Giving birth after caesarean: Identifying shared preferences among pregnant women using Q methodology

BackgroundCaesarean rates are rising worldwide, the main contributor being the elective repeat caesarean. During the past decades, rates of vaginal birth after caesarean dropped considerably. This requires insight in women’s preferences regarding giving birth following a previous caesarean.AimTo gain a better understanding of women’s values and preferences regarding the upcoming birth following a previous caesarean. Using Q methodology, this study systematically explores and categorises their preferences.MethodsQ methodology is an innovative research approach to explore and compare a variety of viewpoints on a certain subject. Thirty-one statements on birth after caesarean were developed based on the health belief model. Thirty-six purposively sampled pregnant women with a history of caesarean ranked these statements from least to most important. By-person factor analysis was used to identify patterns which, supplemented with interview data, were interpreted as preferences.FindingsThree distinct preferences for giving birth after a caesarean were found; (a) “Minimise the risks for me and my child”, giving priority to professional advice and risk of adverse events, (b) “Seek the benefits of normal birth”, desiring to give birth as normal as possible for both emotional and practical reasons, (c) “Opt for repeat caesarean”, expressing the belief that a planned caesarean brings comfort.ConclusionsPreferences for birth after caesarean vary considerably among pregnant women. The findings help to understand the different types of information valued by women who need to decide on their mode of birth after a first caesarean.     

Self reported fear of childbirth and its association with women's birth experience and mode of delivery: A longitudinal population-based study

ObjectiveTo explore fear of childbirth (FOC) during pregnancy and one year after birth and its association to birth experience and mode of delivery.DesignA longitudinal population-based study.PopulationPregnant women who were listed for a routine ultrasound at three hospitals in the middle-north part of Sweden.MethodDifferences between women who reported FOC and who did not were calculated using risk ratios with a 95% confidence interval. In order to explain which factors were most strongly associated to suffer from FOC during pregnancy and one year after childbirth, multivariate logistic regression analyses were used.ResultsFOC during pregnancy in multiparous women was associated with a previous negative birth experience (RR 5.1, CI 2.5–10.4) and a previous emergency caesarean section (RR 2.5, CI 1.2–5.4). Associated factors for FOC one year after childbirth were: a negative birth experience (RR 10.3, CI 5.1–20.7), fear of childbirth during pregnancy (RR 7.1, CI 4.4–11.7), emergency caesarean section (RR 2.4, CI 1.2–4.5) and primiparity (RR 1.9, CI 1.2–3.1).ConclusionFOC was associated with negative birth experiences. Women still perceived the birth experience as negative a year after the event. Women's perception of the overall birth experience as negative seems to be more important for explaining subsequent FOC than mode of delivery. Maternity care should focus on women's experiences of childbirth. Staff at antenatal clinics should ask multiparous women about their previous experience of childbirth. So that FOC is minimized, research on factors that create a positive birth experience for women is required.     

Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial

Problem and backgroundCaesarean section (CS) rates in Australia and many countries worldwide are high and increasing, with elective repeat caesarean section a significant contributor.AimTo determine whether midwifery continuity of care for women with a previous CS increases the proportion of women who plan to attempt a vaginal birth in their current pregnancy.MethodsA randomised controlled design was undertaken. Women who met the inclusion criteria were randomised to one of two groups; the Community Midwifery Program (CMP) (continuity across the full spectrum — antenatal, intrapartum and postpartum) (n = 110) and the Midwifery Antenatal Care (MAC) Program (antenatal continuity of care) (n = 111) using a remote randomisation service. Analysis was undertaken on an intention to treat basis. The primary outcome measure was the rate of attempted vaginal birth after caesarean section and secondary outcomes included composite measures of maternal and neonatal wellbeing.FindingsThe model of care did not significantly impact planned vaginal birth at 36 weeks (CMP 66.7% vs MAC 57.3%) or success rate (CMP 27.8% vs MAC 32.7%). The rate of maternal and neonatal complications was similar between the groups.ConclusionModel of care did not significantly impact the proportion of women attempting VBAC in this study. The similarity in the number of midwives seen antenatally and during labour and birth suggests that these models of care had more similarities than differences and that the model of continuity could be described as informational continuity. Future research should focus on the impact of relationship based continuity of care.     

Taking the reins: A grounded theory study of women's experiences of negotiating water immersion for labour and birth after a previous caesarean section

BackgroundWomen seeking a vaginal birth after a caesarean section (VBAC) frequently want to keep their subsequent labour and birth free from intervention. Water immersion (WI) during labour is potentially an effective tool for women having a VBAC for its natural pain-relieving properties. However, negotiating access to WI can be difficult, especially in the context of VBAC.AimTo explore women's experiences of negotiating WI for labour and birth in the context of VBAC.MethodologyThis Grounded Theory study followed Strauss and Corbin's framework and analytic process. Twenty-five women planning or using WI for their VBAC labour or birth were recruited from two midwifery practices and a social media group across Australia. Participants were interviewed during pregnancy and/or postnatally.Findings‘Taking the reins’, the core category explaining the women’s experiences of assuming authority over their birth, comprised five categories: ‘Robbed of my previous birth experience’; ‘My eyes were opened’; ‘Water is my tool for a successful VBAC’; ‘Actioning my choices and rights for WI’, and ‘Empowered to take back control’. ‘Wanting natural and normal’ was the driving force behind women’s desire to birth vaginally. Two mediating factors: Having someone in your corner and Rules for birth facilitated or hindered their birth choices, respectively.ConclusionThe women became active participants in their healthcare by seeking information and options to keep their birth experience natural and normal. Support from other women and advocacy in the form of continuity of midwifery care was crucial in successfully negotiating WI for their VBAC when navigating the complex health system.     

Caesarean section by country of birth in New South Wales,Australia

ObjectiveTo determine rates of caesarean section by country of birth and by obstetric risks.MethodsWe analysed the New South Wales Perinatal Data Collection data of women giving birth between January 2013 and December 2015. Obstetric risk was classified using the Robson’s 10-group classification. Multilevel logistic regression with a random intercept was used to measure the variation in caesarean section rate between immigrants from different countries and between regional immigrant groups.ResultsWe analysed data from 283,256 women, of whom 90,750 had a caesarean section (32.0%). A total of 100,120 women were born overseas (35.3%), and 33,028 (33.0%) had a caesarean section. The caesarean section rate among women from South and Central Asia ranged from 32.6% for women from Pakistan to 47.3% for women from Bangladesh. For South East Asia, women from Cambodia had the lowest caesarean section rate (19.5%) and women from Indonesia had the highest rate (37.3%). The caesarean section rate for North Africa and the Middle East ranged from 28.0% for women from Syria to 50.1% for women from Iran. Robson groups that accounted for most of the caesarean sections were women who had previous caesarean section (36.5%); nulliparous women, induced or caesarean section before labour (26.2%); and nulliparous women, spontaneous labour (8.9%).ConclusionsThe caesarean section rate varied significantly between women from different countries of birth within the same region. Women from some countries of birth had the higher caesarean section rates in some Robson groups.     

Exploring outcomes for women and neonates having skin-to-skin contact during caesarean birth: A quasi-experimental design and qualitative study

ProblemWomen having an elective caesarean birth are often separated from their babies at birth with newborns transferred to a postnatal ward with the significant other.BackgroundTwo midwives were employed in 2019 to provide skin-to-skin contact for women who planned for elective caesarean births in a public hospital in metropolitan New South Wales with 4000 births per year and a 39% CB rate (57.8% of these births being elective).AimTo compare the outcomes for women and their newborns on the effects of skin-to-skin contact at elective caesarean births within the first five minutes of birth to those who did not have skin-to-skin contact and to explore the lived experiences of women having skin-to-skin contact during their elective caesarean births.MethodsA quasi-experimental design study with a qualitative component of in-depth interviews. Quantitative analyses included independent t-tests, chi square and logistic regression. Thematic analysis was used for the qualitative data.FindingsIn the quantitative results, there was a reduction in the time to the first feed (t(100) = ?11.32, p < 0.001) (M = 38.9, SE = 20.7) (M = 124.9, SE = 50.1) and the first breastfeed (t(100) = ?5.2, p < 0.001) (M = 53.2, SE = 82.5) (M = 277, SE = 295.8) with increased breastfeeding on discharge for women that had skin-to-skin contact at caesarean birth in comparison to those who did not receive skin-to-skin contact χ2(1) = 10.22, p < 0.05. In the qualitative results, women who had skin-to-skin contact during their caesarean birth had a positive experience with improved bonding and reported less anxiety and depression than their previous caesarean birth.ConclusionThis study provides evidence of the benefits of skin-to-skin contact during a caesarean birth.     

Caesarean delivery before 39 weeks associated with selecting an auspicious time for birth in Taiwan

BackgroundCaesarean delivery before 39 weeks of gestation increases the risk of morbidity among infants. Taiwan has one of the highest caesarean rates in the world, but little attention has been paid to this issue. This study aimed to describe the rate of caesarean delivery before 39 weeks gestation among women who did not have labour signs and had a non-emergency caesarean delivery in Taiwan and to examine whether the phenomenon was associated with the Chinese cultural practice of selecting an auspicious time for birth.MethodsWe recruited women at 15–28 weeks of pregnancy at 5 hospitals in northern Taiwan and followed them at 4 or 5 weeks after delivery using structured questionnaires. This analysis included 150 primiparous mothers with a singleton pregnancy who had a non-emergency caesarean delivery without the presence of labour signs.ResultsNinety-three of these women (62.0%) had caesarean deliveries before 39 weeks of gestation. Logistic regression analysis showed that women who had selected an auspicious time for delivery (OR = 2.82, 95% CI: 1.15–6.95) and delivered in medical centres (OR = 5.26, 95% CI: 2.25–12.26) were more likely to deliver before 39 weeks of gestation.ConclusionNon-emergency caesarean delivery before 39 weeks of gestation was common among the study women, and was related to the Chinese cultural practice of selecting an auspicious time for birth. Further studies are needed to examine the risks and benefits associated with timing of caesarean delivery in Taiwan in order to generate a consensus among obstetricians and give pregnant women appropriate information.     

Comparison of breastfeeding in rural areas of Sweden and Australia – a cohort study

BackgroundBreastfeeding rates in Sweden and Australia appears to be decreasing in both countries. National statistics shows that 87% of infants in Sweden and 73% in Australia receive any breastfeeding two months of age.AimTo compare women's experiences of breastfeeding in Sweden and Australia and to identify factors associated with breastfeeding two months after birth.MethodsA cohort study in two rural hospitals in mid Sweden (n = 300) and north-eastern Victoria in Australia (n = 91) during 2007–2009. Participants responded to questionnaires in mid pregnancy and two months after birth. Crude and adjusted odds ratios with a 95% confidence interval were used to detect differences between women in both cohorts.FindingsWomen in Sweden (88.3%) were more likely to report any breastfeeding of the baby two months after birth (OR 2.41; 95% CI: 1.33–4.38) compared to women in Australia (75.8%) but were less satisfied with breastfeeding support and information. The most important factor associated with breastfeeding at two months postpartum for the Swedish women was to have received sufficient information about breastfeeding on the postnatal ward (OR 2.3; 95% CI 1.41–4.76) while for the Australian women receiving the best possible help when breastfeeding for the first time was most important (OR 4.3; 95% CI 1.50–12.46).ConclusionThe results indicate that Swedish women were more likely than their Australian counterparts to breastfeed the baby two months after birth. The findings demonstrated the importance of sufficient information and help when breastfeeding is initiated.     

Breech presentation management: A critical review of leading clinical practice guidelines

ProblemClinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations.BackgroundBreech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation.AimThe aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses.MethodsLeading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline.FindingsAntenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations.DiscussionInconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers.ConclusionClinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women’s autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.     

Pregnancy care and birth outcomes for women with moderate to super-extreme obesity

PurposeTo describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity.BackgroundMaternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40.MethodWomen with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women.Results153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1–16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n = 150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n = 74, 48.4%).ConclusionClinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.     

Genital tract tears in women giving birth on a birth seat: A cohort study with prospectively collected data

BackgroundBirth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive.AimThe objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not.MethodAn observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied.ResultsFewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear.DiscussionIt is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.     

Where do low risk women live relative to maternity services across Victoria? Expanding access to public homebirth models across Victoria

ProblemCurrently <1% of Australian women give birth at home.BackgroundIn Australia there are very few options for women to access public funded homebirth.AimWe aimed to use geo-mapping to identify the number of women eligible for homebirth in Victoria, based on the criteria of uncomplicated pregnancies and residing within 15–25 kms of suitable maternity services, to plan future maternity care options.MethodsRetrospective study of births between 2015 and 2017 in Victoria, Australia. All women who were identified as having a low risk pregnancy at the beginning of pregnancy were included. The number of women within 15 and 25 km of a suitable Victorian public maternity hospital and catchment boundaries around each hospital were determined.FindingsBetween 2015 and 2017, 126,830 low risk women gave birth in Victoria, of whom half live within 25 km of seven Victorian hospitals. Currently, 2% of suitable women who live close to the current public homebirth models accessed them.DiscussionWe present a method to inform the expansion of maternity service options using Victoria as an example. On the basis of the maximum number of low risk women living close by, we have also identified the Victorian maternity services that would be most suitable for creation of public homebirth or low risk continuity of midwifery models.ConclusionThis approach could can be used to plan other maternity care services.     

Trust,privacy, community,and culture: Important elements of maternity care for Aboriginal and Torres Strait Islander women giving birth in Victoria.

BackgroundThe Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited.AimsThe aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing.MethodsWomen having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire.Results343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %).ConclusionsThis study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.     

Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women’s experiences and birth outcomes

IntroductionThe ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women’s experiences and birth outcomes.AimTo evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care.MethodAn anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included.FindingsThe response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6–8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes.ConclusionThis innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators.     

Regardless of where they give birth,women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts

QuestionCan differences in Australian birth intervention rates be explained by women's residence at the time of childbearing?.MethodsData were collected prospectively via surveys in 1996, 2000, 2003, 2006 and 2009 from women, born between 1973 and 1978, of the Australian Longitudinal Study on Women's Health. Analysis included data from 5886 women who had given birth to their first child between 1994 and 2009. Outcome measures were self-report of birth interventions: pharmacological pain relief (epidural and spinal block analgesia, inhalational analgesia and intramuscular injections), surgical births (an elective or emergency caesarean section) and instrumental births (forceps and ventouse).FindingsPrimiparous women residing in non-metropolitan areas of Australia experienced fewer birth interventions than women residing in metropolitan areas: 43% versus 56% received epidural analgesia; 8% versus 11% had elective caesarean sections; and 16% versus 18% had emergency caesarean sections. Differences in maternal age and private health insurance status at first birth accounted for differences in surgical birth rates but did not fully explain differences in epidural analgesia.ConclusionNon-metropolitan women had fewer birth interventions, particularly epidural analgesia, than metropolitan women. Differences in maternal age and private health insurance do not fully explain the differences in epidural analgesia rates, suggesting care provided to labouring women may differ by area of residence. The difference in epidural analgesia rates may be due to lack of choice in maternity services, however it could also be due to differing expectations leading to differences in birth interventions for primiparous women living in metropolitan and non-metropolitan areas.