New research to be published in BJOG: An International Journal of Obstetrics and Gynaecology suggests that ‘choice’ may not be the best way to understand women’s decision-making about birth method. The results of the study question the current focus on choice in UK maternity care policy, and challenge prevailing notions about caesarean delivery for maternal request.
Choice has been established as a central theme in maternity care policy in the UK. Current guidelines highlight the role of women’s preferences in choosing between birth methods such as vaginal birth and caesarean section.
Caesarean delivery on maternal request (CDMR) is a subset of elective caesarean section, performed not by medical necessity, but on request of the pregnant woman. CDMR is perceived as a leading reason for increasing caesarean section rates.
In this study, researchers tracked 454 women at the Liverpool Women's Foundation NHS Trust. The study aimed to explore the views and experiences of women accessing NHS maternity care for the first time, to identify how they report decision-making surrounding birth method. 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 birth.
The key findings indicate that while most women felt that vaginal birth might 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.
The researchers found that women’s preferences changed throughout the course of their pregnancies. By late pregnancy the proportion of women expressing a preference for CDMR had declined to 2%, while those reporting a preference for vaginal birth increased to 80%. The findings stress that choice until the moment of birth is neither static nor final.
Moreover, women felt that health concerns should take precedence in decision-making and entrusted health professionals to act appropriately. Any personal preference, such as convenience, was viewed as secondary to maintaining the safety of the baby.
The study found that the percentage of women who expressed a preference for planned caesarean section was very low. None of the women interviewed thought that they could request planned caesarean section ‘on the NHS’. This was viewed as available only to women with the ability to pay for the operation or women who had experienced a previous traumatic birth.
The authors recommend that for women who do want choice, transparency of actual birth options is paramount. Both women and clinicians should revisit these options at multiple time-points.
Lead author, Dr. Carol Kingdon, from the School of Public Health and Clinical Sciences, University of Central Lancashire, said “This study has highlighted that few women may have any real choice about how they give birth in NHS maternity hospitals. One in four women in the UK now give birth by caesarean section, with maternal request for caesarean delivery supposedly the leading reason as to why national caesarean section rates continue to rise.
“However, our study found that whilst many women supported the principle of choice, in practice their choices were limited by the circumstances of the pregnancy (e.g. baby in breech position) and available care provision. All women felt that medical concerns should take precedence over personal preferences and recognised how any choice expressed can change as pregnancy progresses.”
Prof. Philip Steer, BJOG editor-in-chief, said “This study demonstrates that women remain open-minded when it comes to birth method, and that safety remains a principal concern. The findings also suggest that current debates surrounding CDMR may misunderstand women’s priorities and decision-making.
“Health providers have an important role to play in providing information and in helping women to assess the health risks and benefits of different birth options.”
Ends
Notes
BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Wiley-Blackwell. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote ‘BJOG' or ‘BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal and include the website: www.bjog.org as a hidden link online.
To speak to Dr. Carol Kingdon, please call +44 (0) 79 3574 4004 or email ckingdon@uclan.ac.uk. To speak to Professor Philip Steer, please call +44 (0) 20 7772 6446 or email p.steer@imperial.ac.uk.
Reference
Kingdon C, Neilson J, Singleton V, Gyte G, Hart A, Gabbay M, Lavender T. Choice and birth method: mixed-method study of caesarean delivery for maternal request. BJOG 2009; 116:1-10.
