reflecting the longitudinal nature of the study. Interviews were undertaken at a time and place most convenient for the women; questionnaires were completed and returned separately. Women were also sent a postal invitation to be interviewed 12 months after birth, following confirmation of child health status by the General Practitioner. This final time-point was chosen to explore women’s views and experiences of different birth methods because existing research suggests that in the short term (<6 months) women’s assessments may be overtly optimistic, less relevant to overall experience and less likely to criticise care-givers, whilst in the long term (1 year or more) women usually describe aspects of their labours and birth consistently, despite some lapses or errors in their memories of specific details.27,28 It was also anticipated that some women would be planning a second pregnancy and birth method by this time. In the postnatal period, a purposive sampling strategy was employed weighted by actual method of delivery. Medical data on delivery method in the women’s first pregnancy were downloaded from the hospital information system and cross-checked with hand-written notes. These data were cross-referenced with postnatal interview transcripts.

Data analysis

Numerical data from the three questionnaires and the routinely collected medical records were double entered into the Statistical Package for Social Scientists (SPSS, Chicago, IL, USA) version 13.0. Descriptive statistical analysis was undertaken for the demographic and survey data.

Qualitative interviews were audio-taped and all 153 tapes transcribed verbatim. A modified seven-stage sequential qualitative analysis29 was then undertaken; this in-depth process took 18 months to complete. The particular sequence of analysis used was adapted from an earlier study.30 Key terms in the text were highlighted (step 1) and then key phrases were reinstated (step 2). A mixture of a priori (previously identified) and in vivo (data driven) approaches to coding was used. Labels were attached to key phrases and then, in a variant of pattern coding, the key phrases were reduced to create clusters (step 3). This step was done several times, as different clustering patterns were tried. Following detailed discussion between CK, VS and TL, the number of clusters was condensed (step 4). Propositions (step 5) were then made about the phrases in each meta-cluster and minitheories were generated (step 6). In the final stage of the analysis (step 7), an overarching theory was integrated into an explanatory framework. Negative cases (i.e. examples of talk or events that ran counter to the emerging propositions) were used to refine, revisit and revise each stage. Interview transcripts from each time-point were analysed in isolation before exploring the contradictions and commonalities between all transcripts. Transcripts were imported into MAXqda231 to facilitate data management.

Results

Four-hundred and fifty-four women were recruited. Figure 1 shows the numbers of women who returned questionnaires and/or were interviewed at different time-points during the study. It also illustrates where exclusions occurred and women withdrew from the study. In total, between recruitment and delivery data being collected, 49 women were excluded (23 miscarriages, four multiple pregnancies, one multigravid, one never pregnant, 11 antenatal transfers, two stillbirths, seven did not deliver at the study hospital) and eight withdrew. As the study progressed, the pattern of non-responses to questionnaires was linked to age; the older the woman, the more likely she was to return all three questionnaires (n = 209). A total of 153 semi-structured interviews were undertaken (89 antenatal, 64 postnatal). Twenty-eight women were interviewed at least once during pregnancy and 12 months after their first experience of childbirth.

The median gestation of women completing the booking questionnaire was 12 weeks (range 7–16). The mean age of participants was 27.0 years (SD 5.5, range 17–42). Table 1 lists the socio-demographic profile of women who returned questionnaires at booking, 24 and 36 weeks. These women were slightly older than the general birthing population, but were not dissimilar to the women who typically take part in maternity care research.32Table 1 also lists the characteristics of women who returned all three antenatal questionnaires; these women were also slightly older. Age is as recorded in medical notes, whilst all other details were self-reported in the antenatal questionnaires.

Table 1.   Socio-demographic characteristics of participants returning antenatal questionnaires
 Frequency n (%)
All respondents Booking questionnaireAll respondents 24-week questionnaireAll respondents 36-week questionnaireReturned all three antenatal questionnaires
Age in yearsn = 454n = 300n = 254n = 209
Mean ± SD (range)27.0 ± 5.554 (17–42)27.6 ± 5.738 (17–42)28.3 ± 5.538 (18–42)28.5 ± 5.437 (18–42)
<2046 (10.1)28 (9.3)22 (8.7)13 (6.2)
20–24110 (24.2)68 (22.7)51 (20.0)40 (19)
25–29146 (32.1)85 (28.4)70 (27.5)60 (28.7)
30–34103 (22.7)78 (25.9)71 (27.9)64 (30.7)
35–3943 (9.4)36 (12.0)36 (14.2)28 (13.4)
40–456 (1.2)5 (1.7)4 (1.6)4 (2.0)
Ethnicityn = 395n = 281n = 254n = 209
White378 (95.7)266 (94.7)229 (95.8)200 (95.7)
Black3 (0.8)3 (1.1)3 (1.3)3 (1.4)
Chinese3 (0.8)3 (1.1)1 (0.4)1 (0.5)
Indian5 (1.3)5 (1.8)3 (1.3)3 (1.4)
Asian1 (0.3)1 (0.4)00
Other5 (1.3)3 (1.1)3 (1.3)2 (1.0)
Disabilityn = 395n = 281n = 247n = 209
Yes12 (3.0)9 (3.2)7 (2.8)8 (3.8)
Housingn = 384n = 276n = 233n = 205
Partner/husband301 (78.4)217 (78.6)186 (79.8)165 (80.5)
On own13 (3.4)9 (3.3)9 (3.9)7 (3.4)
With friends2 (0.5)2 (0.7)00
Family members67 (17.4)47 (17.0)38 (16.3)33 (16.1)
Other1 (0.3)1 (0.3)0 
Highest educational qualificationn = 378n = 273n = 230n = 203
None22 (5.8)13 (4.8)7 (3.0)5 (2.5)
GCSE83 (22.0)56 (20.5)46 (20)42 (20.7)
A’Level52 (13.8)33 (12.1)28 (12.2)23 (11.3)
HND/degree47 (12.2)32 (11.7)34 (14.8)29 (14.3)
Professional131 (34.7)107 (39.2)90 (39.1)80 (39.4)
Other43 (11.4)32 (11.7)25 (10.9)24 (11.8)
Employmentn = 383n = 275n = 232n = 204
Full-time (over 24 hours per week)297 (77.5)223 (81.1)192 (82.8)174 (85.3)
Part-time (<24 hours per week)33 (8.6)22 (8.0)17 (7.3)14 (6.9)
No, not at the moment51 (13.3)30 (10.9)23 (9.9)16 (7.8)
No, I have never had paid work2 (0.5)000
NHS or health-related employment    
Womann = 391
78 (19.9)
n = 279
60 (21.5)
n = 237
49 (20.7)
n = 207
44 (21.3)
Partnern = 359
21 (5.8)
n = 258
19 (7.4)
n = 225
18 (7.1)
n = 194
18 (9.3)

Choice as unstable

A total of 397 women (90%) returned the booking questionnaire, amongst which 284 women (72%) reported that they would prefer to give birth vaginally. Ten women (3%) reported that they would prefer to give birth to their baby by planned CS; a similar percentage to the figure reported for pregnant nulliparous women in the UK’s National Sentinel Caesarean Section Audit.11 The other women reported that they did not have a preference, had not thought about birth method, or that their preference was dictated by medical reasons. By late pregnancy the proportion of women expressing a preference for CDMR had declined to 2%, whilst those reporting a preference for vaginal birth increased to 80%. Table 2 shows the reported preferences of a subset of 209 women who returned all three antenatal questionnaires (two women returning the 32- to 36-week questionnaire did not record an answer to this question). These findings suggest that most women would choose to give birth vaginally and that this preference increases as pregnancy progresses. However, analysis of a subset of women who changed their preference from or to a planned CS (n = 15), coupled with qualitative interview data suggests a less straightforward picture. Only one woman indicated that she would prefer to have a planned CS on all three antenatal questionnaires and she had a chronic medical condition (multiple sclerosis). All other women (n = 14) who indicated that they had a preference for a planned CS at booking, 24- or 36-week gestation changed their mind at least once during pregnancy.

The principal theme to emerge from the qualitative data was that knowledge acquisition is a dynamic process. How women come to know about vaginal and caesarean birth is a continuous process that begins before pregnancy and continues beyond a woman’s first experience of childbirth. This challenges the linear notion of informed choice where patients accumulate relevant knowledge until in a position to make an informed decision. Women’s views were informed by accessing different kinds of knowledge (medical, non-medical, written, verbal, visual), from multiple sources (family, friends, media, healthcare professionals), with varying degrees of influence at different time-points. To think of knowledge as a process that is responsive to changing circumstances has implications for the whole notion of expressing a preference for actual birth method. This is because as new information and experiences shift views, any choice expressed becomes inherently unstable. Whilst most women talked about vaginal birth as preferable, at the same time they would not rule out that a caesarean birth may be no less, equally, or even more preferable than vaginal birth in certain circumstances. The importance of ‘keeping an open mind’ was a phrase used spontaneously by over a third of women interviewed during pregnancy.

I’m trying to keep an open mind so I don’t build my hopes up to one thing and then something happens. I mean I would like a normal vaginal birth but at the end of the day if it’s needed and I have to have a caesarean then it’ll have to be that way.

23-year-old woman, 24-week interview

I don’t particularly want to have an arranged caesarean. I think I’d like things to be as normal as possible but I’m not a great mother earth, I’m not going to insist everything has to be all natural. I’ll see how it goes. I have absolutely no idea what its going to go like, so I’m keeping an open mind.

32-year-old woman, 24-week interview

When we found out about the size of it (the baby), I was starting to think in my own head that I have to start mentally preparing myself for a caesarean. Give it another week or two and then if the head is not engaged they will have to take me in for another scan to see. So I’m just keeping an open mind again, I’ll be disappointed but that’s just the way it goes.

37-year-old woman, 36-week interview

A key component contributing to the dynamic nature of choice was the distinction women made between external means of ‘knowing about’ birth, and actually ‘being pregnant’, facing the prospect of ‘doing birth’ for the first time. Whilst women recognised that a particular notion of vaginal birth as natural or normal may be preferable, they accepted that their actual birth method would be determined by the circumstances of their pregnancy, the position of the baby, the course of their labour, and the practices of midwives and obstetricians they encountered.

Choice as limited

None of the women interviewed thought they could request planned CS ‘on the NHS’; this was viewed as available only to women with the ability to pay for the operation or who had experienced a previous traumatic birth.

When I saw it on [television] it’s always been the private patients that have got that (CDMR). So I thought it was kind of a thing that you could, if you went privately, you could choose.

29-year-old woman, 24-week interview

I suppose I associate it [caesarean] with a problem with a normal delivery. I mean it must be hospitals wouldn’t normally want to perform an operation if they didn’t have to.

33-year-old woman, 24-week interview

Women talked about vaginal birth as the physiological endpoint of being pregnant (unless medically advised otherwise), which meant that vaginal birth did not represent an autonomous choice.

If you’re going to have a baby, if you can have a baby by normal birth [vaginally], I don’t think it’s something that’s a matter of choice really. If you choose to have a baby, you’ve got to go with the whole thing. I don’t think its something that you’re given the right to choose about in a sense.

30-year-old woman, 24-week interview

I suppose it’s the baby’s choice when he wants to come out and if you can’t have it naturally then you can’t have it can you [a vaginal birth].

21-year-old woman, 24-week interview

Women also recognised that their choices were limited by the provision of NHS maternity care and the pathology of their individual pregnancy and birth. Moreover, any personal preference was viewed as secondary to maintaining the safety of the baby, which meant some women felt that decision-making regarding actual birth method needed to be entrusted to midwives and obstetricians.

The way I look at it is the safest option for me and the baby and that’s the only way I can think about it [vaginal or caesarean birth] really. At the end of the day that’s the results I’m after; a healthy baby and for me to be ok. I would go with what they [hospital staff] feel is the best option at the time. I mean I’d hope to deliver naturally, but I mean you know.

31-year-old woman, 24-week interview

I’m not bothered [vaginal or caesarean birth] whatever’s the safest. I’m not bothered I’m really not, if I had to have a caesarean then so be it. If they [babies] can’t come out normally and naturally then at the end of the day so long as you get him out in one piece then it’s the same thing.

31-year-old woman, 36-week interview

Questionnaire data from all three antenatal questionnaires support this qualitative finding. Figure 2 shows the levels of agreement to a series of statements about birth reported by women at 36 weeks. At booking, 24 and 36 weeks 100% of respondents either agreed or strongly agreed with the statement ‘I would like a birth that is the safest option for my baby’. Figure 2 also illustrates that their own safety and recovery were important to these women, whilst the convenience of a birth that allowed them to plan the date their baby was born was not. The avoidance of perineal trauma during vaginal birth that can result in continence problems is one of the principal arguments put forward by proponents of planned section. The proportion of women who strongly agreed with the statement ‘I would like a birth that will reduce the chances of stress or cough incontinence had declined as pregnancy progressed, from 48% at booking, to 35% by 24 and 36 weeks (Figure 2).

A total of 394 women delivered a live baby at the study hospital, two women had planned home births and one baby was born before arrival at the hospital. In total, 303 women (76.3%) had a vaginal delivery; 225 women (57%) spontaneous vaginal birth; 78 women (20%) assisted vaginal delivery (forceps/ventouse). The other 23.7% of women (n = 94) experienced a caesarean birth; 21 women (5%) planned CS; 73 women (18%) emergency CS. Only two women had CDMR recorded in their medical records as the primary indication for CS; the woman with progressive MS and a woman who requested the operation during labour. The interview data from these women (both negative cases) suggest that although women exercise a degree of choice, they are ultimately determined by circumstances beyond their control.

You just make the choices that you can when things turn out to not be what you thought they were going to be.

29-year-old woman, Emergency caesarean section (CDMR) 12-month postnatal interview

Choice as undesirable

At the same time as many women supported the principle of ‘a woman’s right to choose’, all women were uncomfortable with the application of this rhetoric to decision-making surrounding vaginal or caesarean birth. Ultimately, women felt health concerns should take precedence in decision-making and entrusted health professionals to act appropriately. Furthermore, they believed any inflexibility of preference was frowned upon, which meant expressing a preference for birth method was not only difficult, it was undesirable too.

I believe women should have the choice for abortion for example, something like that, but I think caesarean [CDMR] its adding complications were there needn’t be any.

35-year-old woman, 24-week interview

You would blame yourself if something went wrong and you had gone against what you had been advised to do by people [midwives and obstetricians] who deal with it everyday. I wouldn’t allow myself that choice; I wouldn’t go against what their opinion was.

28-year-old woman, 24-week interview

Data from the questionnaires also provide evidence that many women believe their right to choice should be overridden by healthcare professionals. At booking, 24 and 36 weeks over 55% of women disagreed with the statement ‘if a woman wants to have a vaginal birth she should be able to have one under any circumstances’. Moreover as their pregnancies progressed, more women agreed with the statement ‘doctors should decide whether a woman has a CS under any circumstances’. Figure 3 shows women’s responses at 36 weeks.

Nine women were pregnant with their second child at the time of the postnatal interviews. Five women were in the later stages of pregnancy, two of whom were booked for planned caesarean births and another woman had declined her obstetrician’s offer of CDMR. Nevertheless, none of these women talked about their plans for their second birth as their ‘choice’: expressing a preference for actual birth mode was no more desirable in their second pregnancy than it was in their first. Whilst planned caesarean birth was favoured by two women and another two believed the option of CDMR should be available, none of these women saw it as desirable to make an association between CDMR and women’s choice. This was principally because actual birth method remained a decision based on an assessment of health risks and benefits where ‘choice’ was not felt to be the most appropriate concept to employ.

Discussion

This study aimed to explore whether or not women report decision-making surrounding actual birth method as their choice. This is the first longitudinal study of women’s views of CDMR in the UK to follow the same cohort of women from their antenatal booking appointment to 12 months after their first experience of childbirth. By using a combination of questionnaires and interviews, we have demonstrated that for women knowledge acquisition is a continuous process, which necessitates a shift in current thinking about patient autonomy in obstetric decision-making. Firstly, to think of knowledge as a process, makes expressing a preference inherently problematic because choice until the moment of birth is neither static nor final. Secondly, this study shows that whilst women may support choice in principle, in practice women’s autonomy is limited by both available care provision and individual circumstance. Thirdly, this study suggests that women’s overriding choice in decision-making is not universally desirable because many of them trust their caregivers as experts. Collectively, this raises the question can choice in a consumerist sense ever really exist in the context of healthcare decision-making.

The main strengths of this study were the use of mixed quantitative and qualitative methods, the follow-up of women until 12 months postnatal, the richness and volume of qualitative data; an inter-disciplinary research team offering multiple perspectives and the contextualisation of data within current debates concerning CDMR. A study limitation was the lower questionnaire response rates as the study progressed. However, the pattern of loss to follow up was similar to that reported in a survey of CDMR and nulliparous women’s views during pregnancy in Hong Kong12 and is a known problem with longitudinal studies. Also, it is a limitation of both questionnaire and interview methods that people can offer orthodox responses (i.e. that which they wish to be seen to believe, not what they actually believe). Efforts were made to try and overcome this via the use of self-complete questionnaires (the majority of which were returned by post) and by an experienced qualitative researcher undertaking all of the in-depth interviews and the thorough exploration of negative cases at the analysis stage. A further limitation was recruitment of women from a single hospital. However, this hospital is not dissimilar to other NHS maternity care providers who follow Department of Health national guidelines.

The term ‘choice’ has become fashionable rhetoric for health professionals, women and media to justify decision-making. This study highlights the multi-dimensional nature of choice suggesting that it may not be the most appropriate term to use in healthcare practice. Our findings indicated that knowledge acquisition is a process, which makes expressing a preference inherently problematic and challenges whether CDMR really exists in the form assumed by most of the existing literature on the subject. This study raises questions about the validity of prospective surveys of CDMR at only one time-point. Moreover, healthcare professionals need to acknowledge choice is only finite in retrospect. We offer stronger evidence (by triangulating quantitative and qualitative data) to existing studies6,12,33 that the final decision on mode of delivery develops as pregnancy progresses. A finding that may not come as any big surprise to many practising obstetricians and midwives, but which has hitherto rarely been considered in the evidence and debate surrounding CDMR. For those women who want to, and remain able to make decisions as their pregnancy progresses, then individual clinicians and maternity care systems need to be able to accommodate women’s flexibility of preference. This may be important within other areas of healthcare decision-making, not just method of birth, and warrants further investigation.

Additionally, our study shows that whilst women may support choice in principle, in practice women’s autonomy is limited by both available care provision and individual circumstance. Whilst choice is advocated in government and local policy,24 the women’s experience was that this was restricted by current norms. The belief that they had to pay for CS if it was not medically necessary, and their expectation of having a vaginal birth, meant that unless medically indicated choice was not an issue. Replication of this study with women who access private maternity care may find that they account for their role in decision-making differently. Clinicians should be transparent about options that are available and provide accurate information that is accessible to all women.

Finally, our findings suggest that women’s choice in healthcare decision-making is not universally desirable. Whilst NHS policy presents a delicate equation between safety and choice, this notion of choice may be at odds with the principal concern of most pregnant women, the safety of their unborn child. For women and clinicians, perceptions of having made the ‘right’ choice are outcome dependent. Healthcare professionals must consider that whilst women want to be informed and involved in the decision-making process surrounding birth method, it does not necessarily follow that they want the final say. For some women, the old adage of ‘doctor knows best’ still holds true.

Conclusion

In conclusion, our findings affirm those of existing research in the UK reporting the percentage of women who express a preference for planned CS during their first pregnancy is low. Only one woman, of 454, consistently expressed a preference for planned CS. Additionally, our findings highlight fundamental problems with the notion of expressed preference, women’s autonomy and actual birth method, which suggest that choice is not the best concept through which to approach the current arrangements for birth in the UK. Clinicians should be mindful of the fact that women do not always want choice; for those that do, transparency of actual birth options is paramount; these options should be revisited and discussed at different time-points. Furthermore, this finding challenges the notion of choice that currently prevails in international debates about CDMR.

Disclosure of interests

All authors declare no conflict of interests.

Contribution to authorship

JPN, TL and CK conceived the study. All developed the methods. CK was responsible for data collection. CK, VS, TL and AH were responsible for the analysis. CK and TL wrote the article. All authors commented critically on the paper. CK revised the paper in the light of these comments.

Details of ethics approval

Liverpool Research Ethics Committee approved this study on the 8 March 2001 (Ref: 01/008).

Funding

CK received a part-time Department of Health Training Fellowship. All researchers were independent from funders.

Acknowledgements

We would like to thank all the women who participated in this research.

Ancillary