Cesarean delivery on maternal request: the birth companions  perspective

doi:10.21203/rs.3.rs-5032579/v1

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Research Article

Cesarean delivery on maternal request: the birth companions perspective

https://doi.org/10.21203/rs.3.rs-5032579/v1

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Background

Many personal and cultural factors, including the perception of family members and close friends, influence women´s attitudes towards their mode of delivery choice. This study aimed to explore the experiences, perceptions, attitudes, and birth companion’s beliefs of women who underwent a C-section under request (CDMR).

Methods

This qualitative study used in-depth, semi-structured individual face-to-face interviews, submitted to thematic analysis, under a phenomenological research framework. Participants: Birth companions who were present in the delivery room during the birth or immediately after birth (partner, mother, sister, mother-in-law or friend) were interviewed at a public university hospital in Brazil.

Results

Men preferred vaginal birth and women had a favorable attitude towards cesarean birth, but everyone considered vaginal birth the ideal mode of delivery. Male partners emphasized that they had limitations in advising women about C-sections, as they had never experienced childbirth, and assumed that their role was limited to supporting the women's decision. On the other hand, the female birth companions invoked memories of a birth experience that was positive for C-section or negative for vaginal delivery to support the woman´s choice. Even if cesarean delivery was perceived as involving greater maternal risks than vaginal birth, birth companions justified these risks by the need to 'guarantee' the woman's right to choose.

Conclusions

There is a different attitude towards the mode of delivery between men and women accompanying a parturient who opt for CDMR. Respect for women's decision on mode of delivery is a disseminated concept among birth companions in this environment.

Birth companions

C-section on request

partners

caregivers

labor companionship

Companions during labor is known to improve maternal and neonatal outcomes and support women to have a positive birth experience (1). However, cesarean birth rates at maternal request have grown significantly around the world, reaching a global rate of 21.1%, varying from 5.0 to 42.8% in different regions (2), this decision in relation to birth appears to be influenced by the attitude of health professionals, especially doctors (3). In the literature, there is a lack of information about birth companion’s perspective and how can influence in the women decisions making related with labor and birth. The people women choose to accompany them during labor to provide emotional support, advice, information, comfort, and other forms of assistance to help the woman cope with labor and birth(4).

However, there are short and long-term risks, both for the woman and the newborn, related to cesarean birth without clinical indications, which cannot be ignored (2)(5). In Brazil, cesarean section rates continue to increase, keeping the country in a prominent position among those with the highest rates in the world (4). If there are regions where there is still a need for efforts to make the procedure accessible to those in need, in other regions the clinical indication cannot explain the rates and distribution of cesarean deliveries.

Social norms and expectations of partners, relatives and friends influence women's perceptions and decision-making to request a C-section. So birth preferences must be understood within women's contexts, as the factors lead her choices is Multifaceted (6) (7). Several studies seek to explore the factors that determine its use, and complex and interconnected factors emerge that point to the woman's socio-demographic context, beliefs and attitudes, financial conditions, hospital characteristics and the profile of professionals involved at the time of birth, in addition to cultural aspects (8)(3)(9)(5).

There are interventions seeking the success represented by safe vaginal birth and experienced as a positive experience. Among them, several studies consider that continuous support for women in labor through the presence of a birth companion or doula (partner or other person of the woman's desire) during childbirth is beneficial (1).

Nevertheless, family members and people close to them may have different perceptions about the procedure. They can contribute to a deeper understanding of the woman's acceptance and request for a C-section, especially if they have had previous birth experience. In Brazil, pregnant women have had the right to choice birth companion to support her during the labor, birth and postpartum since 2005 (4).

However, the role of birth companions and their experiences in supporting women during prenatal care and childbirth, how they perceive, support or oppose their choice, and how they interact with women when they are making decisions about childbirth is hardly ever studied. Therefore, it is important to explore birth companions’ perspectives on CDMR to understand how they could help to prevent unnecessary C-sections. The study aim to explore the experiences, attitudes, perceptions and beliefs of birth companions regarding CDMR in a Brazilian university hospital.

Study design

This is a qualitative study, with a phenomenological approach, using semi-structured interviews. The data were analysed according to the phenomenological method of psychological and human science (10, 11). Phenomenology aims to describe the essence of the meanings expressed by participants about their experiences, distancing themselves from pre-established theories, beliefs or criticism. The researcher puts the world in brackets, stripping away the necessary judgments about what is happening and how the other person expresses their experience to understand the peculiar and singular way of the reported experience, also called phenomenological reduction (10, 12).

Selection of participants

A companying person during labour/delivery and/or post-partum, aged 18 years or older, were eligible to participate. Initially, the principal investigator accessed daily the list of women who had CDMR, at the electronic hospital database system. Their companions approached in the postpartum care ward were invited to participate. The Informed Consent Form was presented and offered, and after clarifying any doubts, the ones who agreed to participate signed the Consent Form.

To carry out the study, ethical standards for research involving human beings in the country were followed and the research project was approved by the Research Ethics Committee of the State University of Campinas (UNICAMP), under CAAE:65052722000005404.

Data collection

The interviews were carried out by a master's student (CSM), of Mozambican nationality, who has higher education in public health and who is inserted in a different cultural context from Brazil, with regard to cesarean section. The interviews were carried out in a private room. An interview guide was developed consisting of open questions, which were discussed and pre-tested. It covered sociodemographic aspects, experiences with C-sections, previous knowledge about birth options, risks and benefits, and the attitude of birth companions on women´s request for C-section.

The interview was carried out on the second or third day after CDMR and lasted 15 minutes on average (ranging from 8 to 23 minutes). The questions were asked in Portuguese and participant’s response were recorded and transcribed without identifying the participants. Saturation determines when to stop interviews.

Data analysis

Data analysis was carried out according to the guidelines proposed by Braun and Clark (13) After multiple readings of the transcripts, the main researcher generated a list of codes that reflected relevant aspects of the data. Two researchers accessed similarities, patterns and differences between respondents and defined themes, using Nvivo®. Once the themes were defined, all responses were read again, categorized and regrouped.

We carried out a total of 14 individual interviews, six with women and eight with men. Women were between 21 and 57 years and men were between 21 and 55 years old. Most male birth companions were white, had completed at least high school, had a family income of up to two minimum wages ($ 544.64), and lived with the women they were accompanying to. Some female birth companions, who lived elsewhere, have moved to support the woman in the postpartum phase. The sociodemographic characteristics of participants are presented in Table 1.

All birth companions of them had birth experience or attended the birth of someone close to them. Some female birth companions have had elective or emergency cesarean deliveries, while some men became fathers for the second time and had already attended a previous cesarean or vaginal birth.

Table 1

Characteristics of Birth companions of women undergoing cesarean section at maternal request
Participant	Age	Education	Skin color	Relationship with woman	Number of children	Type of own or witnessed birth
P1	53	Primary	white	mother	Three	Caesarean
P2	32	High school	white	sister	one	Caesarean
P3	48	Primary	white	mother-in-law	two	Cesarean and vaginal
P4	27	High school	black	partner	None
P5	45	High school	brown	partner	one	Caesarean
P6	29	High school	brown	partner	none
P7*	21	Primary	white	partner	two	Vaginal
P8	57	Primary	white	mother	three	Vaginal, with forceps and cesarean section
P9	43	Primary	white	partner	one	Caesarean
P10	48	High school	brown	mother	one	Caesarean
P11*	51	Primary	white	partner	two	Vaginal
P12	29	Primary	brown	partner	none
P13	33	Higher ed	white	partner	one	Caesarean
P14	39	Primary	white	partner	one	Caesarean

P – Participant *- has children from another marriage

Many female perspectives on CDMR were influenced by beliefs about the risks of vaginal birth in contexts where there are few options for pain relief, but also by having undergone an emergency C-section, often after having experienced labor. For accompanying men, their main role should be to support their partners' decisions as a way of safeguarding their autonomy, in addition to declaring their lack or little knowledge about the labor process, which restricted their contribution to the decision making about the birth.

Three final themes emerged: 1) Supporting the woman's decision 2) Negative experiences in the previous birth 3) the Need to 'guarantee' the woman's right to choose a more comfortable birth. Below is a summary of each theme that emerged from the analysis.

1) Support the woman’s decision

All birth companions considered vaginal birth to be the preferred mode of delivery in the absence of medical indications for C-section. Nevertheless, women were generally more positive about C-sections than men. Having little knowledge on the subject, they considered that their biggest role was to support the woman's decision since she was the one who would go through labor and experience all the phases of childbirth. Although it was a shared decision, they felt that the woman's word should always prevail.

“I don't know exactly what the advantages and benefits are. I always, you know, I followed my mother's pregnancy, I followed the pregnancy of some of my sisters, right, and they always opted for a natural birth precisely because the recovery was easier, better, had less pain and so on, you know, to be able to have a better recovery. So, our initial option was also for the birth to be natural, right, but due to the health problem she had, right, and so on, we preferred to do a C-section.” (P6 first-time father)

2) Negative experiences in the previous birth

Some of the birth companions, particularly women, had memories of negative experiences of vaginal birth. Many times, the woman in labor had to undergo an emergency C-section after prolonged labor or after a failed induction. They reported how painful it was to live or see someone close to them going through these situations. They consider that CDMR guarantees the well-being of the mother and the newborn.

“So, I had three children, the first child was normal, I don't know what was happening, the doctor had to climb on top to try to push the baby out. So, it was horrible. My daughter, the second, didn't wake up, she just slept. So, it wasn't normal. And she tried in different ways, hours and hours of suffering and then they removed the iron base, I can't say which birth it was, which hurt her all over. She was badly hurt in her arms and head. But it was a very long birth. And the last one, I didn't have anything because I had a C-section. I suffered nothing. So, I said, oh, daughter, if you do what is normal, you will have an attack of agony." (P8 mother, two previous vaginal deliveries and one CS)

3) To “guarantee the well-being” of the mother and newborn

Other birth companions considered that there were concerns that did not leave them at ease regarding the possibility of the woman having a natural birth. Generally, the concern was with the size of the fetus or some health problem of the mother. The knowledge about the right to choose the type of birth, justified the choice of C-section, even recognizing the benefits of vaginal birth.

"We follow the information a little, we know about the laws that exist, right, that support pregnant women at this time. So, we chose to do the C-section precisely because we knew that, based on the law, she could already request this C-section. Because the baby was quite big, what they say, I don't know. And we knew that she would have difficulty having a natural birth. So, we chose to have a C-section precisely to prevent any risk that could occur during natural birth.” (P6, first-time father)

There were divergent opinions among companions on the issue of CDMR, and it varied depending on the socioeconomic level and birth experience of those involved. Although most of them considered cesarean birth preferable to guarantee health and well-being in situations where there is a condition of concern for the fetus or mother, positive attitudes towards vaginal birth were also observed.

The perspectives of birth companions regarding childbirth, their experiences and attitudes in the decision-making process of requesting a C-section in an environment with a high incidence of C-sections emerged in this study. The positive attitude towards C-sections accompanies a tendency towards normalization of this method of birth, based on the perception that it is safer and suits the lifestyle of women (14). However, this perspective differs from that observed within birth companions communities which see cesarean birth as a risk to the mother's life, usually living in regions with few resources (2).

Birth Companions who have already experienced cesarean birth disregarded the complications of abdominal surgical birth when talking or giving guidance to other women. These complications include post-operative pain, late breastfeeding, low Apgar, healing problems, longer recovery time and complications in subsequent pregnancies with abnormal placentation, previa and accreta, as well as respiratory and immunological problems that children can experience during childhood (15). Therefore, greater dissemination of these findings to parturient women and their potential birth companions is necessary to support decisions adequately informed.

A fact that reinforces the need for a C-section in the absence of clinical or obstetric indications is the intention of not having more children in future. In Brazil, a federal law (14.443, Sept 2, 2022) authorizes tubal ligation for women during delivery after appropriate counselling during antenatal care (16). Thus, arguments related to protecting the reproductive future have no impact on reflections regarding the risk of unnecessary C-sections. This also differs from studies carried out in developing countries, where cesarean birth is seen as a limitation on the number of children and not desired (7).

No other studies were identified on the perspectives or influence of birth companions on women´s requesting a C-section. Although the present study was carried out in a reference centre for high-risk pregnancies, not representing the general population, it is clear that women's birth companions of this group consider that this mode of delivery can guarantee good results. They neglect or minimize maternal and newborn complications, and they do not have a clear understanding of their long-term consequences. Similar findings have also been reported in other studies (17–19). Therefore, it is necessary to find an effective way to communicate and discuss such risks with birth companions, in addition to women requesting C-sections without medical indication.

Interviewing the birth companions individually allowed them greater freedom to express their opinions, including negative feelings about the decision to have a cesarean or vaginal birth. As we included female and male birth companions, we were able to capture their convergent and divergent perspectives on CDMR. The qualitative design made possible to explore how abdominal deliveries were viewed in the social context of women who underwent C-sections under request and understand surrounding perceptions influencing their birth preferences.

The fact that this study was carried out in a reference service for high-risk pregnancies limits the interpretation of the results to a broader population. Nevertheless, it made explicit the external influences on women´s decision. As all qualitative results are defined by the specific context in which they occur, generalization is often restricted (20).

The World Health Organization (WHO, 2018) proposed many interventions to reduce unnecessary C-section (21). It includes educational interventions for women and families to support decision-making on mode of delivery, use of clinical guidelines, audits of caesarean sections, and timely feedback to health professionals about caesarean section practices and requirement for second opinion for caesarean section indication at point of care in settings with adequate resources(21, 22). A well-informed companion can support women in exercising their autonomy and choice, considering technical and clinical aspects, in addition to subjective perceptions about the route of delivery, largely influenced by culture.

The C-section culture that made Brazil experience a progressive increase in its rates, from 10% in the 1960s to 51% in the 20th century, normalized this method of delivery. And the federal law Nº 2.284/2020 regulates the right for women to request a C-section, to be performed at 39 weeks or later (23). The level of abdominal deliveries raised concerns among researchers and those who deal with health policies. Nevertheless, the implementation of programs to reduce unnecessary C-sections faces a very unfavorable environment, putting pressure on health professionals and women that maximizes risks and perceived inconveniences of vaginal birth.

This study offers a deeper understanding of the reasons behind requesting a C-section and the attitudes of important supporters, who can have a major influence on women's decisions. We understand that the results can guide future interventions on supporting vaginal delivery if future birth companions can participate more actively in counselling sessions during pregnancy. Sharing these important moments may emerge as an opportunity to help women reflect and be more confident about the safety of vaginal birth, feeling their partners, close relatives, and friends support them.

Support from someone chosen and trusted by women during birth is an effective strategy for a successful birth. These results highlight the importance of guiding the risks and benefits of different delivery modes to birth companions, since they may play an important role in supporting pregnant woman in making their decision.

We certify that the data contained in this manuscript is original and has not been published, has not been submitted, and is not being submitted elsewhere.

Conflict of interest: The authors do not have any conflict.

Ethics approval and consent to participate

The internal review boards of UNICAMP -Institutional Review Board, Faculty

of Medicine, University of Campinas, SP, Brazil (CAEE: 65052722000005404)

All the participants gave their informed consent verbally in their presence, with their consent written. The research followed the determinations of the Declaration of Helsinki, as well as the norms that regulate the research involving human beings in Brazil.

Consent for publication

Not applicable.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding sources

There is no funding source for this study. The first author, an MSc student, received a fellowship from HRP/WHO.

Authors’ contributions

CSM, CB and EA designed the study.

CSM and LF collected the data.

CSM, CB, SB and EA analyzed the data.

CSM wrote the first draft and CB, SB, and EA contributed to the final version. All authors read and approved the final manuscript.

Acknowledgements

The authors thank all the birth companions who participated in this study, would not have been possible without their time and generosity, as well as, all the health professionals in the CAISM.

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No competing interests reported.

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You are reading this latest preprint version

Cesarean delivery on maternal request: the birth companions perspective

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

INTRODUCTION

METHODS

Study design

Selection of participants

Data collection

Data analysis

Results

1) Support the woman’s decision

2) Negative experiences in the previous birth

3) To “guarantee the well-being” of the mother and newborn

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1