PERSONAL BELIEFS AND a fear of litigation are among driving factors for clinicians while making decisions about caesarean sections for first-time mothers, a new Irish study has found.
Some clinicians interviewed by researchers posited that first-time mothers are not as ‘healthy’ as in previous years or compared to other countries, with one consultant claiming that the population of women giving birth in Ireland is “fat, old and short”.
Maternity care expert Dr Krysia Lynch said the study highlights a “lack of partnership between providers and service users and indicates that the pregnant person is not at the centre of their care”.
A team of researchers in Trinity College Dublin interviewed 15 midwives and 20 senior obstetricians from three maternity units to examine the decision-making process behind caesarean sections for first-time mothers, which have steadily risen in number over the last decade.
Analysing the interviews, the researchers identified a ‘fear factor’ in clinicians’ decisions linked to worries about adverse outcomes from vaginal births and the risk of subsequent litigation.
One midwife, for example, said it was “better to do a caesarean that’s not necessary” than “end up with cerebral palsy or something awful than that”.
A senior obstetrics registrar said they felt that society has “become more litigious” and “definitely one of the reasons why the rate of caesarean section is going over the board is the fear of litigation”.
However, two consultant obstetricians felt it did not or should not influence their decisions:
Another key influence raised by clinicians were their personal beliefs and preferences, their interpretations of clinical situations, and their practice pattern.
This included a clinician’s ‘level of tolerance’ and threshold to wait for labour to progress naturally or to intervene early in situation with suspected fetal distress.
Multiple clinicians raised the idea of first-time mothers presenting at ‘increased age at birth and high BMI’ and described those as a factor that influences decision-making.
One midwife said they thought women were “very unfit” and that many first-time mothers were not “young” or “healthy and fit and slim”.
“They’re.. a bit older… a lot heavier… I suppose our diabetes, blood pressure all… are on the rise… so therefore our caesareans are on the rise,” the midwife said, according to the study.
A consultant obstetrician said: “People have been going through a long, hard and expensive process to become pregnant. And I think if I had someone in that age group… saying to me I don’t want any risk for this baby… I would be more than happy… to do an elective caesarean section for someone who is 48 and has probably spent 5 or 6 years trying to get to that point to have a healthy baby at term. So those are the situations.”
Another consultant obstetrician said it “it drives me insane when they keep comparing us to the Netherlands… I mean… they are taller than the average Irish person… healthier [and]. . .slimmer”.
“We are fat, old and short. That’s basically the Irish population of women who are giving birth. So it is a huge influence in terms of what, what the caesarean section rate should be for your country.” (Consultant Obstetrician 10)
Clinicians’ level of ‘experience and confidence’ was also regarded as a major influence, with one midwife noting: “If the obstetrician… doesn’t feel confident.. they might just say that it’s not suitable for vaginal delivery and then proceed to section.”
Or a “midwife manager, who feels that an obstetrician doesn’t have the skill… she might suggest a caesarean would be a better option for the woman”.
Hospital guidelines, infrastructural limitations, and the presence of an experienced and skilled midwife were identified as important factors in the decision-making process.
Some clinicians felt there was a discrepancy between decision-making in private and public hospitals due to factors such as private patients having complex cases but also a lack of transparency in the private sector and women under private care being given more choice.
“I would think in a public clinic where you have a woman who states, I want a caesarean section for back pain, and… you’d strongly encourage her to think of alternatives or to keep an open mind. It’s easier to do that when she’s not paying you for her care,” a consultant obstetrician said.
One senior obstetrics registrar said: “I think there is certainly an element of time keeping, for private consultants, and some of that is unreasonable. It’s just at a certain point they want to get home. But some of it is reasonable as well, in that… they’re expected to be in two places at once, as part of their public job… So they just make a decision to [do a CS].”
Clinicians indicated that some women expressed a preference for having a caesarean section, though some said their perspectives were driven by the information given to them by the clinical team.
One consultant obstetrician said they “completely support” requests for a caesarean section if the patient is “aware of the risks”.
One midwife said: “There is a perception by women that it [CS] is an easy option. I don’t think they look at the long-term health consequences, they’re not aware that the fertility reduces after your first caesarean section, scar tissue, pain down the line… They think it’s the easy option.”
Another said: “Women probably… aren’t as involved in the… actual making of the decision. It’s… discussed with them as… the plan of care and this is what’s going to happen. It’s only women who are very adamant or very strong… might have a very strong birth plan, or birth preferences, who are very well informed that might push for… longer time.”
And another said that “it’s hard for them [women] because they… don’t feel empowered to actually make that decision. They’re pretty much presented with our version of the story… their involvement is quite limited.”
The study concluded that the findings should help clinicians to reflect on their day-to-day practice through identifying potentially-modifiable factors that influence their decision-making, including a reduction of ‘too much, too soon’ types of care.
“This has a potential to help women understand the multitude of factors that can lead to a decision to perform a CS,” the study said.
“The complex nature of decision-making will enable maternity care providers, policymakers and researchers consider broader issues related to organisational, socio-cultural and political context when seeking solutions to stop, if not reverse, the rising CS rates.
“There is potential to implement changes in practice through devising future intervention studies and development of the ‘next step action’ to reduce any inappropriate and/or unnecessary CSs for first-time mothers, and repeat CSs in subsequent pregnancies.”
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