Women's role and satisfaction in the decision to have a caesarean section
Deborah A Turnbull, Chris Wilkinson, Anisa Yaser, Vanessa Carty, John M Svigos and Jeffrey S Robinson
MJA 1999; 170: 580-583
Rapid reader response (with authors' reply) added 28/6/99: see Chung
Objective: To examine women's role in the decision to
perform caesarean section (CS).|
Design: Cross-sectional survey. Written questionnaires were completed seven weeks after giving birth by CS.
Setting: An obstetric tertiary referral hospital (Women's and Children's Hospital, Adelaide, South Australia), July to December 1996.
Participants: A consecutive sample of women who underwent CS over a six-month period. To be eligible, women had to be at least 18 years old, able to complete a questionnaire in English and well enough to consent to study participation.
Main outcome measures: Women's involvement in decision making, stated preference for CS, and satisfaction with obstetric care.
Results: 278 women (76.4%) returned questionnaires:
Despite national policy documents calling for a reduction in medical
interventions in birth,1 Australia now has one of the
highest caesarean section (CS) rates among First World
countries.2 At the same time, it is
recognised that the "ideal" or "correct" rate is difficult to
derive,3 given the varying risk
profiles of women attending different institutions. A range of
strategies aimed at obstetricians4,5 have had limited success
in reducing CS rates.
The assumption is often made that the decision to perform a CS is made on clinical grounds only.6 The role of maternal request in decision-making has been raised,7 but so far studies from the woman's perspective have tended to use small samples with unique characteristics.8,9Our study examines the role of women in the decision to have a CS in an effort to identify an alternative approach to lowering the rates.
The study was conducted at the Women's and Children's Hospital in
Adelaide, South Australia. In 1996, this State had the highest CS rate
of any State in Australia (23.1% v. national average of
19.5%).10 The Women's and
Children's Hospital is a major obstetric tertiary referral centre
for South Australia and much of the Northern Territory. In 1996, 23%
(811/3536) of the women giving birth at the hospital were considered
to have very high risk pregnancies and the CS rate for high risk
pregnancies at the Women's and Children's Hospital was 43.9%
(356/811).11 During that year, the
overall CS rate was 25.4% (898/3536).
Over a six-month period (July to December 1996) questionnaires were
sent to consecutive women who underwent CS. To be eligible for our
study, the women had to be at least 18 years old, able to complete a
questionnaire in English, and well enough to give consent to
participate in the study (as decided by the senior midwife on the
We aimed to receive responses from about 288 women having a CS. This would provide a true population proportion of 60% (to within 5%) of women stating they had a say in the decision. To obtain this sample, we allowed for a non-eligibility, non-response rate of about 25% and thus sampled from a consecutive population of 375 women.
The questionnaire was developed on the basis of a review of published
reports, a review of existing questionnaires, and interviews with
women, obstetricians, midwives and perinatal epidemiologists. It
consisted of a combination of questions with forced-choice
responses (mainly presented as a complete statement with a
five-point response scale ranging from "strongly agree" to
"strongly disagree"), open-ended questions and
questions on demographic characteristics. (The
questionnaire is available from the authors.)
Ethical approval was obtained from the Hospital Ethics Committee,
and, with the Committee's permission, a member of the research team (A
Y), not involved in providing care, approached women on the postnatal
ward between the second and fourth day and sought written consent for
participation in the study.
Questionnaires were sent to the participating women's homes seven weeks after the birth, to give women time to recover and to minimise biases such as the "halo" effect and social desirability (ie, the effect on respondents of the intensity of labour; and their tendency soon after the event to be uncritical of healthcare providers, particularly if they think their comments can be attributed to them).12 Follow-up of non-respondents included the mailing of a second questionnaire and a telephone call. A summary of the results was sent to participating women at the conclusion of the study.
|Data analysis||The data were analysed using SPSS for Windows13 and Epi Info 6.14 We assessed whether variables such as age, language spoken at home, age left school, type of care, and type of CS distinguished between those who reported involvement in the decision and those who reported no involvement. Categorical data were analysed by χ2 tests. Point estimates and odds ratios are presented with 95% confidence intervals (CI).|
|Sample||Our sample consisted of 375 women having a CS over a six-month period. Of these, 11 (2.9%) women were not eligible, and 16 (4.3%) were "missed" by the researcher (mainly because they were discharged before contact). Thus, there was a defined sample of 364 women (taking the conservative view that all of the 16 missed women were in fact eligible and thus could be included in the sample). Completed questionnaires were obtained from 278 women (76.4% of our defined sample). The sample included women from a range of sociodemographic backgrounds receiving a diversity of care, including private obstetric care, hospital clinic care and different models of publicly funded midwifery care. About a third of the sample had an elective CS.|
|Women's involvement in decision to have a caesarean section|
|Reasons for the decision to have a caesarean section|
The 171 women who reported involvement in the decision were asked an
open-ended question: "What led you to make the decision to have a
CS?". A content analysis of the 164 responses to this question
indicated that women framed their responses in terms of medical risks
and benefits and not in terms of non-clinical personal issues.
The questions with forced-choice responses gave women the opportunity to reveal that other factors were also important (Table 1). All women were very likely to have been influenced in their decision by information from their doctor. Women who had an elective CS were influenced by factors such as their recovery and the ability to plan. In contrast, women who had an emergency CS were influenced by the physical stress of labour ("I just couldn't go on any longer"), as well their partner's reaction in the labour ward. Other issues which distinguished the two groups were considerations about pain and previous negative experiences of childbirth: and in each of these about twice as many women with an elective CS agreed or strongly agreed that these issues had influenced their decision. In addition, about four times as many women with an elective CS reported that they had been influenced by family and friends during their pregnancy.
|Rejecting alternative options to caesarean section|
We examined women's responses to:|
Fifty of 209 women (23.9%) for whom these data were available reported one previous CS; 17 of these women (34.0%; 95% CI, 21.2%-48.8%) reported that their doctor talked to them about the possibility of having a vaginal delivery, but they did not subsequently try to have the baby vaginally.
Of the total sample, 62 women (22.3%) reported that they had a breech presentation, and were asked "Did the doctor suggest that it would be possible to have the baby vaginally even though it was positioned bottom first?". In 14 of 37 women (37.8%; 95% CI, 22.5%-55.2%) with whom the doctor had discussed this option, the women reported "I decided against it".
The women with a breech presentation were also asked "Did the doctor talk to you about the possibility of turning your baby while it was still in the womb?". In 12 of 39 women (30.8%; 95% CI, 17.0%-47.6%) with whom the doctor had discussed this option, the woman reported "I decided against it".
|Reporting preference for caesarean section|
Women having an emergency CS were less likely to agree with this statement. Demographic factors did not affect the response.
Agreement: 27.9% of 269 women (95% CI, 22.5%-33.2%) (including 13.8% who strongly agreed); 18.8% of 181 women having emergency CS v. 46.4% of 84 women having elective CS (OR, 0.27; 95% CI, 0.15-0.49).
Women having an emergency CS were less likely to agree with this statement, and the only demographic factor affecting the response was educational level, with women in an intermediate category for education being more likely to agree.
Agreement: 21.3% of 268 women (95% CI, 16.4%-26.2%) (including 11.6% who strongly agreed); 13.3% of 181 women having an emergency CS v. 38.5% of 83 women having an elective CS (OR, 0.24; 95% CI, 0.13-0.47), and 29.2% of 106 women in an intermediate education category v. 16% of 159 women in lower and higher education categories (χ2 = 6.31, df = 2, P = 0.04).
Agreement was not affected by demographic factors, but fewer women attending a private obstetrician agreed (non-significant difference), and fewer women having an elective CS agreed.
Agreement: 64.6% of 274 women (95% CI, 58.9%-70.3%) (agreed or strongly agreed); 57.3% of 75 women in private obstetric care v. 68.0% of 178 women in other care (OR, 0.63; 95% CI, 0.35-1.15), and 52.4% of 84 women having elective CS v. 71.0% of 186 women having emergency CS (OR, 0.45; 95% CI, 0.26-0.79).
Interpretation of the results for satisfaction is based on the
assumption that women who answered anything other than "strongly
agree" to positively worded items were not entirely satisfied or
may have experienced problems with their care. This approach has been
recommended in previous research15 and has been applied to
other Australian studies examining satisfaction in
childbirth.16 An appreciable number of
women were only able to "agree" to such items or were "not
sure" about their care (Table 2).
For example, while half the women were satisfied with the decision to
have a CS (as judged by indicating "strongly agree"), a
further 40.9% only "agreed" and 4.7% were "not sure".
Similarly, about a third and a half of women, respectively, were
unable to "strongly agree" that they were "confident in
the final decision" and "believe that caesarean section was
the only alternative". More than two-thirds of women were unable
to "strongly agree" that they had been "given good
information to prepare for the possibility of a CS".
Using the related assumption that we should pay attention to any level of affirmative responses (ie, "strongly agree", "agree", or "not sure") to negatively worded items, it can be seen that about 20% of women reported that they "needed more information on other options". Similarly, between about one in 10 and one in four women expressed some degree of dissatisfaction with the decision-making process.
Over a third of the women in our study felt that they were not involved in
the decision to have a CS, and an appreciable proportion expressed
some degree of dissatisfaction with the decision, or may not have been
given sufficient information.
The strengths of our study include the good response rate and the fact that we used a hospital-based sample of women, including those with private health insurance. This is an important consideration given that about one-third of childbearing women are privately insured.10 The study also avoided some of the pitfalls of recently published research which relied on women giving feedback to the clinicians involved in their care.17
A shortcoming of our study was that it was conducted in only one hospital and may not be representative of women attending other Australian centres. For example, the average age of women in our study was 30 years, compared with a mean age for childbearing women in Australia of 28.6 years.10
The broader implications of the findings need to be considered, and should be the subject of further research. Clearly, there would be public health benefits in increasing the proportion of women who feel that they have been involved in the decision to have a CS, to avoid the possibility of psychological sequelae.18 While this may not be possible for the 50% of women who felt uninvolved in the decision to have an emergency CS, there may be scope for addressing the one in five women who felt uninvolved in the decision to have an elective CS. There are, of course, some absolute indications for CS (eg, major placenta praevia, massive placental abruption where the baby is still alive, transverse lie with shoulder presentation, and cord prolapse before full dilatation), and alternatives in these instances would not be discussed. These defined reasons may comprise up to 5%-8% of all births,19 and may account for a proportion of those who felt uninvolved in the decision-making process.
Our study findings suggest that an informational package would be worth testing in a randomised controlled trial. This package should be broad based, rather than targeted to specific sociodemographic groups. In addition, it should be aimed not only at women, but also their partners, and families and friends. The package, which would include videos, posters and pamphlets, should address issues such as recovery after a CS and the risks and benefits of alternatives to CS. Evaluation of outcomes could be stratified for type of CS (elective or emergency), as it is possible that education would have a more substantial impact on elective CS rates, which appear to be influenced by non-clinical issues outside the labour ward experience. Any such intervention should aim to provide women with balanced information for making a truly informed choice. It is imperative that health messages are not framed in a way that makes women feel inadequate, or that they have failed in some aspect of their pregnancy. To this end, any evaluation of interventions should include outcome data examining not only intervention rates and associated morbidity, but also looking at psychosocial outcomes, such as maternal well-being and satisfaction.
The need for information is well recognised in countries such as Britain, where there has been a major drive to develop evidence-based information pamphlets for pregnant women on issues such as ultrasound scans.20 This is not to suggest that information alone will address the high rates of CS,21 which relate to a multiplicity of factors. However, this strategy may help to create a different clinical climate and would at least partially meet the needs of the almost one in five women who agreed that they needed (or were unsure whether they needed) more information on other options.
|We wish to thank the women who participated in the study. We would also like to thank the obstetricians and the postnatal ward midwives of the Women's and Children's Hospital for their support. This study was funded by a grant from the Women's and Children's Hospital Foundation and was supported by the Department of Public Health, University of Adelaide. Dr Yaser's position was funded by the Commonwealth Government Jobskills Participation Scheme.|
(Received 21 Sep 1998, accepted 30 Apr 1999)
University of Adelaide, Adelaide, SA.
Deborah A Turnbull, MPsych(Clin), PhD, Senior Lecturer in Public Health (Epidemiology), Department of General Practice;
Anisa Yaser, MB BS, Research Officer, Department of Public Health;
Vanessa Carty, MPsych, Research Student, Department of Public Health;
Jeffrey S Robinson, FRCOG, FRACOG, Professor, and Head, Department of Obstetrics and Gynaecology.
Department of Perinatal Medicine, Women's and Children's Hospital,
Reprints will not be available from the authors.
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Reader response to:
Women's role and satisfaction in the decision to have a caesarean section
I commend the authors for this paper. However I wonder if the contention that unless the respondents "strongly agree" or "strongly disagree", the response is mixed is debatable. Patient satisfaction is multidimensional and to focus on patient's response to assess whether for example the information given has been adequate may be unnecessarily harsh on the care givers. Almost all major decisions are accompanied by a degree of regret and doubt by a proportion of people. To infer, unless the patient is entirely satisfied with something, that the care given was somehow less than satisfactory is to demand too much of a complex human relationship, that of a technically dependent patient and a care giver.
I note that only 61.5% felt that they were involved in the decision to have a caesarean section, and only 81.4% in the elective cases where presumably there was ample time to ask for further information. I presume that they had in fact legally consented to the decision. What would have been interesting is a personality study on all the respondents. It may be that information are not the issue but the inherent psychological characteristics of the study subjects.
Information packs may be useful but the decision to consent to a caesarean section rests with the woman alone. Packs aimed at her partner, family and friends may do more harm than good where there are conflicting opinions. One only has to look at the diverse response in this study itself to confidently predict that there will be such conflict amongst any group and an already potentially emotional decision may be further complicated.
Reply by the authors
We would like to thank Dr Chung for his thoughtful reply to our paper. The use of 'strongly agree' and 'strongly disagree' as markers of satisfaction has a precedence in the literature on satisfaction with hospital care.1 Importantly, it has been used in relation to maternity service provision.2 Although this approach may seem unnecessarily critical, it avoids over-simplistic interpretations, as demonstrated in a British report into this issue which concluded (after using disputed methodology) that attempts to reduce caeasrean section rates may be futile, because of women's preferences.3-5
Dr Chung's second point relates to the issue of legal consent. In contrast, our paper examines participation in decision making, for which the signing of informed consent is only one part of a broader process. The paper does not intend to infer that the requirements for informed consent for a procedure have been neglected.
The point about measuring women's personalities is an interesting one. There is research which finds increased psychological morbidity in women demanding caesarean section in the absolute absence of clinical indications.6 In contrast to this somewhat rare individual,6 our study examines a cross-section representing about one quarter of the women at the study hospital. Dr Chung's point implies that the problem rests with these women. This seems an unreasonable assumption to make of such a large proportion of childbearing women. It is imperative that we avoid 'blaming' the women.
Finally Dr Chung is concerned that the provision of information to the broader community may lead to conflict. Our research suggests that there is already an involvement of family and friends in the decision making process. It is for this very reason that we hypothesize that providing evidenced based information may lead to a more beneficial outcome. To this end any randomized controlled trial evaluating such a strategy should include not only clinical outcomes but also psychosocial variables such as anxiety, feelings of failure and reassurance.
1. Carey RG, Posavac EJ. Using patient information to identify areas for service improvement. Health Care Manage Rev 1982; 7(2): 43-48.
2. Brown S, Lumley J. Satisfaction with care in labour and birth. A survey of 790 Australian women. Birth 1994; 21(1): 4-13.
3. Mould TA, Chong S, Spencer JAD, Gallivan S. Women's involvement with the decision preceding their caesarean section and their degree of involvement. Br J Obstet Gynaecol 1996; 103: 1074-1077.
4. Grant JM, Women are satisfied with caesarean section [editorial; comment]. Br J Obstet Gynaecol 1996; 103 (11): 7-8.
5. Hemminki E. Cesarean Sections: Women's choice at giving birth? Birth 1997; 24: 124-125.
6. Ryding EL. Investigation of 33 women who demanded a cesarean section for personal reasons. Acta Obstet Gynecol Scand 1993; 72: 280-285.
Received 18 September 2019, accepted 18 September 2019
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