Exploring healthy pregnant women's decisions to opt for an elective caesarean section

The rate of Caesarean sections (CS) in the UK is on the increase. In the year 1989-90 the rate was 11.3% rising to 17% for the year 1997-98 (Marx et al, 2001). The World Health Organisation (WHO) recommends that no more than 15% of all births are by CS. Today in the UK 22% of all babies are born by CS (Song et al, 2004). Research by Jackson and Irvine (1998) and Marx et al (2001) suggests that maternal requests are an important factor in the increase. Marx et al (2001) report that the rate of elective CS has doubled in the UK in the last 10 years. However, there is little consensual information as to why more pregnant women are choosing Caesarean delivery. The media frequently portray such choices in terms of personal convenience, employing phrases such as "too posh to push". Such stereotypes, however, are unhelpful for understanding what may be a decision informed by complex social changes in attitudes to surgery and childbirth. Recently published NICE Guidelines (2004) have suggested that women who opt for elective CS may need to be counselled. However, this group of women may be well informed about the risks and benefits of Caesarean delivery, so this suggestion may be experienced as intrusive or undermining of their autonomy. The aim of this study was to explore factors that influence and inform a decision to have an elective CS. Participants were 6 women attending a London teaching hospital who indicated at their 20 week scan that they wished to have a CS. Inclusion criteria were: 1) singleton pregnancy deemed 'low risk' by a consultant obstetrician, 2) no previous history of CS or 3) a previous history of CS but vaginal birth was medically feasible, and 4) without acute mental health problems. Data were collected using individual semi-structured interviews. These were recorded on tape, transcribed and analysed using Interpretative Phenomenological Analysis. The 6 main themes that emerged in the analysis were general attitudes around childbirth, the decision to have children and experiences of pregnancy, the importance of choice, the perception of risks & benefits of Caesarean section and vaginal birth, the salience of knowledge and the influence of relationships with maternity staff. These findings are discussed in terms of their implications for understanding the decision making process leading to an elective CS and the ways in which women are advised and supported in coming to this decision