Caesarean section in nulliparous women: a mixed methods study of factors influencing decision-making and outcomes for women - the MAMMI Study Caesarean Section Strand

Abstract

Background: Caesarean section (CS) rates are on a rise over the last number of decades with increased postpartum morbidities, and limited understanding of factors that influence decision-making for CS. Understanding clinicians’ and women’s perspectives is a way to explore these complex factors.

Aim: This research aimed to identify and explore the non-clinical and clinical factors that influence the decision to perform CS in nulliparous women, and to identify postpartum morbidities experienced by women following birth by CS.

Methods: A sequential explanatory mixed methods design was conducted in two phases. Nulliparous women (n=3047) aged ≥18 years, who could read or understand English, were recruited in early pregnancy from three maternity hospitals in the Republic of Ireland, and completed surveys antenatally and at 3, 6, 9 and 12 months postpartum. In the qualitative phase in-depth interviews were conducted with a subsample of women (n=20) who had birthed by CS and clinicians (obstetricians (n=20) and midwives (n=15)) who were involved in decision-making for CS.

Findings: The rate of CS in the study sample was 32.2% (888/2755). Being aged (≥35-40 years) and overweight/obese/very obese, having had treatment for infertility, fetus in breech presentation and being in private care were factors significantly associated with CS. The risk of an unplanned CS increased significantly for women who had an induction of labour and epidural, with (ARR 1.70, 95% CI 1.44-2.01, p<0.001) or without IV oxytocin (ARR 2.06, 95%CI 1.57-2.69, p<0.001). Only a small proportion of women (4.76%) had requested a CS. CS increased the risks of increased blood loss (≥500mls) at birth, increased duration of hospital stay postpartum (≥4 days), increased use of antibiotics, wound infection in the immediate (ARR 7.05, 95% CI 3.09-16.08, p<0.001) and up to three months postpartum (ARR 3.25, 95% CI 2.20-4.79, p<0.001).

Several themes (five from clinicians’ and three from women’s interview data) emerged from thematic analysis of qualitative data. Clinicians: ‘A fear factor’; ‘Personal preferences versus a threshold – clinician driven factors’; ‘Standardised versus individualised care-a system perspective’; ‘Private versus public care’; and ‘Lack of experience or loss of skills and confidence’. Women: ‘I wanted a natural birth, but…’; ‘Involvement in decision-making’; and ‘A timely decision’. Four key findings were derived from integration of quantitative and qualitative findings: ‘A system within the system’, ‘Women’s involvement’, ‘Clinician driven factors’, and ‘Consequences for women’. Findings explored a ‘parallel system’ within the existing system of maternity care, with clinicians believing their decisions to be appropriate and safe, and made in consultation with women, and, women describing themselves as ‘agreeing’ or ‘going along with’ the professional’s decisions while feeling not being involved in the process.

Conclusion: Findings indicated that the factors influencing decision-making for CS are complex. Understanding these complexities has the potential to help reduce the rate of CS through revisiting policies, further research and implementation of strategies.