© Springer International Publishing Switzerland 2017
Giorgio Capogna (ed.)Anesthesia for Cesarean Section10.1007/978-3-319-42053-0_1515. Maternal Expectations and Satisfaction with Caesarean Section
(1)
Centre for Maternal and Child Health Research, City University London, London, EC1R 0HB, UK
(2)
School of Psychology, University of Sussex, Brighton, East Sussex, UK
15.1 Introduction
Human reproduction is a critical and life-changing process which depends on complex biological, psychological, social, and environmental factors. Pregnancy and birth are surrounded by many cultural beliefs and rituals which influence women’s expectations and experiences [1, 2]. Maternal mortality and morbidity are low in high-income countries and reducing in low-income countries. Surgical intervention in the form of caesarean section has certainly increased the safety of birth with the World Health Organisation estimating caesareans are necessary in 10–15% of births to reduce mortality and morbidity for women and their babies [3]. However, the overall rate of caesarean has risen well above this in high-income countries: the USA and the UK seeing rises to 25–32% over a 20-year period to 2015. Rapidly developing countries such as Brazil and China have seen even greater increases with no significant improvement in perinatal outcomes. There are many possible reasons for the consistent increase in caesareans, including an increase in risk factors such as maternal obesity, maternal anxiety over the risks of vaginal birth [4, 5], convenience for medical staff or women of scheduled births [6, 7], and the popular phenomenon cited in the media of women being ‘too posh to push’ for which there is very little evidence [8]. None of these factors consider the risk of the anaesthetic and surgical procedure. Although the numbers of maternal deaths from anaesthetic complications are small and falling [9, 10], surgical procedures of any type carry a risk, which can be exacerbated by pre-existing comorbidities and also by pregnancy itself [11]. With these factors in mind, this chapter looks at what women expect in relation to birth and caesarean section, how they experience birth by caesarean section, and how caesareans can be managed to improve the experience for women.
15.2 Expectations of Birth and Caesarean Section
Birth is a significant life event for women and their partners, and women have detailed expectations of events of pregnancy, labour, and birth. Expectations are important because they influence a woman’s choices about where to give birth, how to give birth, and use of pain relief. The widespread provision of antenatal classes during pregnancy is partly driven by the assumption of a causal relationship between a woman’s expectations and her experience of birth. The first proponent of antenatal classes, Read [13], believed that expectations of pain caused fear and that this fear resulted in increased tension and therefore pain during labour. Read argued that if women are educated so they change their expectations and learn relaxation techniques to combat tension, then pain will be reduced. Although research does not provide unequivocal support for the attendance at antenatal classes leading to a reduction of pain in labour [13], the incorporation of antenatal classes is now an accepted part of antenatal care.
Women’s expectations of birth are complex and dynamic. Research shows most women have well-formed expectations of many aspects of childbirth, the baby, their own role as a parent, and their partner’s role as a parent. Women hold both positive and negative expectations of different aspects of birth, such as emotions, control, pain, and obstetric events, as well as detailed expectations regarding assistance with baby care, household tasks, emotional support, financial help, and their relationship with the baby [14]. These expectations are continually refined and developed with new information and experience [15].
The expectations a woman has will influence her birth experience and satisfaction with birth [16]. Positive expectations of birth are associated with greater control in birth, greater satisfaction, and emotional well-being [16–18]. Conversely, negative expectations are associated with finding birth less fulfilling, being less satisfied with birth, and reporting less emotional well-being after birth [17, 18]. There is also evidence that if a woman’s expectations are not met they are more likely to report negative experiences and poor satisfaction. For example, a study of 1700 women in Norway found that women who wanted an elective caesarean but had a vaginal delivery had significantly more post-traumatic stress symptoms following birth, compared to women who wanted and had a vaginal delivery. Interestingly, women who wanted a caesarean and had one, or who wanted a vaginal delivery but had a caesarean, did not have greater symptoms of traumatic stress [19]. The authors suggest these results may be due to women who are frightened of childbirth requesting elective caesareans and being more likely to have negative experiences and symptoms of traumatic stress if they are denied a caesarean. It is therefore important to listen to maternal requests for caesarean and identify if there are psychological reasons underlying these.
The way in which the baby is delivered is one of the most significant factors in the healthy completion of pregnancy [20] and important in terms of women’s choices and expectations. It is important to emphasise that most women expect their baby to be born vaginally [1, 21]. The majority of women also expect labour and birth to be painful. For example, a study in Jordan found that the majority of primiparous women expected childbirth to be a frightening, long, and painful process. However, most of these women still expected to have a normal vaginal birth [22]. A review of the literature on women’s expectations and experiences of pain found many women underestimate the pain they will experience and hope to cope without pharmaceutical pain relief [23]. Women differ in their choices and expectations of pain relief with some preferring pharmaceutical methods and others preferring non-pharmaceutical methods. However, evidence suggests the majority of women who say in pregnancy that they want to try to cope without pain relief end up having some form of analgesia [24]. The review of expectations and experience of pain therefore concluded that ‘women may have ideal hopes of what they would like to happen with respect to pain relief, control and engagement in decision-making, but experience is often very different from expectations’ [23].
An important influence on women’s expectations and experiences is anxiety and fear of childbirth. Fear of childbirth occurs in between 7 and 26% of pregnant women [25, 26], with a smaller proportion developing extreme fear or tokophobia [27]. The BIDENS study of 7200 women in six European countries found significant differences between countries with prevalence of severe fear of childbirth ranging from 1.9 to 14.2% [28]. Symptoms include high levels of anxiety about pregnancy and birth, fear of harm or death during birth, poor sleep, and somatic complaints. As with most psychological problems, the cause of fear of childbirth is multifactorial. It has been associated with factors such as nulliparity [29], increased gestation [29], poor mental health [26, 30], a history of abuse [31], younger age [26], lower education [26], and low self-efficacy [32]. Although fear of childbirth is more common in nulliparous women, women who have a negative or traumatic experience of birth are almost five times more likely to report fear of childbirth in a subsequent pregnancy [33]. The importance of traumatic birth experiences and fear of childbirth is apparent from the impact it has on women’s preferences for intervention during birth. There is good evidence from large epidemiological studies that women with fear of childbirth are more likely to want interventions such as epidural analgesia and caesarean sections [27, 29].
15.3 Experience of Birth and Caesarean Section
How women experience caesareans and the impact of caesarean on their satisfaction and mental health is not straightforward. Al Nuaim [34] observes from clinical experience in Saudi Arabia that women who deliver by caesarean are often less satisfied with their experience, and with themselves. Al Nuaim argues they might experience feelings of resentment towards the physician, profound disappointment at the treatment expectation, and loss of the happy moment of natural birth which may lead to post-partum depression. Caesarean delivery also carries considerable disadvantages in terms of pain and trauma of an abdominal operation and complications associated with it. This is an interesting comparison to the conclusions drawn by Hobson [35] in which when exploring the psychology of successful caesarean birth, she proposes that well-supported women with a successful outcome rationalise this after the event to assimilate the caesarean birth as a personal, positive event that was right for her in these circumstances.
Whether a woman’s birth matches her expectations might also be important. Retrospective studies that ask women whether their birth was as expected consistently find that poorer psychological outcomes are associated with birth being worse than expected. Findings from prospective studies where expectations are measured in pregnancy so a more ‘objective’ measure of the difference between expectations and experience can be calculated are more rigorous. Findings from these studies are mixed but increasingly provide support for the importance of the match between a woman’s expectations and experience. For example, a prospective study of over 700 women in Israel found lowest satisfaction in women whose deliveries were different to how they planned. Poor satisfaction was reported by women who planned a natural birth but experienced emergency caesareans or unplanned epidural use, and/or women who felt they had low control over what staff were doing or over the birthing environment [36].
An emergency caesarean is likely to be frightening for most women and their partners. There is now substantial evidence that women who have assisted deliveries or emergency caesareans are at greater risk of experiencing birth as traumatic and suffering from post-traumatic stress symptoms after birth [37], as well as developing severe fear of future childbirth. This is supported by Jolly et al.’s [38] work on the sequelae of caesarean section and its effect on future pregnancies, birth, and neonatal outcomes for the women concerned. Fear of further pregnancy stands out in this study with 13% more women who had a primiparous caesarean section not having a second child after 5 years when compared to those who had a normal vaginal birth. Similarly, as we have seen, severe fear of childbirth is associated with preference for an elective caesarean. The literature on evidence for medical and psychosocial reasons for requesting an elective caesarean currently makes opposing recommendations. On the one hand, a Cochrane review concluded there is no robust medical evidence to support the recommendation of caesarean for non-medical reasons [39]. On the other hand, a review of women’s reasons for requesting elective caesareans found most women do so because of a previous traumatic birth experience [40]. The latter review also found that most women chose caesarean surgery in the belief that it would enhance safety for themselves and their infant [40] indicating a need to listen to women and discuss their preferred option, along with information on risk and safety for this and other options.
However, it is clear that not all women who have emergency caesareans develop post-traumatic stress symptoms or fear of birth. Research also shows that women who have elective caesareans do not have the same low satisfaction [41] or traumatic stress response [19] as women who have emergency caesareans. This led Spaich et al. [42] to conclude that the actual mode of delivery may not have a direct influence on women’s satisfaction with childbirth but is mediated by maternal involvement in decision-making, support during labour from a person of trust, and effective analgesia, all of which play a major role in providing a positive birth experience for women. Hobson [35] and Hobson et al. [43] add to this list the importance of providing information to women. The way we care for women before, during, and after caesarean is therefore critical.
15.4 Improving Satisfaction with Caesarean Birth
Patient satisfaction has become an important factor for all areas of health care in industrialised societies [44, 45]. Problems conceptualising and measuring satisfaction have been widely discussed and need to be borne in mind when interpreting the evidence [46]. However, despite these problems there is substantial evidence that a satisfied patient will be significantly more likely to engage with healthcare services, be amenable to treatments and recommendations and achieve more successful health outcomes. In the UK, the Department of Health (DH) has emphasised the importance of choice in maternity services. Reports on Maternity Matters, Choice, Access and Continuity of Care in a Safe Service [47] and Making It Better for Mothers and Babies [48] both emphasise that all women should be able to choose their place of birth in terms of home birth, midwifery-led birth units, or obstetric units. A recent extensive review of maternity services in England which consulted with women and stakeholders over a year concluded that consistent support for women, coupled with an individually tailored maternity service, is important and likely to increase safety and positive birth outcomes as well as satisfaction with care [49].
As we have seen, it is important not to conflate caesareans with poor satisfaction or negative psychological outcomes. Although poor psychological outcomes are more likely following a caesarean, the evidence shows this is not necessarily a causal relationship. Emergency caesareans can be stressful due to the context in which they are needed, but a woman’s experience can still be positive if staff provide support, information, and involve women in decision-making. This is illustrated by the case study in Box 1 of a mother who had two babies by caesarean, one of which was a traumatic experience and the other a very positive experience. This case study also illustrates the potential long-term impact a traumatic experience can have on the mother and the baby. Guidelines from the Birth Trauma Association on how to reduce the likelihood a woman will find birth traumatic are shown in Box 2.
Box 1. Case Study a Woman’s Experience of Two Caesarean Births
Caesarean 1
Louisea had two children by caesarean section. The first baby was born after a long labour (36 h latent phase and 20 h in established labour). The baby was in an occipito posterior (OP) position with an asynclitic head. Although she had an epidural, it wasn’t effective and was not re-sited because the anaesthetists had time constraints. After 2.5 h of pushing, she went to theatre for assisted delivery. In theatre it took 90 min to site the spinal block. Louise says ‘this was the most traumatic experience of my life. I had planned for a homebirth and nothing could have prepared me for the outcome. I felt completely out of control and scared. The worst part was the fact that the spinal took 1.5 hours to be sited. I was fully dilated with an ineffective epidural and pushing with each contraction, and there were 6 people holding me in left lateral and telling me to be completely still for the whole time because they were trying to get the spinal sited. My glasses were dirty through all the tears I was crying and I couldn’t see. I was petrified, tired and I just wanted it to be over. No one communicated with me while this was going on, apart from telling me to stay completely still, which was awful. I remember one person who took my glasses off and cleaned them for me so I could see, this meant a lot to me’.
Eventually, the spinal anaesthesia was sited with Louise in a seated position. A vaginal forceps delivery was unsuccessful so Louise had a caesarean with Barton’s forceps to the fetal head, followed by a post-partum haemorrhage of 1.6 L. After the birth, Louise and the baby were both traumatised. Breastfeeding did not go well. Louise did not bond with her baby and said ‘The whole experience was extremely traumatic for me and it took me nearly 2 years of counselling and help to bond with my son’.
Caesarean 2
For the birth of her next child, Louise planned a vaginal birth at home. However, her membranes ruptured before labour and after 72 h she had to go to hospital to be induced. In hospital, the forewaters were artificially ruptured, and there was thin meconium staining. Louise had contractions for 6 h, but there was no progress in terms of dilation. She was given the option of having Syntocinon or a caesarean. She opted for a caesarean and agreed a plan for a ‘gentle caesarean’b with the consultant beforehand so everyone was aware. Louise was in a seated position for the insertion of the spinal anaesthetic, and it was sited in 4 min. The lights were low in theatre (with only the theatre overhead lights on), music was playing, and the theatre team were friendly and chatty. Before the baby was born, the screen was lowered so Louise could see her baby being born, and he was passed straight to her. Cord clamping was delayed for 2+ min, and the baby remained skin to skin until the surgery was completed. Louise did not have exceptional blood loss (EBL 500 mL) and breastfeeding went really well. She was discharged after 24 h. Louise says ‘this was such a healing birth for me. Even though it didn’t go to plan, I felt completely in control and listened to. I was still in labour and contracting as they did the spinal—but they listened to what I wanted and made sure it happened. Everyone took care to talk me through what was happening, and take care of me. Seeing my baby being born and having him passed straight to me felt like I had birthed him naturally. It was the most amazing feeling in the world and I immediately bonded with him. He was calm as a result and we both had a brilliant, healing experience because of it. The care from the team made such a difference, and the gentle nature of the c section made me feel empowered and stronger than I ever had. Even though I had c sections with both my babies, they were worlds apart in terms of the impact on me and my babies’.
aPseudonyms have been used to protect the identity of people involved
Box 2. Preventing Births Being Traumatic for Women (Birth Trauma Association)
http://www.birthtraumaassociation.org.uk/policy.htm
- 1.
Women must be fully informed of their options, of details of obstetric procedures, and their associated physical and psychological risks.
- 2.
The woman must be central to the decision-making process.Related posts:
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