The characteristics of the hospitals from which women were recruited are described in Table 1. The participating hospitals median percentage of birth by CS was 39.5% (29.9% – 45.5%). The number of live births ranged from 1,100 to 7,900 per year. The hospitals are financed by government taxes and are free of charge at point of care. Even though they share a similar financing structure, they differ greatly in workforce numbers and services. The total number of midwifes, obstetricians and residents working in maternal care varied from 8.8 to 40.7 per 1,000 live births, while the number of midwifes ranged from 0 to 8 per 1,000 live births. Only one hospital (Hospital C) had comprehensive pain management interventions available to women 24 hours —, which included access to hot water showers and epidural― and offered an extended schedule of antenatal education. The other four hospitals had limited availability to epidural or non-medical pain management interventions and provided a restrictive antenatal education schedule (e.g. one morning a week). The five hospitals reported to provide safe emergency caesarean surgeries 24/7, as they had access to emergency anaesthetists, blood bank, surgeon, neonatal intensive care unit, operating rooms, and adult Intensive Care Unit. The embolization of the uterine artery was available in only one hospital (Hospital C).
Table 1
Hospitals’ characteristics, CS rates, number of live births and number of healthcare professionals /1,000 births
|
Hospital A
|
Hospital B
|
Hospital C
|
Hospital D
|
Hospital
E
|
Number of live births (2017)
|
1220
|
2798
|
7930
|
2200
|
3467
|
C-section rates (2017)
|
41.3
|
37.6
|
29.2
|
42.3
|
45.5
|
Number of midwifes/1,000 live births
|
13.1
|
0
|
1.6
|
0
|
7.2
|
Number of OBY/GY /1,000 live births
|
16.3
|
8.5
|
3.6
|
6.8
|
6.6
|
Number of trainees in OBY/GY /1,000 live births
|
11.4
|
4.6
|
3.5
|
0
|
0
|
Access to Emergency C-section
|
yes
|
yes
|
yes
|
yes
|
yes
|
Access to Epidural 24 hours. 7 days a week
|
no
|
no
|
yes
|
no
|
no
|
Access to hot shower facilities during birth24 hours. 7 days a week
|
no
|
no
|
yes
|
no
|
no
|
Access to massage, relaxation for pain management 24 hours, 7 days a week
|
no
|
no
|
yes
|
no
|
no
|
Antenatal education offered AM/PM
|
no
|
no
|
yes
|
no
|
no
|
Companionship during VB 24 hours. 7 days a week
|
yes
|
no
|
yes
|
no
|
no
|
Companionship during CS 24 hours, 7 days a week
|
no
|
no
|
no
|
no
|
no
|
The 621 participating women gave written informed consent. Their mean age was 26 + SD 6. 12.4% were adolescents and six out of ten had a VB in the index pregnancy. Women’s median number of previous pregnancies was 1.2 (range 0 to 7) and 40% of them had had a prior CS. Most women who had a VB had someone of their choice during birth (N = 314, 88.5%) while only a third of women who had a CS had companionship during birth (N = 213, 34. %). There were differences across hospitals. In Hospitals B, C, and E most women that experienced a CS birth did not have companionship during birth (Table 2).
Table 2
Women demographics, obstetric history, and mode of birth preferences
|
Total
|
Hospital A
|
Hospital B
|
Hospital C
|
Hospital D
|
Hospital E
|
Number of women interviewed, N (%)
|
621 (100)
|
130 (20.9)
|
127 (20.4)
|
129 (20.7)
|
101 (16.2)
|
134 (21.5)
|
Age, mean (SD)
|
26 ± 6
|
27.4 ± 5
|
25.4, ± 5
|
26 ± 6
|
25 ± 5
|
26 ± 6
|
Parity, median (range)
|
1 (0–6)
|
2 (0–6)
|
1 (0–5)
|
1 (0–6)
|
1(0–6)
|
1 (0–5)
|
Women with previous CS, N (%)
|
171 (40.6)
|
41 (40.5)
|
30 (36.1)
|
31 (35.2)
|
20 (32.7)
|
49 (55.6)1
|
Adolescents (16–19 years of age) N (%)
|
77 (12.4)
|
9 (6.9)
|
17 (13.3)
|
17 (13.1)
|
12 (11.8)
|
22 (16.8)
|
VB in the index pregnancy, N (%)
|
355 (57.1)
|
69 (53)
|
74 (58,6)
|
68 (52)
|
64 (63)
|
80 (59.6)
|
Preference for VB, N (%)
|
467 (75.2)
|
119 (91)
|
87 (69)2
|
108 (92)
|
82 (93)
|
71 (64)2
|
Was accompanied during birth by someone of her choice (total), N (%)
|
404 (65.1)
|
94 (72.3)
|
73 (57)
|
65 (50.4)
|
95 (94.1)
|
77 (57%)
|
Yes BV3
|
314 (88.5)
|
50 (72.5)
|
70 (94.6)
|
60 (88)
|
63 (98.4)
|
71 (88)
|
Yes CS3
|
213 (34.3)
|
44 (72)
|
3 (5.7)
|
5 (8)
|
32 (86.5)
|
6 (11)
|
No answer
|
4 (0.6)
|
|
3 (2.4)
|
|
|
1(0.7)
|
1 Compared against all the other hospitals statistically significant (p0.000 chi square).
2 Compared against all other hospitals statistically significant (p0.000 chi square).
3 Percentage of women that reported being accompanied during birth % over the total number of births on that MOB in that hospital or the total
Most women (N = 467, 75%) preferred VB to a CS; however, the preferences varied across hospitals. In hospitals A, C and D, more than 90% preferred VB over CS, whereas in hospitals B and E this preference was lower, 64% and 69% respectively (chi square p 0.001). A logistic regression model was conducted to explore the association between MOB preferences and maternal obstetric history, age, and hospital where birth occurred. Preference for VB was the reference group. The following variables were associated to MOB preferences: the number of previous miscarriages (OR = 0.58, 95% CI 0.34–0.99), MOB on the index pregnancy (OR = 2.06, 95% CI 0.93–4.55), and the hospital in which delivery took place if CS was the preferred MOB (Hospital B OR 0.14, 95% CI 0.05–0.40; Hospital E OR 0.09, 95% CI 0.03–0.25) (Table 3).
Table 3
Mode of birth preferences. Univariate and multivariate analysis1. Preference for VB is the reference group for the dependent variable.
|
Univariate analysis
MOB preference
Vaginal Birth
|
Multivariate analysis
MOB preference
Vaginal Birth
|
Age2
|
1.0 (0.97–1.04)
|
1.02 (0.97–1.06)
|
Previous miscarriages
|
0.88 (0.59–1.60)
|
0.58 (0.34–0.99)
|
Mode of Birth in the index pregnancy
|
3.96 (2.50–6.28)
|
2.06 (0.9–4.55)
|
Previous pregnancies
|
1.08 (0.92–1.27)
|
Dropped (ns)
|
Hospital in which birth took place
Hospital C3
Hospital B
Hospital A
Hospital D
Hospital E
|
0.90 (0.35–2.25)
0.2 (.10 − 0.40)
1.10 (0.44–2.77)
1.08 (0.40–2.90)
0.16 (0.08–0.24)
|
0.14 (0.05–0.4)
0.70 (0.21–2.37)
0.85 (0.81–3.17)
0.09 (0.03–0.25)
|
1 Vaginal birth preference as the control group
2 Continuous variables
3 Hospital C referent
Women that preferred VB over CS (N = 467, 75%) explained their preferences based on their birth experience —faster recovery after birth (N = 263, 56.3%), more natural/feeling ready (N = 137, 29.3%) ― or in opposition to the birth experience of a CS ―more pain post-partum/you can’t move/you have to stay more time in the hospital (N = 152, 32%) (Table 4). The most frequent reasons for a CS preference (N = 104, 16.7%) fell under two domains: birth experience and safety. The former included not having to go through contractions/not feeling pain during birth (N = 32, 30.7%) and faster procedure (N = 20, 18%). The latter included feeling the procedure is safer (N = 42, 40.3%) and the doctor controls the procedure (N = 15, 14%). Interesting, only women who gave birth at the two hospitals with the lowest preference for VB (Hospital B and Hospital E) explained their preferences using safety as the main reason.
Table 4
Women preferences, MOB in the index pregnancy, and reason more frequently cited by preferences
VB preference
N = 467 (75%)1
|
VB in index pregnancy
|
293 (62.7%)
|
CS in index pregnancy
|
174 (37.3%)
|
Faster recovery after birth
|
263 (56.,3%)
|
More natural
|
137 (29.3%)
|
CS more painful /CS limited autonomy after birth /more time in hospital
|
152 (32%)
|
CS preference
N = 104 (16.7%)
|
Not feeling birth pain
|
32 (30.7%)
|
Faster procedure
|
20 (18%)
|
Safety
|
42 (40.3%)
|
The doctor controls the procedure
|
15 (14%)
|
1 Women gave more than one reason for preference
Women also gave their general opinions on the advantages and disadvantages of VB and CS regardless of the preferred MOB. The most cited advantages for VB were fast recovery (N = 438, 70%), more natural than a CS (N = 311, 49%), feeling less pain after birth (N = 305, 48%), being able to move right after (N = 274, 43%), partner can be present (N = 239, 38%), and requires less time at the hospital (N = 272, 44%). The most cited advantages for CS included not feeling pain (N = 207, 33%), faster process (N = 194, 30%), the prediction of the birth date (N = 189, 29%), not feeling the contractions (N = 181, 29%), safer (N = 119, 19%), can save the baby in an emergency (N = 115,18%), and better for the body/no perineal tears (N = 29,4%).
The most frequent disadvantages of a VB were related to the birth experience (N = 356, 57%), mostly pain (N = 331, 53%) but also perineal tears and discomfort with the physical examination. It is worth noting that a significant proportion of women answered that VB did not have any disadvantage (N = 183, 29.4%) while most women in the sample (N = 503, 81%) mentioned the post-partum experience as the main disadvantage of CS. More specifically, these disadvantages were related to either pain after the procedure, the lack of independence to look after the newborn, or the risk for the mother or the baby.
Six out of ten women responded they would have liked to be asked for their preferable MOB (N = 363, 58.4%), and only 18 answered ‘I don’t know’. The most frequent reasons for wanted to be asked were related to women’s entitlement: the right of women to choose and have her voice considered and valued (N = 242, 38%).
Lastly, women were asked about the circumstances in which a CS is needed. Overall, women cited medical conditions like life risk for the mother or mother with severe disease (N = 345, 55%), baby on breach position (N = 267, 42%), nuchal cord (N = 239, 38%), birth date overdue (N = 201, 32%), prolonged labour/women exhaustion (N = 193, 31%), or having had a previous CS (N = 142, 22%).
Table 5
Women’s views of advantages and disadvantages of CS irrespective of preference
VB advantages
|
Fast recovery
|
438 (70%)
|
More natural
|
311 (49%)
|
Less pain after birth
|
305 (48%)
|
Regaining independence after birth
|
274 (43%)
|
Partner can be present
|
239 (38%)
|
Less time at the hospital
|
272 (44%)
|
CS advantages
|
Not feeling birth pain
|
207 (33%)
|
Faster process
|
194 (34%)
|
Birth date predictable
|
189 (29%)
|
Not feeling contractions
|
181 (29%)
|
Safer1
|
119 (19%)
|
Can save the baby in an emergency
|
115 (18%)
|
No perineal tears
|
29 (4%)
|
1 Women from hospitals with higher preference for CS