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Prebirth education and childbirth decision making.

Motivations for requesting medically unnecessary cesarean sections (C-sections) are unclear, and information on the risks and benefits of elective C-section may not be made available to all women. Women's fear of childbirth is considered an important contributor to their request for C-section in the absence of medical indication; and no studies have systematically examined childbirth decision making information provided to women (Gamble, Creedy, McCourt, Weaver, & Beake, 2007). There is also a gap in the literature regarding whether patients are being informed about the short- and long-term psychological risks of C-sections, which may include anxiety, stress, lack of sleep, fear of death, nightmares, Post Traumatic Stress Disorder (PTSD) and medical consequences. A C-section can be a lifesaving operation when medically indicated, but women have a legal right to know the risks associated with treatment options, as well as the right to accept or refuse it. Childbearing women should be encouraged to take advantage of their rights to find out more about the risks of C-sections so they can make informed decisions about how they want to give birth.

Historical and Contemporary Use of C-Section

The motives for use of cesarean sections have changed since ancient times. C-section procedures had their origin in early beliefs that when the mother died with the child, they had to be buried separately from each other; therefore, the infant was removed from the womb (Lurie, 2005; Todman, 2007). Ancient cultures, such as those of the Mesopotamians, Indians, Egyptians, Hebrews, and Romans, primarily used C-section for postmortem delivery of a deceased or living child (Lurie, 2005). During the Renaissance, focus shifted from postmortem delivery to viewing C-section as a possible life-saving operation (Lurie, 2005). As hospital environments became increasingly safe and sterile, the C-section became an increasingly important surgery to save the lives of women and children, substantially reducing childbirth-related morbidity and mortality (Lurie, 2005). Although cesarean deliveries date as far back as 1750 B.C.E., the reasons for use of cesarean deliveries have changed from ancient times, beginning as a post-mortem procedure, progressing to a medical necessity, to current procedures that are both medically necessary and those that are elective (Lurie, 2005). Elective birth is requested by a mother when there is no medical indication. According to Huang, Sheu, Tai, Chiang, and Chien (2012), cesarean delivery has gradually evolved from a life saving operating to a common mode of childbirth delivery.

Over the last 30 years, the rates for C-sections have increased, especially for older women. Todman (2007) reported that the most common indications for C-section were dystocia, repeat cesarean, breech presentation, and fetal distress. In Western countries, cesarean birth was the most commonly performed operation in hospitals (Todman, 2007). During the beginning of the 21st century, a new focus for C-sections emerged, that is, maternal choice by women for childbirth delivery with no medical indications; however, there was much controversy about cesarean births for reasons other than medical necessity. The controversy was in western countries, such as the United States, Canada, Australia, and Latin America (Liu, Mazzoni, Zamberlin, Colomar, Chang, Arnuad, Althabe, & Belizan (2013). According to Todman (2007), the controversy surrounded the increased rate of medically unnecessary cesarean deliveries, commonly called elective C-sections. Medically necessary cesarean deliveries are performed for the safety of the mother and baby. Williams and Chen (1983) reported that the controversy of increased elective cesarean births is a growing public health concern, and Lavender and Kingdon (2009) confirmed the controversy. Bogg, Huang, Long, Shen and Hemminki (2010) reported that the World Health Organization (WHO) advocated a goal to decrease cesarean births to 1015% in developing countries in 1985, but C-sections worldwide have far exceeded this percentage.

Between 1996 and 2007, Menacker and Hamilton (2010) reported a 53% increase in C-sections in the United States, resulting in 1.4 million births, or approximately 32% occurring by cesarean delivery. According to WHO (2010), 673,047 unnecessary cesarean sections (30.3% of total births) were performed in the United States in 2008. In six states, (Colorado, Connecticut, Florida, Nevada, West Virginia, and Rhode Island), the C-section rates rose to over 70% (Menacker & Hamilton, 2010).

Health Risks of a C-section

Whether elective or medically indicated, major health risks to the mothers and their babies are associated with C-section surgery (Menacker & Hamilton, 2010). Some of the health risks are infections, blood clots, organ damage, surgical injuries, anesthesia problems, and maternal death (American College of Obstetricians and Gynecologists, 2013). More medical complications and anesthetic complications accompany C-section surgery when compared to vaginal delivery, and C-sections carry psychological and economic consequences as well (Menacker & Hamilton, 2010).

Psychological Impact of a C-section

Carter, Frampton, and Mulder (2006) reported that psychological issues appeared to be a significant risk factor for cesarean delivery. The International Childbirth Education Association (ICEA) Cesarean Opinion Committee (2010), reported in their Cesarean Fact Sheet that C-sections pose psychological complications. Psychological consequences of C-section surgery include depression, anxiety attacks, sleep disorders, and flashbacks to the childbirth experience (Carter et al., 2006). Cesarean sections are at-risk surgeries associated with anesthesia complications, which can cause psychological problems (Daunderer and Schwender, 2010; Forman, 2006).

Economic Impact of C-section and Vaginal Births

Before 2013, the average hospital charge for an uncomplicated C-section was $14,894, while the hospital charge for an uncomplicated vaginal birth was $8,919.00 (Johnson & Norsigian, 2010). However, Ornitz and Andress (2015) reported that the cost for a vaginal birth has increased to about $30,000, and the cost for a C-section has increased to approximately $50,000. The WHO (2010b) emphasized that cost is a major concern. According to WHO (2010), public services spent approximately $687,167,996.00 on medically unnecessary C-sections in 2008.

Serious C-section Complications

Although C-section rates are increasing, there is a lack of understanding on the part of women regarding potentially dangerous complications (WHO, 2010a). Health care professionals need to ensure that women from all population groups understand the relative risks and benefits of their choices. Reinberg (2011) indicated that women need to have a better understanding of C-sections and not go into the childbirth procedure blindly.

Making Informed Childbirth Decisions

Limited information is available on how women make informed decisions on birthing options (Gamble et al., 2007). It is important to examine whether women are being thoroughly informed in advance of making childbirth delivery decisions. It is a social responsibility to raise the awareness of all childbearing women about the risks and the benefits of childbirth options. Attitude formation can be influenced by providing more prebirth educational information. McCants (2015) conducted a qualitative study, using in-depth interviews on the preferences of 16 women (age 19-50) before and after reading a prebirth education brochure to understand their experiences in childbirth decision making. The brochure contained information about the risks and benefits of childbirth options, including C-section versus spontaneous vaginal delivery.

Following exposure to the material, McCants (2015) conducted interviews to find out if reading prebirth educational information influences childbirth decision making. A Prebirth Educational Brochure, which informed women of the risks, benefits, and consequences of birth methods was given to the participants to read before the interview regarding childbirth preferences.

Results of Analysis

All participants agreed that the Prebirth Educational Brochure did raise their awareness about the risks and benefits of childbirth options and women should be thoroughly informed (McCants, 2015). Overall the participants agreed that the brochure confirmed why they preferred natural childbirth over a C-section birth (McCants, 2015). Participants believed that prebirth educational information can change women's decision making (McCants, 2015). An example of this is from a study participant who commented that she did not realize that there were so many C-sections being performed, and believed it should be the last birthing option a woman decides to take (McCants, 2015). Only a few participants indicated that they previously read prebirth information prior to childbirth (McCants, 2015). All the participants agreed that the Prebirth Educational Brochure was informative, and prior to reading the brochure thought that cesarean delivery was an easier process than vaginal delivery (McCants, 2015). In addition, the participants believed that doctors and healthcare providers should provide information and advice on birthing choices (McCants, 2015). One participant asserted that women should be provided with magazines on the risks and benefits of C-sections and should be thoroughly informed before making a decision (McCants, 2015). All participants agreed that women should be thoroughly informed before making childbirth decisions (McCants, 2015).

The purpose of the Prebirth Educational Brochure in the McCants (2015) study was to provide facts about the risks and benefits of vaginal and cesarean childbirth methods. This intervention was introduced to find out if it influenced childbirth decisions. All participants in this study agreed that the Prebirth Educational Brochure did raise their awareness about the risks and benefits of childbirth options as well as helped them to reduce their uncertainty (McCants, 2015). The Prebirth Educational Brochure did have an impact on all participants. The Childbirth Connection (2015) indicated that it is crucial for women to have full and accurate information, and childbirth educators are in a unique position to provide this information.


Women need more information on the risks and benefits of C-section and vaginal births. There is a need for prebirth educational information to raise women's awareness regarding childbirth decision making. Atan, Duran, Kavlak, Donmez, and Sevil (2013) believe that if women receive the correct information about the risks and benefits of childbirth methods, vaginal births would increase. According to Weaver, Statham, and Richards (2007), research universally failed to explore the information given to women before making birth choices. Many research articles confirmed that there is a lack of information on whether women are fully informed of the risks and benefits of childbirth information. Results from the McCants (2015) research indicated that women are in need of more information about childbirth safety and consequences, and that woman are not being adequately informed. Most participants thought that C-sections were safe and easy before reading about the risks and benefits in the Prebirth Educational Brochure (McCants, 2015). These responses could be evidence that pregnant women do not receive information about childbirth options and potential risks, and women may be making childbirth decisions without being thoroughly informed.

According to Welbourne (2010), the literature does not provide any evidence that women are being informed about the consequences of childbirth decisions, and there are significant risks to consider when making these birthing decisions. Women who request C-sections, particularly in the absence of any medical indication, may require counseling on the potential risks associated with childbirth methods. Childbirth educators can give women what they need to make informed decisions, such as prebirth educational information on the risks and benefits of vaginal delivery and cesarean delivery. Furthermore, childbirth educators can ensure that women from all population groups understand the relative risks and benefits of their choices, empowering women to make informed decisions regarding birthing options.


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Atan, S. U., Duran, E. T., Kavlak, O., Donmez, S., & Sevil, U. (2013). Spontaneous vaginal delivery or caesarean section? What do Turkish women think? International Journal of Nursing Practice, 19, 1-7. doi:10.1111/1jn.12029

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by Bessie M. McCants, PhD and Jay R. Greiner, PhD

Bessie M. McCants, PhD completed her doctoral research and education from Walden University, College of Social and Behavioral Sciences, specializing in Health Psychology. Research interests: womens health, childbirth decision making, and health promotion (communications).

Jay R. Greiner, PhD is a Professor of Health and General Psychology at Walden University, and a Developmental Psychologist who has worked clinically with infants, children, adolescents and adults. Dr. Greiner currently supervises ongoing research involving developmental health across the lifespan.
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Title Annotation:In Practice
Author:McCants, Bessie M.; Greiner, Jay R.
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
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