European Journal of Obstetrics & Gynecology and Reproductive Biology 192 (2015) 54–60
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Caesarean section at maternal request – the differing views of patients and healthcare professionals: a questionnaire based study A.N. Sharpe a,*, G.J. Waring b, J. Rees c, K. McGarry d, K. Hinshaw e,f a
South Tees NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, Tyne and Wear NE1 7RU, United Kingdom City Hospitals Sunderland NHS Foundation Trust, United Kingdom c University of Sunderland, United Kingdom d Department of Pharmacy, Health and Well-being, Faculty of Applied Science, University of Sunderland, SR1 3RG, United Kingdom e City Hospitals Sunderland NHS Foundation Trust, SR4 7TP, United Kingdom f Department of Pharmacy, Health and Well-being, University of Sunderland, SR1 3SD, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 28 May 2015 Accepted 12 June 2015
Objective: The number of caesarean sections at maternal request without medical indication is increasing. We aimed to explore the views of pregnant women, midwives and doctors using six hypothetical clinical scenarios and compare group views on: (a) perceived appropriateness of requests for caesarean section and (b) the reasons underlying these requests. Study design: A questionnaire was distributed to 166 pregnant women, 31 midwives and 52 doctors within maternity units at two hospitals in the North East region of England. Six hypothetical clinical scenarios for maternal requests were used: (1) uncomplicated first pregnancy, (2) one previous normal delivery, (3) one previous instrumental delivery, (4) one previous caesarean section, (5) one previous caesarean section with vaginal delivery since and (6) uncomplicated twin pregnancy. To highlight the differences in group responses, two main questions were asked for each scenario: 1. Should women be able to request a caesarean section?
Keywords: Caesarean section Maternal request Doctors Midwives Pregnant women
2. What do you feel are the reasons for requesting a caesarean section? Data was analysed using Chi-squared or likelihood ratio as appropriate. Results: In scenarios 1–3, professional groups were ‘less likely’ than pregnant women to always support a request (2.4% vs. 19.4%), (2.6% vs. 15.6%), (4.6% vs. 22%), (p < 0.001). No significant differences were shown between doctors and midwives except for scenario 6 (twins), where midwives more often felt maternal requests should be declined (26.1% vs. 1.9%) (p = 0.001). Multiparous women (n = 95) were more likely to agree ‘sometimes’ to maternal requests in scenarios 1, compared to nulliparous women (n = 71) (21.1% vs. 4.2%) (p = 0.04). ‘Safety of the baby’ was ranked highly with pregnant women in scenarios 1–3 (mean 24.4%, range [15.8–38%]) compared with healthcare professionals (7.6% [3.4–12.8%]). However in scenario 3, healthcare professionals attributed ‘fear of injury to self’ (29.6%) as the most likely reason compared to 14.6% of pregnant women. Conclusion: Healthcare professionals and pregnant women’s views differ significantly. Multiparous patients’ views differ from those who have not had children before. We should provide clearer information on risks and benefits which encompass areas that concern women most. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Introduction Caesarean section (CS) rates are rising worldwide. In the UK, 25% of women have a CS and 6–8% of women express a preference
* Corresponding author. Tel.: +44 1915699782. E-mail address: [email protected] (A.N. Sharpe). http://dx.doi.org/10.1016/j.ejogrb.2015.06.014 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
for CS [1]. Worldwide estimates of CS at maternal request (CS-MR) are 6–8% in Northern Europe, 11.2% in USA, 17.3% in Australia and 70% in Brazil [1–4]. In situations such as breech presentation and position of the placenta, the mode of delivery can improve both neonatal and maternal outcomes [5]. However when there is no specific medical reason for a CS, the impact of this mode of delivery is unclear [1,5,12,14]. A history of previous CS increases the risk of future uterine rupture and also abnormal placentation (placenta
A.N. Sharpe et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 192 (2015) 54–60
praevia and accreta). However, this risk does not always outweigh the psychological stresses burdening women whom fear childbirth [5,12,14]. The definition of a CS-MR is when a woman explicitly asks for an elective CS in the absence of any medical or obstetric indications. Common reasons include previous negative birth experience, fear of childbirth, complications in current pregnancy and the belief that a CS will be safer for the baby [1,6]. The changing attitudes regarding preference for a CS in the absence of medical indications is not just limited to pregnant women. A greater number of obstetricians are opting for women to have a CS in the absence of medical indications. A study in Canada showed that 25% of healthcare professionals working with pregnant women thought that a CS protected women from urinary incontinence and sexual dysfunction problems in the future [7]. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2011 to state that when a woman requests a CS and there are no medical indications, the clinician should explore the woman’s reasoning and discuss both the risks and benefits of all modes of delivery [1]. If elective CS is still the preferred mode of delivery then it should be offered to the patient [1]. Alongside publishing these guidelines, NICE also published data on the cost of CS [8]. The financial cost of having a planned caesarean section (£2369) is more expensive compared with an uncomplicated vaginal delivery (£1665) [8]. Rising CS rates could have financial consequences for the NHS. It is thought that CS-MR rates are contributing to rising CS rates since the introduction of the new NICE guidelines. Supportive evidence from a large UK obstetric unit confirms an increase in the rate of CS-MR over the last 3 years (Norman J – personal communication): 2012 6.9% (n = 73); 2013 9.0% (n = 95); 2014 9.8% (n = 94 [10 months]) p = 0.048 Pearson Chi-squared 2df. Results expressed as percentage of total elective CS. In 2001, 7% of all CS in England were at maternal request [8–10]. The excess cost of a caesarean delivery is £700, which results in additional annual NHS costs of £7,710,444 for CS-MR (from 2010 n = 157,356 CS). A continued rise in the rate of CS-MR of 1% per annum would result in increased NHS expenditure (England) of at least £1.13 million per year [9]. Data comparing the risks of having a planned CS with the risks of vaginal delivery are limited. Hence, the opinions of doctors, midwives and patients will greatly influence clinical practice and the use of NHS resources [11]. The aim of this study is to compare the views of pregnant women, midwives and doctors about firstly whether women should be able to choose a CS-MR and secondly what do they feel are the reasons for women to choose a CS-MR, using hypothetical clinical scenarios in which NICE will now support maternal requests.
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1. No previous children and the current pregnancy is normal and the baby is healthy and head down. 2. Previous normal delivery and the current pregnancy is normal and the baby is healthy and head down. 3. Previous forceps or vacuum delivery and the current pregnancy is normal and the baby is healthy and head down. 4. One previous C-secon only and the current pregnancy is normal and the baby is healthy and head down. 5. One previous C-secon and delivered vaginally since and the current pregnancy is normal and the baby is healthy and head down. 6. Current pregnancy is twins and both twins are healthy and head down
Fig. 1. The six scenarios.
1. Yes always 2. Yes most times 3. Yes sometimes 4. No 5. I really don’t know
Fig. 2. Questionnaire response options for ‘Should women be able to choose to have a caesarean section when there are no medical indications?’
1. Convenience 2. They are put off by other people’s negative experiences of child birth 3. They believe that a caesarean section is safer for the baby 4. They fear injury to self such as damage to the bladder 5. They fear childbirth 6. Other
Fig. 3. Questionnaire response options for ‘What do you think is the most common reason why women choose to request a Caesarean Section’ in each scenario?
Materials and methods
Data collection
Questionnaire
Trust registration was obtained for permission to distribute questionnaires between January and March 2012. Verbal consent was obtained prior to distributing 249 questionnaires to pregnant women, midwives and doctors either attending or working in the obstetric department Monday to Friday during working hours 9–5, at two district general hospitals in the North East region. Attempts were made to ascertain as many views as possible from healthcare professionals and pregnant women within a three month period. The distribution of questionnaires was prospective and opportunistic, where each recipient was informed beforehand that the questionnaire was optional and anonymous. The aim was to get 250 completed questionnaires in total to encompass the views of pregnant women, doctors and midwives attending or working in the departments.
A pilot questionnaire was designed and divided into three parts; Part 1: Basic demographic information was obtained about age, occupation and education. Part 2: Based on six hypothetical clinical scenarios (Fig. 1), participants were asked should women be able to choose a CSMR for each scenario. Five response options were provided as numbers 1–5 (Fig. 2). Part 3: Based on the six hypothetical clinical scenarios (Fig. 1), participants were asked what they felt were the reasons for women to choose a CS-MR? Six response options were provided as numbers 1–6 (Fig. 3).
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Statistical analysis Data was analysed using SPSS v21 and tests of association (Chisquared). Comparisons were made between pregnant women and healthcare professionals (doctors and midwives combined), between doctors and midwives as well as between nulliparous and parous women. An alpha level significance of p = 0.05 was used and the z score (>1.96) identified which responses contributed to the significant difference. Results Responses were analysed from 166 pregnant women, 31 midwives and 52 doctors. The median age of the pregnant women was 28 (15–43) years, 55 women (66%) had continued education after 16 years and 71 (43%) were nulliparous. The median age of participating midwives was 33 (19–51) years; 35% were student midwives and 65% were qualified. The median age of doctors was 29 (24–62) years, although 5 (10%) of participating doctors failed to complete their age on the questionnaire. Unfortunately not all the questionnaires were filled out correctly. There was no group identified in 2 questionnaires and these results were discarded.
Section 1: Should women be able to choose a CS-MR for each scenario? i. The opinions of pregnant women and health care professionals differed significantly. All scenarios showed a significant difference between healthcare professionals and pregnant women (p < 0.05) (see Fig. 4). In scenarios 1–3, healthcare professionals were less likely to think women should ‘always’ be able to choose a CS-MR compared with pregnant women (2.4% vs. 19.4%), (2.6% vs. 15.6%) and (4.6% vs. 22%) (z = 2.8, 2.3, 2.6), However, this discrepancy between healthcare professionals and pregnant women was still significant albeit less so in scenarios 4–6, where only 3.9% of healthcare professionals (z = 2.4) compared to 19.5% of pregnant women thought ‘no’ in scenario 4 (p = 0.001) and there were no z scores in the significant range for healthcare professionals vs. pregnant women in scenarios 5 and 6 (p = 0.042, p = 0.05). ii. Nulliparous and parous women’s opinions differed significantly. There was a significant difference between parous and nulliparous pregnant women in scenario 1 only (p = 0.004) (see Fig. 5). Parous women are more likely to say ‘yes sometimes’ in scenario 1 (21.1%) (z = 1.9) compared with 4.2% of nulliparous
Fig. 4. Graphs to show the number of responses from pregnant women, midwives and doctors to the question ‘Should women be able to request a CS in the absence of medical indication?’ for each specific scenario. Solid black box represents midwives, stripes represent doctors and dots represent pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between pregnant women and healthcare professionals. *P values represent level of significant difference between doctors and midwives.
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Fig. 5. Graphs to show the number of responses from nulliparous pregnant women and parous pregnant women to the question ‘Should women be able to request a CS in the absence of medical indication?’ for each specific scenario. Black dots represent parous pregnant women, grey dots represent nulliparous pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between parous and nulliparous pregnant women.
women (z = 2.2). There were no significant differences in scenarios 2–6 (p > 0.05). iii. The opinions of doctors and midwives did not differ significantly in most cases. There were no significant differences between doctors and midwives in scenarios 1–5 (see Fig. 4). In scenario 6, twin pregnancy, 26.1% of midwives disagreed with CS-MR compared with 1.9% of doctors (p = 0.001) (z = 2.6). Section 2: What do you feel are the reasons for choosing CS-MR in each scenario? i. Pregnant women and healthcare professionals opinions differed significantly. There was a significant difference between healthcare professionals and pregnant women for the reasons why women choose a CS-MR in scenarios 1–3 (p = 0.04, p = 0.023, p < 0.001) (see Fig. 6). Pregnant women were more likely to feel that ‘safer for the baby’ was a reason for women to choose a CS-MR compared with healthcare professionals in scenario 1 (19.3% vs. 3.4%) (z = 2.5), scenario 2 (15.8% vs. 6.5%) (z = 1.5) and scenario 3 (38.0% vs. 12.8%) (z = 2.7). In scenario 3, 29.9% of healthcare professionals felt ‘fear of injury’ was a reason for CSMR compared with 14.7% of pregnant women (z = 2.0). ii. Nulliparous and parous womens’ opinions did not differ significantly.
Fig. 7 shows that significant differences were absent between parous and nulliparous women for reasons for women to choose a CS-MR across all six scenarios. iii. The opinions of doctors and midwives did not differ significantly in most cases. Reponses between midwives and doctors did not differ significantly in all scenarios (p > 0.05) (see Fig. 6). In scenario 4, only 4.2% of midwives felt that ‘fear of childbirth’ was a reason for CS-MR compared with 26.9% of doctors (p = 0.054) (z = 1.7).
Comments This is the first study to compare the views of patients, midwives and doctors about women who choose CS-MR in hypothetical scenarios recently approved by NICE. Main findings Firstly in the less complicated scenarios (1–3) pregnant women felt strongly that women should be able to choose CS-MR compared to healthcare professionals who disagreed. This demonstrates a divergence of views between healthcare professionals and pregnant women. This study showed no significant differences between the views of professional groups in terms of
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Fig. 6. Graphs to show the number of responses from pregnant women, midwives and doctors to the question ‘What are the reasons for this request?’ for each specific scenario. Solid black box represents midwives, stripes represent doctors and dots represent pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between pregnant women and healthcare professionals. *P values represent level of significant difference between midwives and doctors.
perceived appropriateness of requests for CS-MR. There were minor differences in the scenario: ‘uncomplicated twin pregnancy’ with midwives tending to disagree with women who request a CSMR for this scenario. As both groups are involved in taking care of women whom are in the process of requesting a CS, it is important that they are both advising consistent, accurate and unbiased information. Secondly this study demonstrated that nulliparous women were more likely to disagree that women could choose CS-MR. However, both nulliparous and parous women felt that having one previous CS was not an appropriate indication of requesting another CS. Current practice promotes vaginal delivery after a previous CS as a safe and beneficial option for mode of delivery [12,13]. This response from pregnant women implies that the current education initiatives are successfully promoting vaginal delivery as a safe mode of delivery after previous CS.
Thirdly, uncertainty arose in scenarios involving both instrumental delivery and twin pregnancy. This suggests that these scenarios are viewed with differing risk profiles by women and health care providers and that they both feel less clear about which is the safest mode of delivery. Assessment of risk is an important contributor to women’s views. Since the evidence of the risks and benefits of a planned CS are limited, women will decide themselves what they believe is safer [11]. This highlights the need for clarification of risks in order for women to be accurately informed prior to making the decision [14]. Finally in scenarios 1–3, which many health care professionals would regard as low risk scenarios, the baby’s safety was a key contributory factor that pregnant women felt provoked CS-MR. Whereas healthcare professionals believe that the common reasons are injury to maternal health as opposed to the welfare of the child. These results coincide with previous studies where the most common reasons were fear of childbirth, fear of injury to self
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Fig. 7. Graphs to show the number of responses from nulliparous and parous pregnant women ‘What are the reasons for this request?’ for each specific scenario. Black dots represent parous pregnant women, grey dots represent nulliparous pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between parous and nulliparous pregnant women.
and concern for the baby’s safety [6,15]. The key message here is that pregnant women fear for their baby’s safety whereas healthcare professionals consider multiple factors that influence the decision to choose a CS-MR. NICE state that a planned CS is more expensive than an uncomplicated vaginal delivery [8]. However, it is difficult to assess how much a complicated vaginal delivery compares with added costs such as interventional delivery and epidurals. CS rates are rising along with the associated cost and operative morbidity, our study suggests that women’s fear for the safety of their baby may be a contributive factor. This is all the more concerning as no clinical benefits of CS have been established.
region of England, therefore these results cannot be generalised across the country where different social classes, culture and attitudes may influence opinions [15]. Furthermore this study is restricted to public hospitals within the National Health Service. Maternal requests for a CS rates vary between private and public sectors. In Brazil, 70% of women in the private healthcare sector have a CS compared with 25–30% in the public health sector [3]. CS rates are higher in developed countries compared with developing countries and these results are unlikely to be representative worldwide. However, even in the developing world, the CS rates are rising, likely due to increasing facilities and greater attention to the prospect of a ‘safer alternative to childbirth’ [16].
Strengths and limitations
Interpretation
This study is an anonymous, questionnaire based study but the sample size was small and limited to two hospitals in the northern
This study has highlighted the divergent views between doctors, midwives and pregnant women for specific scenarios. It
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is important that this discrepancy in views does not hinder the care and support provided by healthcare professionals. Actively listening and exploring pregnant womens views including the use of decision aids and option grids such as those developed from ‘Making Good Decisions in Collaboration’ programmes could be valuable in helping healthcare professionals and pregnant women reach a shared decision most appropriate for each woman [17]. The results from our study showed that concerns for the baby’s safety are of most importance to pregnant women. The national sentinel audit in 2001 showed that women want more information about the risks and benefits of CS and most women participating in the audit wanted a birth that was safest for the baby [16]. Therefore, these risks and concerns need to be addressed by communicating the available evidence and conducting further research to clarify the limited evidence of the risks and benefits of a CS [14]. Until the risks and benefits can be accurately established, the views of pregnant women will remain a dominant force impacting on clinical practice. This study is only scratching the surface in an attempt to understand the multiple factors that influence women to choose a CS-MR. Further research should involve larger sample sizes across multiple centres. Comparison of views between private and public sectors, as well as between women who have chosen a CS-MR with those who did not choose a CS-MR, would help establish the dominant contributing factors. Since 2011, the incidence of maternal requests has risen therefore it would be worthwhile determining whether views have changed with increasing awareness. As the views of pregnant women and healthcare professionals do differ, we could explore further by facilitating more complex interviews and discussions with pregnant women and healthcare professionals. This would give further information so that we can tailor healthcare services to be more patient centred. Conclusion The continual increase in CS rates suggests that more women are choosing surgical intervention over normal vaginal delivery without proven clinical benefit. It is clear there is a gap between the pregnant women’s understanding of risk and that of healthcare professionals, as evidenced in this study. In order to allow women to make an informed decision about the most appropriate mode of delivery, both midwives and doctors need to work together with pregnant women in order to provide relevant support and advice for individuals. Adequate exploration of women’s ideas, concerns and expectations as well as encouraging patient questions and
providing unbiased information about the options available would facilitate the shared decision making process. Acknowledgement We are grateful to Gordon Alexander, Julie Jones, Jane Norman and all the questionnaire participants for their assistance. References [1] NICE Clinical Guidelines. Caesarean section, in maternal request for caesarean section. Royal College of Obstetricians and Gynaecologists; 2011. p. 96–103. [2] Robson SJ, Tan WS, Adeyemi A, Dear KBG. Estimating the rate of cesarean section by maternal request: anonymous survey of obstetricians in Australia. Birth-Issues Perinat Care 2009;36(3):208–12. [3] Potter JE, Berquo E, Perpetuo IH. Unwanted caesarean sections among public and private patients in Brazil: prospective study. Br Med J 2001;323:1155–8. [4] MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008;35(2):293–307. [5] Villar J, Valladares E, Wojdyla D, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367(9525):1819–29. [6] Dursun P, Yanik FB, Zeyneloglu HB, Baser E, Kuscu E, Ayhan A. Why women request cesarean section without medical indication? J Matern-Fetal Neonatal Med 2010 [Early online 1–5]. [7] Klein MC, Liston R, Fraser WD. Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors? Birth 2011;38(2): 129–39. [8] National Institute for Health and Clinical Excellence. Caesarean section costing report (Implementing NICE guidance). In: Basis of unit cost. 2011;p. 17–9. [9] Health and Social Care Information Centre. NHS Maternity Statistics England 2012–2013 – Main tables, 2012–2013 05.12.2013 [cited 2015 24.01.15]. Available from: http://www.hscic.gov.uk/article/2021/Website-Search?productid= 13418&q=caesarean+section+elective+and+emergency&sort=Relevance&size= 10&page=1&area=both#top. [10] Royal College of Obstetricians and Gynaecologists. The national sentinel caesarean section audit report. London: RCOG Press; 2001. 17. [11] D’Souza R. Caesarean section on maternal request for non-medical reasons: putting the UK National Institute of Health and Clinical Excellence guidelines in perspective. Best Pract Res Clin Obstet Gynaecol 2013;27(2):165–77. [12] Walmsley K, Hobbs L. Vaginal birth after lower segment caesarean section. Mod Midwife 1994;4(4):20–1. [13] Solheim K, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta and maternal mortality. J Matern-Fetal Neonatal Med 2011;24(11):1341–6. [14] Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2013;27(2):297–308. [15] Mazzoni A, Althabe F, Liu N, et al. Women’s preference for caesarean section: a systemic review and meta analysis of observational studies. BGOG 2010;118: 391–9. [16] Stanton CK, Holtz SA. Levels and trends in cesarean birth in the developing world. Stud Fam Plann 2006;37(1):41–8. [17] Elwyn G, Lloyd A, Joseph-Williams N, et al. Option grids: shared decision making made easier. Patient Educ Couns 2013;90(2):207–12.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Caesarean section at maternal request – the differing views of patients and healthcare professionals: a questionnaire based study A.N. Sharpe a,*, G.J. Waring b, J. Rees c, K. McGarry d, K. Hinshaw e,f a
South Tees NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, Tyne and Wear NE1 7RU, United Kingdom City Hospitals Sunderland NHS Foundation Trust, United Kingdom c University of Sunderland, United Kingdom d Department of Pharmacy, Health and Well-being, Faculty of Applied Science, University of Sunderland, SR1 3RG, United Kingdom e City Hospitals Sunderland NHS Foundation Trust, SR4 7TP, United Kingdom f Department of Pharmacy, Health and Well-being, University of Sunderland, SR1 3SD, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 28 May 2015 Accepted 12 June 2015
Objective: The number of caesarean sections at maternal request without medical indication is increasing. We aimed to explore the views of pregnant women, midwives and doctors using six hypothetical clinical scenarios and compare group views on: (a) perceived appropriateness of requests for caesarean section and (b) the reasons underlying these requests. Study design: A questionnaire was distributed to 166 pregnant women, 31 midwives and 52 doctors within maternity units at two hospitals in the North East region of England. Six hypothetical clinical scenarios for maternal requests were used: (1) uncomplicated first pregnancy, (2) one previous normal delivery, (3) one previous instrumental delivery, (4) one previous caesarean section, (5) one previous caesarean section with vaginal delivery since and (6) uncomplicated twin pregnancy. To highlight the differences in group responses, two main questions were asked for each scenario: 1. Should women be able to request a caesarean section?
Keywords: Caesarean section Maternal request Doctors Midwives Pregnant women
2. What do you feel are the reasons for requesting a caesarean section? Data was analysed using Chi-squared or likelihood ratio as appropriate. Results: In scenarios 1–3, professional groups were ‘less likely’ than pregnant women to always support a request (2.4% vs. 19.4%), (2.6% vs. 15.6%), (4.6% vs. 22%), (p < 0.001). No significant differences were shown between doctors and midwives except for scenario 6 (twins), where midwives more often felt maternal requests should be declined (26.1% vs. 1.9%) (p = 0.001). Multiparous women (n = 95) were more likely to agree ‘sometimes’ to maternal requests in scenarios 1, compared to nulliparous women (n = 71) (21.1% vs. 4.2%) (p = 0.04). ‘Safety of the baby’ was ranked highly with pregnant women in scenarios 1–3 (mean 24.4%, range [15.8–38%]) compared with healthcare professionals (7.6% [3.4–12.8%]). However in scenario 3, healthcare professionals attributed ‘fear of injury to self’ (29.6%) as the most likely reason compared to 14.6% of pregnant women. Conclusion: Healthcare professionals and pregnant women’s views differ significantly. Multiparous patients’ views differ from those who have not had children before. We should provide clearer information on risks and benefits which encompass areas that concern women most. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Introduction Caesarean section (CS) rates are rising worldwide. In the UK, 25% of women have a CS and 6–8% of women express a preference
* Corresponding author. Tel.: +44 1915699782. E-mail address: [email protected] (A.N. Sharpe). http://dx.doi.org/10.1016/j.ejogrb.2015.06.014 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
for CS [1]. Worldwide estimates of CS at maternal request (CS-MR) are 6–8% in Northern Europe, 11.2% in USA, 17.3% in Australia and 70% in Brazil [1–4]. In situations such as breech presentation and position of the placenta, the mode of delivery can improve both neonatal and maternal outcomes [5]. However when there is no specific medical reason for a CS, the impact of this mode of delivery is unclear [1,5,12,14]. A history of previous CS increases the risk of future uterine rupture and also abnormal placentation (placenta
A.N. Sharpe et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 192 (2015) 54–60
praevia and accreta). However, this risk does not always outweigh the psychological stresses burdening women whom fear childbirth [5,12,14]. The definition of a CS-MR is when a woman explicitly asks for an elective CS in the absence of any medical or obstetric indications. Common reasons include previous negative birth experience, fear of childbirth, complications in current pregnancy and the belief that a CS will be safer for the baby [1,6]. The changing attitudes regarding preference for a CS in the absence of medical indications is not just limited to pregnant women. A greater number of obstetricians are opting for women to have a CS in the absence of medical indications. A study in Canada showed that 25% of healthcare professionals working with pregnant women thought that a CS protected women from urinary incontinence and sexual dysfunction problems in the future [7]. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2011 to state that when a woman requests a CS and there are no medical indications, the clinician should explore the woman’s reasoning and discuss both the risks and benefits of all modes of delivery [1]. If elective CS is still the preferred mode of delivery then it should be offered to the patient [1]. Alongside publishing these guidelines, NICE also published data on the cost of CS [8]. The financial cost of having a planned caesarean section (£2369) is more expensive compared with an uncomplicated vaginal delivery (£1665) [8]. Rising CS rates could have financial consequences for the NHS. It is thought that CS-MR rates are contributing to rising CS rates since the introduction of the new NICE guidelines. Supportive evidence from a large UK obstetric unit confirms an increase in the rate of CS-MR over the last 3 years (Norman J – personal communication): 2012 6.9% (n = 73); 2013 9.0% (n = 95); 2014 9.8% (n = 94 [10 months]) p = 0.048 Pearson Chi-squared 2df. Results expressed as percentage of total elective CS. In 2001, 7% of all CS in England were at maternal request [8–10]. The excess cost of a caesarean delivery is £700, which results in additional annual NHS costs of £7,710,444 for CS-MR (from 2010 n = 157,356 CS). A continued rise in the rate of CS-MR of 1% per annum would result in increased NHS expenditure (England) of at least £1.13 million per year [9]. Data comparing the risks of having a planned CS with the risks of vaginal delivery are limited. Hence, the opinions of doctors, midwives and patients will greatly influence clinical practice and the use of NHS resources [11]. The aim of this study is to compare the views of pregnant women, midwives and doctors about firstly whether women should be able to choose a CS-MR and secondly what do they feel are the reasons for women to choose a CS-MR, using hypothetical clinical scenarios in which NICE will now support maternal requests.
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1. No previous children and the current pregnancy is normal and the baby is healthy and head down. 2. Previous normal delivery and the current pregnancy is normal and the baby is healthy and head down. 3. Previous forceps or vacuum delivery and the current pregnancy is normal and the baby is healthy and head down. 4. One previous C-secon only and the current pregnancy is normal and the baby is healthy and head down. 5. One previous C-secon and delivered vaginally since and the current pregnancy is normal and the baby is healthy and head down. 6. Current pregnancy is twins and both twins are healthy and head down
Fig. 1. The six scenarios.
1. Yes always 2. Yes most times 3. Yes sometimes 4. No 5. I really don’t know
Fig. 2. Questionnaire response options for ‘Should women be able to choose to have a caesarean section when there are no medical indications?’
1. Convenience 2. They are put off by other people’s negative experiences of child birth 3. They believe that a caesarean section is safer for the baby 4. They fear injury to self such as damage to the bladder 5. They fear childbirth 6. Other
Fig. 3. Questionnaire response options for ‘What do you think is the most common reason why women choose to request a Caesarean Section’ in each scenario?
Materials and methods
Data collection
Questionnaire
Trust registration was obtained for permission to distribute questionnaires between January and March 2012. Verbal consent was obtained prior to distributing 249 questionnaires to pregnant women, midwives and doctors either attending or working in the obstetric department Monday to Friday during working hours 9–5, at two district general hospitals in the North East region. Attempts were made to ascertain as many views as possible from healthcare professionals and pregnant women within a three month period. The distribution of questionnaires was prospective and opportunistic, where each recipient was informed beforehand that the questionnaire was optional and anonymous. The aim was to get 250 completed questionnaires in total to encompass the views of pregnant women, doctors and midwives attending or working in the departments.
A pilot questionnaire was designed and divided into three parts; Part 1: Basic demographic information was obtained about age, occupation and education. Part 2: Based on six hypothetical clinical scenarios (Fig. 1), participants were asked should women be able to choose a CSMR for each scenario. Five response options were provided as numbers 1–5 (Fig. 2). Part 3: Based on the six hypothetical clinical scenarios (Fig. 1), participants were asked what they felt were the reasons for women to choose a CS-MR? Six response options were provided as numbers 1–6 (Fig. 3).
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Statistical analysis Data was analysed using SPSS v21 and tests of association (Chisquared). Comparisons were made between pregnant women and healthcare professionals (doctors and midwives combined), between doctors and midwives as well as between nulliparous and parous women. An alpha level significance of p = 0.05 was used and the z score (>1.96) identified which responses contributed to the significant difference. Results Responses were analysed from 166 pregnant women, 31 midwives and 52 doctors. The median age of the pregnant women was 28 (15–43) years, 55 women (66%) had continued education after 16 years and 71 (43%) were nulliparous. The median age of participating midwives was 33 (19–51) years; 35% were student midwives and 65% were qualified. The median age of doctors was 29 (24–62) years, although 5 (10%) of participating doctors failed to complete their age on the questionnaire. Unfortunately not all the questionnaires were filled out correctly. There was no group identified in 2 questionnaires and these results were discarded.
Section 1: Should women be able to choose a CS-MR for each scenario? i. The opinions of pregnant women and health care professionals differed significantly. All scenarios showed a significant difference between healthcare professionals and pregnant women (p < 0.05) (see Fig. 4). In scenarios 1–3, healthcare professionals were less likely to think women should ‘always’ be able to choose a CS-MR compared with pregnant women (2.4% vs. 19.4%), (2.6% vs. 15.6%) and (4.6% vs. 22%) (z = 2.8, 2.3, 2.6), However, this discrepancy between healthcare professionals and pregnant women was still significant albeit less so in scenarios 4–6, where only 3.9% of healthcare professionals (z = 2.4) compared to 19.5% of pregnant women thought ‘no’ in scenario 4 (p = 0.001) and there were no z scores in the significant range for healthcare professionals vs. pregnant women in scenarios 5 and 6 (p = 0.042, p = 0.05). ii. Nulliparous and parous women’s opinions differed significantly. There was a significant difference between parous and nulliparous pregnant women in scenario 1 only (p = 0.004) (see Fig. 5). Parous women are more likely to say ‘yes sometimes’ in scenario 1 (21.1%) (z = 1.9) compared with 4.2% of nulliparous
Fig. 4. Graphs to show the number of responses from pregnant women, midwives and doctors to the question ‘Should women be able to request a CS in the absence of medical indication?’ for each specific scenario. Solid black box represents midwives, stripes represent doctors and dots represent pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between pregnant women and healthcare professionals. *P values represent level of significant difference between doctors and midwives.
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Fig. 5. Graphs to show the number of responses from nulliparous pregnant women and parous pregnant women to the question ‘Should women be able to request a CS in the absence of medical indication?’ for each specific scenario. Black dots represent parous pregnant women, grey dots represent nulliparous pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between parous and nulliparous pregnant women.
women (z = 2.2). There were no significant differences in scenarios 2–6 (p > 0.05). iii. The opinions of doctors and midwives did not differ significantly in most cases. There were no significant differences between doctors and midwives in scenarios 1–5 (see Fig. 4). In scenario 6, twin pregnancy, 26.1% of midwives disagreed with CS-MR compared with 1.9% of doctors (p = 0.001) (z = 2.6). Section 2: What do you feel are the reasons for choosing CS-MR in each scenario? i. Pregnant women and healthcare professionals opinions differed significantly. There was a significant difference between healthcare professionals and pregnant women for the reasons why women choose a CS-MR in scenarios 1–3 (p = 0.04, p = 0.023, p < 0.001) (see Fig. 6). Pregnant women were more likely to feel that ‘safer for the baby’ was a reason for women to choose a CS-MR compared with healthcare professionals in scenario 1 (19.3% vs. 3.4%) (z = 2.5), scenario 2 (15.8% vs. 6.5%) (z = 1.5) and scenario 3 (38.0% vs. 12.8%) (z = 2.7). In scenario 3, 29.9% of healthcare professionals felt ‘fear of injury’ was a reason for CSMR compared with 14.7% of pregnant women (z = 2.0). ii. Nulliparous and parous womens’ opinions did not differ significantly.
Fig. 7 shows that significant differences were absent between parous and nulliparous women for reasons for women to choose a CS-MR across all six scenarios. iii. The opinions of doctors and midwives did not differ significantly in most cases. Reponses between midwives and doctors did not differ significantly in all scenarios (p > 0.05) (see Fig. 6). In scenario 4, only 4.2% of midwives felt that ‘fear of childbirth’ was a reason for CS-MR compared with 26.9% of doctors (p = 0.054) (z = 1.7).
Comments This is the first study to compare the views of patients, midwives and doctors about women who choose CS-MR in hypothetical scenarios recently approved by NICE. Main findings Firstly in the less complicated scenarios (1–3) pregnant women felt strongly that women should be able to choose CS-MR compared to healthcare professionals who disagreed. This demonstrates a divergence of views between healthcare professionals and pregnant women. This study showed no significant differences between the views of professional groups in terms of
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Fig. 6. Graphs to show the number of responses from pregnant women, midwives and doctors to the question ‘What are the reasons for this request?’ for each specific scenario. Solid black box represents midwives, stripes represent doctors and dots represent pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between pregnant women and healthcare professionals. *P values represent level of significant difference between midwives and doctors.
perceived appropriateness of requests for CS-MR. There were minor differences in the scenario: ‘uncomplicated twin pregnancy’ with midwives tending to disagree with women who request a CSMR for this scenario. As both groups are involved in taking care of women whom are in the process of requesting a CS, it is important that they are both advising consistent, accurate and unbiased information. Secondly this study demonstrated that nulliparous women were more likely to disagree that women could choose CS-MR. However, both nulliparous and parous women felt that having one previous CS was not an appropriate indication of requesting another CS. Current practice promotes vaginal delivery after a previous CS as a safe and beneficial option for mode of delivery [12,13]. This response from pregnant women implies that the current education initiatives are successfully promoting vaginal delivery as a safe mode of delivery after previous CS.
Thirdly, uncertainty arose in scenarios involving both instrumental delivery and twin pregnancy. This suggests that these scenarios are viewed with differing risk profiles by women and health care providers and that they both feel less clear about which is the safest mode of delivery. Assessment of risk is an important contributor to women’s views. Since the evidence of the risks and benefits of a planned CS are limited, women will decide themselves what they believe is safer [11]. This highlights the need for clarification of risks in order for women to be accurately informed prior to making the decision [14]. Finally in scenarios 1–3, which many health care professionals would regard as low risk scenarios, the baby’s safety was a key contributory factor that pregnant women felt provoked CS-MR. Whereas healthcare professionals believe that the common reasons are injury to maternal health as opposed to the welfare of the child. These results coincide with previous studies where the most common reasons were fear of childbirth, fear of injury to self
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Fig. 7. Graphs to show the number of responses from nulliparous and parous pregnant women ‘What are the reasons for this request?’ for each specific scenario. Black dots represent parous pregnant women, grey dots represent nulliparous pregnant women. X-axis shows each response option. Y-axis represents the number of responses. P values represent level of significant difference between parous and nulliparous pregnant women.
and concern for the baby’s safety [6,15]. The key message here is that pregnant women fear for their baby’s safety whereas healthcare professionals consider multiple factors that influence the decision to choose a CS-MR. NICE state that a planned CS is more expensive than an uncomplicated vaginal delivery [8]. However, it is difficult to assess how much a complicated vaginal delivery compares with added costs such as interventional delivery and epidurals. CS rates are rising along with the associated cost and operative morbidity, our study suggests that women’s fear for the safety of their baby may be a contributive factor. This is all the more concerning as no clinical benefits of CS have been established.
region of England, therefore these results cannot be generalised across the country where different social classes, culture and attitudes may influence opinions [15]. Furthermore this study is restricted to public hospitals within the National Health Service. Maternal requests for a CS rates vary between private and public sectors. In Brazil, 70% of women in the private healthcare sector have a CS compared with 25–30% in the public health sector [3]. CS rates are higher in developed countries compared with developing countries and these results are unlikely to be representative worldwide. However, even in the developing world, the CS rates are rising, likely due to increasing facilities and greater attention to the prospect of a ‘safer alternative to childbirth’ [16].
Strengths and limitations
Interpretation
This study is an anonymous, questionnaire based study but the sample size was small and limited to two hospitals in the northern
This study has highlighted the divergent views between doctors, midwives and pregnant women for specific scenarios. It
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is important that this discrepancy in views does not hinder the care and support provided by healthcare professionals. Actively listening and exploring pregnant womens views including the use of decision aids and option grids such as those developed from ‘Making Good Decisions in Collaboration’ programmes could be valuable in helping healthcare professionals and pregnant women reach a shared decision most appropriate for each woman [17]. The results from our study showed that concerns for the baby’s safety are of most importance to pregnant women. The national sentinel audit in 2001 showed that women want more information about the risks and benefits of CS and most women participating in the audit wanted a birth that was safest for the baby [16]. Therefore, these risks and concerns need to be addressed by communicating the available evidence and conducting further research to clarify the limited evidence of the risks and benefits of a CS [14]. Until the risks and benefits can be accurately established, the views of pregnant women will remain a dominant force impacting on clinical practice. This study is only scratching the surface in an attempt to understand the multiple factors that influence women to choose a CS-MR. Further research should involve larger sample sizes across multiple centres. Comparison of views between private and public sectors, as well as between women who have chosen a CS-MR with those who did not choose a CS-MR, would help establish the dominant contributing factors. Since 2011, the incidence of maternal requests has risen therefore it would be worthwhile determining whether views have changed with increasing awareness. As the views of pregnant women and healthcare professionals do differ, we could explore further by facilitating more complex interviews and discussions with pregnant women and healthcare professionals. This would give further information so that we can tailor healthcare services to be more patient centred. Conclusion The continual increase in CS rates suggests that more women are choosing surgical intervention over normal vaginal delivery without proven clinical benefit. It is clear there is a gap between the pregnant women’s understanding of risk and that of healthcare professionals, as evidenced in this study. In order to allow women to make an informed decision about the most appropriate mode of delivery, both midwives and doctors need to work together with pregnant women in order to provide relevant support and advice for individuals. Adequate exploration of women’s ideas, concerns and expectations as well as encouraging patient questions and
providing unbiased information about the options available would facilitate the shared decision making process. Acknowledgement We are grateful to Gordon Alexander, Julie Jones, Jane Norman and all the questionnaire participants for their assistance. References [1] NICE Clinical Guidelines. Caesarean section, in maternal request for caesarean section. Royal College of Obstetricians and Gynaecologists; 2011. p. 96–103. [2] Robson SJ, Tan WS, Adeyemi A, Dear KBG. Estimating the rate of cesarean section by maternal request: anonymous survey of obstetricians in Australia. Birth-Issues Perinat Care 2009;36(3):208–12. [3] Potter JE, Berquo E, Perpetuo IH. Unwanted caesarean sections among public and private patients in Brazil: prospective study. Br Med J 2001;323:1155–8. [4] MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008;35(2):293–307. [5] Villar J, Valladares E, Wojdyla D, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367(9525):1819–29. [6] Dursun P, Yanik FB, Zeyneloglu HB, Baser E, Kuscu E, Ayhan A. Why women request cesarean section without medical indication? J Matern-Fetal Neonatal Med 2010 [Early online 1–5]. [7] Klein MC, Liston R, Fraser WD. Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors? Birth 2011;38(2): 129–39. [8] National Institute for Health and Clinical Excellence. Caesarean section costing report (Implementing NICE guidance). In: Basis of unit cost. 2011;p. 17–9. [9] Health and Social Care Information Centre. NHS Maternity Statistics England 2012–2013 – Main tables, 2012–2013 05.12.2013 [cited 2015 24.01.15]. Available from: http://www.hscic.gov.uk/article/2021/Website-Search?productid= 13418&q=caesarean+section+elective+and+emergency&sort=Relevance&size= 10&page=1&area=both#top. [10] Royal College of Obstetricians and Gynaecologists. The national sentinel caesarean section audit report. London: RCOG Press; 2001. 17. [11] D’Souza R. Caesarean section on maternal request for non-medical reasons: putting the UK National Institute of Health and Clinical Excellence guidelines in perspective. Best Pract Res Clin Obstet Gynaecol 2013;27(2):165–77. [12] Walmsley K, Hobbs L. Vaginal birth after lower segment caesarean section. Mod Midwife 1994;4(4):20–1. [13] Solheim K, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta and maternal mortality. J Matern-Fetal Neonatal Med 2011;24(11):1341–6. [14] Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2013;27(2):297–308. [15] Mazzoni A, Althabe F, Liu N, et al. Women’s preference for caesarean section: a systemic review and meta analysis of observational studies. BGOG 2010;118: 391–9. [16] Stanton CK, Holtz SA. Levels and trends in cesarean birth in the developing world. Stud Fam Plann 2006;37(1):41–8. [17] Elwyn G, Lloyd A, Joseph-Williams N, et al. Option grids: shared decision making made easier. Patient Educ Couns 2013;90(2):207–12.
