Factors influencing decision-making for caesarean section in Sweden – a qualitative study

Abstract

BackgroundRising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians’ and midwives’ perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden.MethodsA qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin.ResultsThe thematic analysis resulted in three main themes; ‘Belief in normal birth – a cultural perspective’; ‘Clarity and consistency – a system perspective’ and ‘Obstetrician makes the final decision, but...’, and each theme contained a number of subthemes. However, ‘Belief in normal birth’ emerged as the core central theme, overarching the other two themes.ConclusionFindings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a ‘team approach’ helped them achieve their goal and keep their CS rate low.

Shared decision‐making in maternity care: Acknowledging and overcoming epistemic defeaters

“…In general, obstetricians are seen as more likely than midwives to agree to a women's request for CS . A recent study, interviewing 11 midwives and five obstetricians in Sweden, where the CS rate is only 17%, found that women were very involved in decision‐making for most aspects of care, including CS on request in very rare situations . The midwives described how women who were fearful of birth were cared for:

“We have Aurora, counselling team with midwives.

…”

“…[A] woman who wish for a CS comes to this counselling programme and talks to a midwife, so we give them options like induction, pain relief, birth plan and … a CS contract. Which means when… in labour [if] the woman feels that it's too traumatic or too painful… she can by herself request for CS… And when they have this contract they feel … in control…” (FGI with Midwives, Site 1).” (p4)…”

“…This description seems to epitomize SDM at its best and, as can be clearly seen from the overall low CS rate, did not lead to high intervention rates because the Swedish clinicians had an overriding belief in, and support of, normal birth, the term commonly used to convey no interference with physiological labour and birth processes.…”

“…Despite the acceptance of health care professionals in various countries of the principle that women should be able to choose a CS birth, in general, they do not think that women should be allowed to refuse a CS when their care givers believe it is necessary. In a Swedish study by Panda et al, women had little role to play in decision‐making around unplanned (“emergency”) CS, yet because of the culture of belief in normal birth and SDM, CS rates remained low. An Australian study by Bryant showed how, in the following situation of a country with high CS rates, women were not accorded the right to an informed choice, let alone any SDM:

“You must distinguish between the attempt at vaginal delivery and an elective Caesarean section.

…”

“…[19][20][21][22] A recent study, interviewing 11 midwives and five obstetricians in Sweden, where the CS rate is only 17%, found that women were very involved in decision-making for most aspects of care, including CS on request in very rare situations. 23 The midwives described how women who were fearful of birth were cared for: 23(p4) This description seems to epitomize SDM at its best and, as can be clearly seen from the overall low CS rate, did not lead to high intervention rates because the Swedish clinicians had an overriding belief in, and support of, normal birth, 23 the term commonly used to convey no interference with physiological labour and birth processes. (obstetrician 1)."…”