Historically, the natural process of Vaginal Birth (VB) has been viewed as the unquestioned
mode of birth, whereas Caesarean Section Delivery (CD), which involves an operative
incision, has been perceived as a risky procedure designed for women with medical
indications 57]. With advances in reproductive technology, an increase in the number of CDs has been
observed in recent years 9]. There has also been a shift in the attitudes, so that it is no longer unusual for
couples to request a CD 30]. “Caesarean Delivery on Maternal Request†(CDMR) refers to a primary CD performed
prior to labor in the absence of medical indications, where women are choosing for
themselves their preferred mode of birth 57].
Childbirth is regarded as an important life event for women, and growing numbers of
them are making the choice to give birth by CD. The escalating CDMR rate is associated
with the perception of women that CD is the safer mode of birth 51]. However, the evidence to support this belief is limited.
Rates of CDMR seems to be increasing worldwide, more so in some countries than others.
According to a report by the National Institute of Health 38], approximately 4–18% of all babies in the United States were born by CDMR in 2004.
Overall, CDs in the United States have increased from 22.9–32.8% between 2000 and
2010 31]. In 2011, it was reported that 8% of the increase in CDs at a major hospital in the
United States was attributable to CDMR 3].
Much higher rates of CDs are observed in Asian countries. In the urban regions of
China, a CD rate of 54.1% was reported in 2008 54] followed by Taiwan at 35.2% in 2007 8]. Between the years 1998 to 2008 in China, the rate of CDs in rural regions rose from
3.6 to 23.6%, and that for urban regions rose from 19.9 to 54.1% 54]. There is evidence of an increase in the CDMR rate from 0.8% in 1994 to 20% in 2006
24]. According to a territory-wide obstetric audit in Hong Kong, elective CDs for non-medical
indications increased from 5.5% of all CDs in 1994 to 16.7% in 2004 19]. A more complete picture of the number of babies being delivered by CDMR will help
to determine whether rates of CDs are indeed increasing.
Factors influencing maternal preference of mode of birth
There are various factors influencing a woman’s choice of mode of birth. Demographic
factors and an individual’s expectation of childbirth have a bearing on her decision-making
process. Others are previous birth experience, potential complications arising from
the mode of birth, and concerns over the health and safety of mother and baby 41].
Application of the health belief model on the maternal choice of mode of birth
In the present study, the Health Belief Model (HBM) was adopted as a conceptual framework,
to provide a sound theoretical basis for understanding the factors that influence
women’s childbirth decisions. The HBM can specify the relationship between health-related
beliefs/factors and maternal behaviors, which can help in predicting the possibility
of a woman choosing a particular mode of birth. Using this model, mode of birth and
maternal choice and its determining factors can be explored within the five domains
of the HBM, namely: perceived susceptibility, perceived severity, perceived benefits,
perceived barriers, and cues to action 23].
Perceived susceptibility
Perceived susceptibility is a person’s belief in his/her vulnerability to some medical
condition. The more that a person believes he/she is at great risk, the more likely
that person is to adopt a particular health-related behavior to minimize such risk
23]. For instance, a negative experience in a previous birth could affect a woman’s preference
for a particular mode of birth in subsequent births, due to the belief that the negative
experience could occur again 40].
Perceived severity
Perceived severity is defined as one’s belief in the intensity of the medical condition
and its undesirable outcomes 23]. If it is believed that there are very serious or intolerable complications associated
with a specific mode of birth, women are more likely to express a preference for an
alternative method of delivery, so as to reduce their risk.
For both VB and CD, the most severe complications are maternal and neonatal mortality
47]. A global survey by the World Health Organization between 2004 and 2008 reported
the risks of maternal mortality and morbidity in CD without medical indications 28]. The risks due to CD were three times greater than those for VB, including in the
areas of maternal mortality, admission to an intensive care unit, the need for a blood
transfusion, and the need to carry out a hysterectomy or internal iliac artery ligation.
It was noted that CD can have several negative consequences on maternal health, including
adverse outcomes related to anesthesia, adhesion formation, and uterine rupture 47]. Neonatal respiratory depression secondary to maternal anesthesia has also been identified
as a risk associated with CD 10].
However, VB is not without risk. Maternal complications associated with VB include
pelvic organ prolapse, prolonged labor, and perineal trauma 1], 41]. For the neonate, there is also an increased risk of contracting infections such
as Hepatitis C, HIV, and HPV during vaginal birth from maternal to neonate transmission
47].
Perceived benefits
Perceived benefits are defined as one’s belief that outcomes can be positively affected
by engaging in a particular health behavior 23]. The advantages of maternal and fetal health and a sense or anticipating fulfillment
and satisfaction of sociocultural beliefs have been identified as important factors
in maternal decision making.
When considering the perceived benefits for the health of childbearing women, it has
been noted that in a number of countries women associate VB with a greater number
of benefits than CD. Women in Singapore (91.5%), Turkey (89%), and the USA (42%) believed
that VB offers a faster recovery, earlier discharge, and the absence of a CD scar
7], 10], 27], 42].
When focusing on neonatal health, nearly 60% of women believed that VB is safer for
the baby 10]. Women also reported that VB enables earlier bonding with their baby and early initiation
of breastfeeding.
In comparison, a fear of labor (50%) and repetitive vaginal examinations (23%) were
underlying reasons why women showed a preference for CD 10]. This was supported by women identifying tocophobia (an intense fear of labor contractions),
prolonged labor, fetal distress, and the perineal trauma associated with VB as reasons
for why they planned to have a CD 5], 32], 40], 52]. Women also took into consideration the advantages of CD in maintaining genital appearance
(24%), facilitating tubal ligation (20.6%), and minimizing sexual dissatisfaction
(0.8%) following delivery 5], 10].
From another perspective, women also perceived CD as more convenient, allowing them
to better plan their maternity leave. It is also of significance that within the Chinese
culture, some women strongly believe that an auspicious time of birth is vital to
a person’s lifelong fate and destiny 21]. It has been noted that the birth rate in the year of the dragon in the Chinese zodiac,
a particularly auspicious year, rises 55].
Perceived barriers
Perceived Barriers refers to an individual’s perception of the difficulties stopping
them from following a specific health-related behavior 23]. The desire to choose VB is hindered by existing medical contraindications. There
are some medical contraindications of VB for mothers, including pelvic disproportion,
pre-eclampsia, severe cardiovascular disease, diabetes mellitus, active genital herpes,
HIV infection, and multiple pregnancies 4], 29], 48]. On the other hand, the medical contraindications for babies include fetal malpresentation,
fetal malformation, cord prolapse, and macrosomia 39], 49].
In Hong Kong, CDMR is only available in the private sector, as public hospitals will
not permit this practice. The cost of a CDMR in the private sector ranges from $23,000
to $66,800 (all figures are quoted in Hong Kong dollars) or even higher, which is
far more expensive than a VB 18], 20]. Given that the median monthly household income in Hong Kong was about $18,000 in
2010 22], this implies that women of lower financial status cannot afford the CDMR plan in
the private sector. Both public hospital policy and low financial status could act
as barriers to choosing a CD. Studies have shown that insurance coverage is a vital
element in the maternal choice of delivery, with studies conducted in Australia and
Chile indicating that insurance coverage encourages women to attend private hospitals
and hence encourages CDMR 12], 37].
Cues to action
Cues to action refer to the factors that help individual make health-related decisions
23]. Advice from relatives, friends, health care professionals, as well as an awareness
of the rights of women are crucial factors guiding the maternal decision on delivery
method.
Women’s beliefs and attitudes towards a particular mode of delivery are strongly influenced
by the stories and advice that they hear from relatives and friends 5], 11]. Women were driven to an alternative mode of delivery after hearing negative stories
about a particular mode increasing concern that they might have the same experience
when they gave birth 33], 46]. In addition, the pregnant woman might also worry if there is a family history of
poor obstetric outcomes 43]. Advice from health care professionals such as midwives and doctors very much influences
a woman’s understanding of a particular delivery mode and her preference for it 13].
Other than advice from others, some women perceived that they should have their own
right to decide the mode of delivery 25]. This is a major reason why CDMR rates are increasing worldwide 41].
Significance of the study
The issue of maternal preference for a particular mode of birth is complex. The aim
of this study is to examine the perceptions of Hong Kong women towards CD and VB,
as well as their priorities when they are considering their mode of birth. With insight
into women’s attitudes and preferences on mode of birth, midwives and obstetricians
can better support women by providing appropriate information during pregnancy, enabling
them to make an informed choice and take an active part in the decision-making process.