Childbirth Decision Making Processes: Influences on Mode of Birth After a Previous Caesarean Section

Background: An increasing proportion of Canadian women are experiencing a Caesarean section (CS) and a subsequent repeat CS. While CS can be necessary and lifesaving for mothers and their infants in some situations, it is also associated with greater morbidity risks to women and infants than vaginal birth. Clinical practice guidelines recommend the involvement of pregnant women in making decisions about mode of birth and shared decision making improves the informed consent process. This research examines the factors that influence mode of birth after a previous CS. Methods: Two cross sectional descriptive studies and a prospective pre-post cohort study with control were conducted to investigate the high use of repeat CS at the levels of health care providers, maternity care clients, and the organizational structure of a birthing unit. 1. Interviews and surveys with obstetricians, family physicians, midwives, and nurses were conducted to investigate the attitudes, values, and perceptions that guide their care practices for clients with a previous CS. The specific research question was: What are the factors that influence the practices of maternity care providers (obstetricians, family physicians, midwives, and nurses) regarding mode of birth after a previous CS? Data was analyzed using iterative deductive and inductive coding. 2. Interviews and surveys were conducted during pregnancy and after giving birth with healthy women who have had a previous CS to explore their decision making processes regarding mode of birth after a previous CS. The specific research question was: How do women eligible for a VBAC make decisions about their upcoming mode of birth? A thematic framework approach was used for data analysis. 3. Data from the Better Outcomes Registry and Network (“BORN”) Ontario was analyzed to examine the effectiveness of a hospital based strategy on overall proportions of CS and within Robson groups 1, 2a, and 5. The Caesarean section reduction (CARE) strategy includes interventions that target health care providers, pregnant women, and hospital policies. Results: 1. Maternity care providers would recommend a vaginal birth after CS (VBAC) for healthy pregnant women with a previous CS. They had different perceptions of the safety of birth to the health of women and infants and different approaches to engage in decision making during consultation. Providers believed women make their decision about mode of birth outside of the clinical consultation and often prior to their subsequent pregnancy. 2. The main themes that influenced the decisions of maternity care clients about mode of birth were mothers’ experiential reasoning regarding mode of birth and recovery, experiential knowledge from significant others, scheduling of CS regardless of the mode of birth decision, rating and prioritizing risks, fear of risks, and decisional conflict. When women discussed the factors that impacted their decisions about mode of birth six to eight weeks after they had given birth, the main themes were the recovery experience and fear related to the mode of birth. A lack of time during consultation was identified as a major barrier inhibiting shared decision making, specifically among clients of obstetricians. Other barriers included reliance on routine obstetric practices that are not evidence based. 3. Proportions of CS decreased at the intervention hospital by 3.9% (p=0.0006), from 30.3% (n=964) in 2009/10 to 26.4% (n=803) in 2012/13. During the same time frame, proportions of CS in the control group were stable with 28.1% (n=23,694) in 2009/10 and 28.2% (n=23,683) in 2012/13. Within the Robson classification system, the proportions of repeat CS among all low risk women with a previous CS decreased at the intervention hospital by 5.6% (p=0.0044) from 84.3% to 78.7%. In the control group, also fewer women had a repeat CS over the study period, but the decrease was smaller with 3.9% (p<0.0001) from 84.5% to 80.6%. Conclusion: A true shared decision making process addresses the power imbalance between providers and women through an incorporation of the clinical expertise of providers and the experiential expertise of pregnant women before reaching a decision about mode of birth. The use of routine obstetric practices that are not evidence based inhibited women to make decisions about their mode of birth. The introduction of the CARE strategy to a hospital birthing unit was associated with improvements in proportions of CS and VBAC among low risk women.

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