Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education

Abstract

BackgroundEfforts to reduce unnecessary Cesarean sections (CS) in high and middle income countries have focused on changing hospital cultures and policies, care provider attitudes and behaviors, and increasing women’s knowledge about the benefits of vaginal birth. These strategies have been largely ineffective. Despite evidence that women have well-developed preferences for mode of delivery prior to conceiving their first child, few studies and no interventions have targeted the next generation of maternity care consumers. The objectives of the study were to identify how many women prefer Cesarean section in a hypothetical healthy pregnancy, why they prefer CS and whether women report knowledge gaps about pregnancy and childbirth that can inform educational interventions.MethodsData was collected via an online survey at colleges and universities in 8 OECD countries (Australia, Canada, Chile, England, Germany, Iceland, New Zealand, United States) in 2014/2015. Childless young men and women between 18 and 40 years of age who planned to have at least one child in the future were eligible to participate. The current analysis is focused on the attitudes of women (n = 3616); rates of CS preference across countries are compared, using a standardized cohort of women aged 18–25 years, who were born in the survey country and did not study health sciences (n = 1390).ResultsOne in ten young women in our study preferred CS, ranging from 7.6% in Iceland to 18.4% in Australia. Fear of uncontrollable labor pain and fear of physical damage were primary reasons for preferring a CS. Both fear of childbirth and preferences for CS declined as the level of confidence in women’s knowledge of pregnancy and birth increased.ConclusionEducation sessions delivered online, through social media, and face-to-face using drama and stories told by peers (young women who have recently had babies) or celebrities could be designed to maximize young women’s capacity to understand the physiology of labor and birth, and the range of methods available to support them in coping with labor pain and to minimize invasive procedures, therefore reducing fear of pain, bodily damage, and loss of control. The most efficacious designs and content for such education for young women and girls remains to be tested in future studies.

A Survey of University Students’ Preferences for Midwifery Care and Community Birth Options in 8 High‐Income Countries

“…In the current study, anxiety and depression were not linked to preferences for midwifery care and community birth options. These findings align with results from a previous analysis of sociodemographic and psychological factors that relate to preferences for cesarean without health indications among young women from 8 OECD countries . Fear of physical changes after birth and fear of pain but not depression, general anxiety and stress were significantly associated with increased odds of preferring a cesarean.…”

“…These findings align with results from a previous analysis of sociodemographic and psychological factors that relate to preferences for cesarean without health indications among young women from 8 OECD countries. 15 Fear of physical changes after birth and fear of pain but not depression, general anxiety and stress were significantly associated with increased odds of preferring a cesarean. These results indicate that addressing childbirth fears through education might promote interest in, and comfort with, midwifery care and community birth options and has the potential to decrease rates of unnecessary cesareans.…”

“…14 The second article focused on preferences for cesarean birth without health indications and reasons for this preference. 15 Preferences for cesarean birth ranged from 8% in Iceland to 18% in Australia, with an average of 10% across samples. The main reasons why students preferred cesarean without health indications were fear of labor pain and to avoid physical damage or to maintain vaginal integrity.…”

“…This article is the last in a series based on data collection and analysis in 8 countries in the Organisation for Economic Co-operation and Development (OECD). [14][15][16] The first article described the development of the online survey tool, the forward-backward translation process, and the psychometric properties of a 10-item scale that measures childbirth fear prior to pregnancy (CFPP). 14 The second article focused on preferences for cesarean birth without health indications and reasons for this preference.…”

“…A dose-response relationship between childbirth fear scores and preferences for cesarean was observed; that is, 3% of students who scored in the bottom quartile of the scale preferred a cesarean compared with 23% who scored in the top quartile (ie, reported the highest fear levels). 15 In the third publication, attitudes toward obstetric technology were more closely examined. 16 More than half of students agreed that technology makes birth easier (56%), and half felt that birth technology protects fetuses from harm (49%) and that a woman has the right to choose a medically unnecessary cesarean (51%).…”