Why do women request an elective cesarean ... - Wiley Online Library

Received: 21 July 2017 DOI: 10.1111/birt.12319

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Revised: 22 September 2017

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Accepted: 22 September 2017

SYST E M AT I C R E V I E W

Why do women request an elective cesarean delivery for non- medical reasons? A systematic review of the qualitative literature Charles O’Donovan MSc1 1

London School of Hygiene and Tropical Medicine, Bloomsbury, London, UK 2

Division of Medicine, Addenbrookes Hospital, Cambridge, UK Correspondence James O’Donovan, 3 Creskeld Crescent, Bramhope, Leeds, LS16 9EH, UK. Email: [email protected]

| James O’Donovan MBBS, MRes2 Abstract Background: Cesarean rates have increased significantly over the past decade. The reasons for this are both complex and context specific, and have significant consequences for health resources. The aim of this systematic review was to assess published, peer-reviewed, and gray qualitative literature on the reasons behind cesarean delivery on maternal request (CDMR). Methods: A systematic search of MEDLINE, EMBASE, CINAHL, LILACS, and PsycINFO databases was performed for all relevant articles published between January 2006 and June 2016. Reference lists of all included studies were also searched in addition to select web-based sources. Studies were included if they qualitatively evaluated women’s preferences for CDMR, with no geographic restriction. Findings from the studies were narratively and thematically synthesized. Results: Sixteen studies were included in this review. Three themes were identified as to why women choose CDMR, which were: social norms, emotional experiences, and personal experiences. A woman’s decision was often shaped by various influences including family, friends, and the media. In addition, previous experience of childbirth and interactions with health care professionals contributed to a strong preference for CDMR. CDMR provided women with a sense of control over the birth and diminished feelings of fear. Conclusions: The reasons behind CDMR are multifactorial and complex. Situation- specific cultural factors, fear of pain during childbirth, previous experience, and interactions with health care professionals are likely to have led to the increase in CDMR. Multifaceted, context-specific approaches are required if there is to be a reduction in CDMR rates. KEYWORDS cesarean, cesarean delivery, cesarean delivery on maternal request

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| IN T RO D U C T ION

According to the World Health Organization (WHO), cesarean rates have reached “epidemic proportions.”1-3 Cesarean rates have been reported at 36% in Korea and over 50% in China and Brazil.2,4,5 A recent study using survey data collected by the WHO concluded that, at the population level,

rates higher than 10% are not associated with reductions in maternal or newborn mortality rates.6 Furthermore, the rise in cesareans is contributing to significant economic pressures on health care systems globally, especially those in low-and middle-income countries (LMICs).7 Cesareans can broadly be classified depending on whether they are an emergency or planned procedure. An emergency

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Birth. 2017;1–11. wileyonlinelibrary.com/journal/birt © 2017 Wiley Periodicals, Inc. 1

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cesarean is usually performed where a vaginal delivery would be detrimental to maternal and/or fetal health. A planned cesarean is arranged ahead of time due to a medical indication, or maternal request; the latter being known as a cesarean delivery on maternal request (CDMR). For the purpose of this review, we will be focusing on CDMR, which is defined as an elective surgical procedure to deliver an infant without any medical or obstetrical indication.8 CDMR contributes to high cesarean rates worldwide, and is the source of extensive debate.9 Rates of CDMR are particularly high in China, where it is estimated to account for up to 40% of all cesareans.10 The reasons behind the rise in CDMR are multifactorial and include cultural factors, the changing attitudes of women and clinicians, and fear of giving birth known as tocophobia. As with any surgical procedure, cesareans are associated with risks that can affect the health of the woman, her child, and future pregnancies.6 These risks are higher in women with limited access to comprehensive obstetric care, often in low-and middle-income countries (LMICs).11-13 In 2015, the WHO concluded that there was no evidence to support cesareans benefitting women or infants who did not require the procedure.6 Therefore, it is important to better understand the reasons and underlying socio-cultural norms contributing to increasing cesarean rates. Four existing reviews have been identified which examine the views of why women choose CDMR. McCourt et al. concluded that before 2006 very few women elected for CDMR. Of those who did, “personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinned these requests.”14 Mazzoni et al. summarized quantitative data on women’s preferences for cesarean.15 Thompson reviewed qualitative literature, but searched limited databases and only included studies from high-income countries.9 Lavender et al.16 assessed evidence from randomized controlled trials; however, in the absence of data, they concluded there is “an urgent need for a systematic review and synthesis of qualitative data.” This review systematically and comprehensively synthesizes qualitative information from both LMICs and high- income countries about reasons underlying CDMR. The objectives of this study were to (1) critically review published, peer-reviewed, and gray literature on women’s reasons for CDMR and (2) identify the key themes within current literature pertaining to women’s perceptions and reasoning behind CDMR.

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| METHODS

The Cochrane Library, the Campbell Collaboration, and the International Prospective Register of Systematic Reviews (PROSPERO) were searched to identify available or

C. O’DONOVAN and J. O’DONOVAN

ongoing systematic reviews. The following databases were then searched to identify primary, peer- reviewed studies published between 2006 and 2016: MEDLINE, EMBASE, CINAHL, LILACS, and PsycINFO. These five databases were chosen based on relevance and geographical scope. The search strategy was developed by searching within the results for important articles identified through initial exploratory scoping. The search was an iterative process, with search terms and key words being refined to maximize sensitivity and specificity of search results. Combinations of key concepts from the Medical Subject Headings (MeSH) database were used in the literature search. The University of Texas search filter for qualitative studies was combined with the search terms to detect relevant studies.17 Please refer to Appendix S1 (available online) for the full search strategy and search terms used for each database. Despite issues relating to data quality, non-peer reviewed ‘gray’ literature was included in this review to encapsulate a broad overview of women’s preferences for CDMR. The following sources were searched to identify relevant literature: e-theses online service (ETHoS), conference proceedings on Index of Conference proceedings, Google Scholar, and the websites of the King’s Fund, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, National Childbirth Trust, and Birth Choice UK. Only full-text qualitative studies were included in this review. This facilitated the incorporation of “real life” experiences in evidence-based policy-making, enabling worldviews of participants to be unpacked at a particular time and location.18,19 Only views of pregnant women without medical indication for cesarean were included. The review was limited to work published between 2006 and 2016 since a similar review was published by McCourt et al. in 2007.14 Studies containing only quantitative data or using structured questionnaires were excluded as they did not provide the depth of information required to understand why women prefer CDMR. There was no exclusion based on setting. Due to translation service resource constraints, articles not in the English language were excluded. All papers identified via database searching were exported into EndNote 7.1 and duplicate references removed. Titles and abstracts of all publications identified in the search were screened using three questions by both authors independently (Appendix S2—available online). This determined whether they would be considered for a full text review. Once studies were determined to have met the inclusion criteria, each study was read in-depth and data systematically collated using a predefined data extraction form (Appendix S3— available online). The lists of the studies identified for inclusion by both authors were then compared. Where the authors disagreed on the inclusion or exclusion of a study, the full text was retrieved and re-reviewed against the criteria found in Appendix S3 until an agreement was made. Information


was then tabulated using an Excel spreadsheet. Details recorded included author, year, title and country, aims and sample details, data collection methods, findings, and limitations (Table 1). The methodological rigor and quality of each study was assessed by a single reviewer (COD) using the standardized 10point Critical Appraisal Skills Program (CASP) Qualitative Study checklist.20 This involved asking two screening questions—did the review address a clearly focused question and did the authors look for the right type of papers—followed by an 8-point assessment with respect to precision, applicability, and overall quality of the research.20 The purpose of the checklist was to help inform judgments, rather than encourage mechanistic approaches to quality assessment. No studies were excluded on the basis of quality; instead the checklist was used to compare the quality of selected studies, identify possible limitations, and enrich synthesis. Studies were then rated as “high”, “medium,” or “low” quality depending on their CASP score (Appendix S4— available online). The rating of “high”, “medium,” or “low” was assigned by the studies meeting between 10-8, 7-5, or 4-0 of the criteria, respectively. Findings from the studies were narratively and thematically synthesized. Data synthesis was conducted in three overlapping stages, using the model described by Thomas.21 First, textual findings from primary studies were coded and data which were of interest tabulated. Second, descriptive, recurrent themes were analyzed, and relationships explored within and across included studies.22 Finally, this resulted in the generation of “analytic” themes (third-order interpretations) derived from a “line of argument” based on translation of textual findings from primary studies (first-order concepts) and recurrent, descriptive themes (second-order concepts). This enabled similarities and differences across group codes to be analyzed and new interpretations beyond those of the original studies to be derived. Greater weight was given in the synthesis to the studies identified as “high” quality based on the CASP tool assessment. The project was assessed by the Research Governance and Integrity Office at the London School of Hygiene and Tropical Medicine as not requiring ethical approval from the ethics committee.

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| R E S U LTS

The PRISMA diagram outlines the number of papers included or excluded at each stage of the search process (Figure 1). A total of 16 articles are included in this review.23–38 The characteristics of each study are summarized in Table 1, with an in-depth analysis and critique included in the supplementary material (Appendix S4—available online). Fifty percent (n = 8) of studies included in this review were published

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since 2013. The majority of studies (56%, n = 9) collected data in the public health care setting. The sample size of the selected studies ranged between 6 and 392 participants; however, most studies (75%, n = 12) had samples of 49 or less. The selected studies included women aged between 16 and 43 years old, with the exception of one study where age was not stated.31 Only two studies reported ethnicity, where the significant majority of women were Caucasian (85% and 97%, respectively).18,37 Six studies enrolled only primipara,24–28,35 four enrolled only multipara,33,34,36,37,39 while six included primipara and multipara.23,28–30,32,37 Eleven studies included the views of pregnant women in their third trimester (weeks 29-40), with two including women from week 20 and 26.34,35 Eight studies collected data on women’s relationship status.24-26,32,33,35-37 All women who participated in the studies were in a relationship or married, with the exception of one participant in the study by Lagomarsino et al., who was single.32 Of the ten studies which reported educational status, seven found that the majority of participants had a university education,22–24,26,30,37 while two contained a majority of participants with a secondary school education25,32 and one a primary school education.24 Fourteen studies used purposive sampling. The two remaining studies used a convenience sample,28 or randomized women to two groups to receive a decision-aid booklet or usual antenatal care.36 Thirteen studies explained their method of participant recruitment, which involved a mixture of health care professional recruitment, external advertisements, and a mixture of these two or self-selection. Three studies did not explain their recruitment method.23,33,34 In terms of data collection, most (14) studies used individual in-depth interviews, lasting between 20 minutes and 2 hours. Of these, 13 were semi-structured based on an interview guide,24–27,29–35,38 and one used unstructured interviews, whereby interviews began with a general question, followed by specific questions.23 Two studies did not use interviews, but rather a written questionnaire28 and an open-ended written survey.36 Most studies (n = 12) analyzed the data themati23,25,26,28,30,32-38 cally. This enabled analysis to be driven by the insights of participants. It followed a similar pattern whereby data were familiarized, then coded. When common concepts emerged, these were connected into themes and subthemes. Three studies analyzed data using grounded theory24,27,31 and one used both thematic analysis and grounded theory.29 All 16 studies were assessed for quality against criteria from the CASP Qualitative checklist (Figure 2 and Appendix S5—available online). Overall, the studies were considered to be of moderate rigor, with all providing some description of the strategies used to select participants and collect and analyze data. All studies considered context and identified the importance of informed consent and ethical approval.

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T A B L E 1 Summary of studies included in qualitative review of women’s reasons for choosing CDMR, 2006-2016 Study details (author, year, and country)

Data- analysis methods

Participant details

Data-collection methods

Findings

Moffat et al., 2007, United Kingdom34

30 pregnant women from 20 weeks of gestation to immediately postnatally (all had previous cesarean)

Diaries (by participants); Thematic observations of consultaanalysis tion; interviews; field notes

Weaver et al., 2007, UK38

44 women who had considered/ Semi-structured interviews asked to consider cesarean during pregnancy were interviewed postnatally

Thematic analysis

Safer, more controlled and strong social influence

McGrath et al., 2008, Australia33

20 pregnant women who all had Open-ended interviews a previous cesarean and have an upcoming birth

Thematic analysis

Easier; quicker; exact date set; controlled; fear and pain of childbirth; safer for baby; easier recovery; not cope with labor alone; avoidance of induction

Previous negative vaginal delivery/emergency cesarean; acceptance from medical profession of CDMR

Kornelson et al., 17 women who gave birth by 2010, Canada CDMR at seven study sites

In-depth, open-ended interviews

Grounded theory

Informed consent and influence of birth stories (social influence) on attitudes toward mode of delivery

Fenwick et al., 2010, Australia26

14 women who requested a CDMR during their first pregnancy

Telephone questionnaire and Thematic interview analysis

Childbirth fear, control and safety, devaluing of the female body and birth process

Hull et al., 2011, UK

Convenience sample of 359 pregnant women who stated preference for CDMR

Internet semi-structured Thematic survey with an open analysis question asking why certain mode of delivery was chosen

Anti-vaginal birth (avoidance of mortality, preventing the inevitable and dread of birth experience) and physical/psychological validation (negative previous birth experience)

Jamshidi 26 pregnant women purposively Semi-structured, individual, Manesh, 2011, selected in third trimester with in-depth interviews Iran tendency toward a cesarean

Thematic “Fear of mysterious,” “physical and spiritual analysis and comfort” and “sharing experiences” grounded theory

Sahlin et al., 17 first-time mothers with 2011, Sweden normal pregnancies who were scheduled for a CDMR

Individual interview

Thematic analysis

No other options, more controlled and safer and personal negative experiences of health care

Huang et al., 20 primiparas women who 2013, Taiwan27 initiated CDMR

Open-ended in-depth interviews

Grounded theory

“Controlling risks of childbirth and ensuring well-being”: risk perception, risk assessment and marching onward fearlessly

Kabakian- Khasholian, 2013, Lebanon30

22 primiparas/multiparas women Semi structured, in-depth who delivered by cesarean interviews

Thematic analysis

Fear of labor pain, providers’ role in reinforcing beliefs about cesareans being pain free deliveries, easier, safer, offers control of unexpected and reduced fear

Lagomarsino et al., 2013, Brazil32

Six women located from medical records delivered a child in previous 6 months

Thematic analysis

Anxiety related to natural childbirth, previous deliveries women deemed unnecessary and fear of unpredictability and uncontrollability of vaginal delivery

Semi-structured interviews

Tully et al., 115 women on postnatal ward 2013, England after the women underwent cesarean

Semi-structured, open-ended Thematic interviews analysis

Previous maternal experience (including traumatic birth either complicated vaginal delivery or unscheduled cesarean), more control, safer and straightforward

Abbaspoor et al., 2014, Iran23

Unstructured interviews

Cesarean considered higher class, modern and fashionable (due to high frequency in Iranian society), easy and normal method, able to provide higher support and economically acceptable

18 women (4 pregnant and 14 postnatal)

Thematic analysis

(Continued)

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T A B L E 1 (Continued) Study details (author, year, and country)

Participant details

Data-collection methods

Faisal et al., 2014, Iran25

14 primigravidae pregnant women requesting CDMR

Semi-structured face-to-face Thematic interviews analysis

Shorten et al., 2014, Australia36

Women at 12-20 weeks of Open-ended questions in pregnancy who were eligible to written surveys choose mode of delivery

Eligibility

Screening

Identification

Boz et al., 2016, 29 nulliparous women selected Turkey24

Semi-structured, in-depth, face-to-face interviews

Data- analysis methods

Fear of labor pain, injury to mother/infant, complications after vaginal delivery, trust in obstetricians and lack of trust in maternity ward staff

Thematic analysis

Avoidance of risk, prior experience with labor and emergency cesarean, plan the birth, influence of others, and a perception recovery better

Grounded theory

Easier and minimizes pain and risks of vaginal birth

Potentially relevant articles identified through Literature search: Databases (n= 12042): MEDLINE (n= 1387) EMBASE (n= 7768) CINAHL (n= 851) LILACS (n= 1440) PsycINFO (n= 596) Duplicates removed (n= 2167) Search results combined, removing duplicates (n= 9875)

Articles screened on basis of title and abstract

Full text articles assessed for eligibility (n= 58)

Included

Findings

Identified from snowballing useful papers (n=1)

Included (n=16)

F I G U R E 1 PRISMA flow diagram of study selection process

Articles excluded failed to meet selection criteria (n= 9817) Excluded after reading full article (n= 43) • Quantitative questionnaires and surveys (n=32) • Qualitative preference for vaginal delivery (n=4) • Qualitative medical indications (n=1) • Literature review (n=2) • Full-text unavailable (n=4)

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Percentage of studies inclduing criteria

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100 90

100

100 82

88

82

80

71

70 60

53

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50 40 30 20 10 0

Appropriate Appropriate Justified data Relationship Ethical issues Rigorous Respondent More than between considered data analysis validation one analyst research recruitment collection resarcher strategy design and particpant considered

Quality criteria outlined in CASP F I G U R E 2 Proportion of studies reporting each quality criteria, as outlined by CASP

Seven studies were awarded high level of rigor for meeting the requirements of all eight quality criteria after the two initial screening questions.23–25,27,34,35,38 Eight were classified as moderately rigorous for meeting the requirements of five criteria.26,28–30,32,33,36 The remaining study by Sahlin et al. was awarded a low methodological rigor, having met only four quality criteria.35 Unlike the other studies, it did not consider reflexivity and respondent validation. Moreover, it did not explain how the data were selected from the original sample, nor did the authors critically examine their role or use triangulation. Qualitative analysis of each study resulted in the identification of three main themes and an additional nine subthemes (Figure 3).

3.1 | Theme A—Social Norms The first key theme identified across studies was that of social norms and the importance of culture and social influences when deciding mode of delivery.31 Studies revealed that many women considered it to be a common and normal procedure and, in certain societies, both “modern” and “fashionable.”23,40 Under the theme of social norms we identified three major subthemes: social influence, culture, and choice.

Social influence was described in 12 s tudies.23,25–29,31,32,34–37 The decision for CDMR was often shaped by pressure from partners, family, friends, and the media.25 This social influence was often deep-rooted, with numerous women across studies identifying their own mothers had negative experiences of vaginal delivery.26,28,29 No woman in my family has been able to give birth vaginally for 4 generations. They all have long 2nd stage (around 24 hours), baby then becomes distressed and an emergency C-section is required. (Hull et al.)28 I ask…my mother who has three to four normal pregnancy that is normal delivery good or not? She says that cesarean is good. (Jamshidi Manesh et al.)29 This was coupled with the perceived “guaranteed safety” of a cesarean. This view was reinforced by relatives who recently experienced childbirth. My sister always recommended C- section to all pregnant women because of some problems after vaginal delivery. (Faisal et al.)25

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Themes

Subthemes

(i) Social influence (A) Social Norms

(ii) Culture (iii) Choice

(i) Fear of vaginal delivery (B) Emotional Experiences

(ii) Safety and risk perception (iii) Control (iv) Avoidance of memory (i) Previous births

(C) Personal Experience

(ii) Health care encounters

F I G U R E 3 Themes and subthemes identified across studies as to why women choose CMDR

Several studies also highlighted the role of the media and popular culture reinforcing a negative impression of vaginal delivery.27,31,34

I don’t see any reason to give birth like a cow in this day and age when there are more civilized means available. (Hull et al.)28

I want a cesarean delivery because Dee Hsu [a well-known female star in Taiwan] said that childbirth affects the tightness of vagina… (Huang et al.)27

Finally, for some women, CDMR represents a forward progress in women’s reproductive rights. Many felt that they should have autonomy over what happened to their body during childbirth, as illustrated by the following quotes:

A second important subtheme mentioned in several studies was culture. One specific example was in Iran, whereby the woman’s husband and in-laws have a major influence on the mode of delivery. The idea that the husbands needs should be taken into account, combined with a consumer-based approach to birth often lead to women opting for CDMR as illustrated by the following quotes:

It is my body, I should be able to choose. (Faisal et al.)25 We live in a civilized society where we can choose our method that best suits our fears and concerns. (Hull et al.)28

My husband said: “Do C-section, I will pay all its costs, I cannot see your pain during normal vaginal delivery.” (Abbaspoor et al.)23 Some studies equated a cesarean with modernity and better quality of care, as expressed by one postnatal woman:

3.2 | Theme B—Emotional Experiences The second main theme concerned emotional experiences. This theme emerged from four subthemes: feelings of fear, safety, control, and avoidance of memory. Thirteen studies reported one of the main reasons women prefer CDMR was fear of vaginal delivery or “tocophobia.” The combination of fear of pain, unpredictability, and loss of dignity were often internalized and resulted in CDMR.

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I can’t imagine that the head of the baby, so big, should come out of the vaginal opening that is so small. This hurt me seriously. (Faisal et al.)25 I am terrified of the idea of vaginal birth… It seems barbaric. (Hull et al.)28 All studies, except those by Lagomarsino et al.32 and Abbaspoor et al.,23 reported women considered a cesarean safer than vaginal delivery.


3.3 | Theme C—Personal Experience The third theme was personal experience, which encapsulated previous birth experience and previous encounters with health care professionals and the health care system more broadly. Several studies reported a previous negative birth experience, either by vaginal delivery through a lack of assistance28,32,37 or emergency cesarean through a traumatic experience.33,34 Many believed an emergency cesarean would be inevitable, so planning a cesarean provided control.37 I would rather have a safe planned, calm birth for my 2nd child. I’m aware of risks…rather than go through what I went through last time resulting in emergency surgery. (Hull et al.)28

I want to do the best and everything that is necessary, I could make sure, I will have a healthy baby without any physical harm. (Faisal et al.)25 Fear of unpredictability and uncontrollability of vaginal delivery impacted on women’s preference for CDMR. Birth reminds me of staying in the dark. I’m afraid of darkness. One cannot know what will happen in darkness, and birth is something like that… (Boz et al.)24 Unlike vaginal delivery where the time of birth is unknown, the time and date can be set in a cesarean, giving the mother a sense of control over both the situation and her body. One woman in Fenwick’s study expressed this level of control to that of a “perfectly orchestrated birth” with “all the right people in the right place at the right time” (Fenwick et al. 2010).26 Control was particularly important for women who had undergone a prior emergency cesarean and is associated with the subtheme “previous birth experience.” With the second one, by having another Cesarean, felt more of a control over it…I knew where it was going to happen… the process …and what it was going to be like. (McGrath et al.)33 The final subtheme was that of avoidance of memory. Some women elected for delivery by cesarean, as they assumed that by having an anesthetic they would not remember anything about the birth.24,29 In order to not remember anything about the birth, I’ll have a cesarean. It means recalling nothing about the birth. (Boz et al.)24 Since I won’t feel pain or anything else at the birth, I don’t care about what will happen later. Nothing will happen and I’ll endure the pain later. At least I won’t feel pain while birthing. (Boz et al.)24

For many, the need for control was directly attributed to a sense of disempowerment from the previous birthing experience.33 Fears about labor and vaginal birth were reinforced through discussions women had with clinicians. One woman reported: My physician told me that it (cesarean) is safe, it will spare me the pain during labor and it is better than to end up with cuts and sutures with a vaginal birth. (Kabakabian)30 Clinicians’ professional judgment and guidance had a significant role in decision-making. Many women acknowledged risks and reassigned responsibility to their doctor, trusting their skill and experience to reduce the chance of an adverse incident.26 I trusted them. I handed control of myself over to them. (Fenwick)26 This was juxtaposed with distrust of health care staff involved in previous vaginal deliveries, with frequent, inappropriate examinations being a key factor as to why women stated a preference for CDMR. When a woman experiences labor… the nurses replace frequently. They examine you so much, you must suffer too much… It was very bad, but cesarean wasn’t in this manner… in the beginning they took me to operation ward and made me unconscious, then I was comfortable. (Jamshidi Manesh et al.)29

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| DISCUSSION

The findings of this review suggest a complex interplay of various factors as to why many women elect for CDMR.

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These include prevailing ideologies, mediated by the wider milieu in which people live, such as their cultural context, structural and geographical location, and personal biography. In Iran, for example, the influence of family plays an important role in the choice of mode of delivery.23 CDMR has also been shown to be higher in older women, with higher socioeconomic status, delivering in private hospitals.41,42 Social norms featured more prominently in primiparous women, emphasizing the importance of choice. Primiparous women were greatly influenced by accessing different forms of knowledge (medical, non-medical, written, verbal, and visual) from multiple sources, (family, friends, health care professionals, and media) with varying degrees of influence.43 Recognizing this, it is important to note that the current rate of increase in cesareans is unsustainable. Efforts should therefore be taken to reduce rates to comply with WHO guidelines. As outlined in this review, factors affecting CDMR are complex; therefore any interventions need to reflect this. One strategy to help decrease cesarean rates is to promote vaginal delivery.42 This could be achieved through health promotion programs and improving the birthing environment.44 It is also important to educate women as to the risks associated with cesarean delivery, particularly for repeat pregnancies. Likewise, certain mistruths about vaginal delivery, particularly those around compromising sexual function, need to be addressed though a range of educational programs. For these programs to be effective, it is important that prior exploratory research is undertaken to better understand social, cultural, and symbolic contexts surrounding CDMR. The views and behaviors of health care providers play a key role in women’s preferences. Clinicians should ideally be impartial and use evidence-based guidelines when helping a woman make a decision. In the United Kingdom, the National Institute for Health and Care Excellence has issued guidelines which take into account the clinical, social, and economic factors pertaining to CDMR with the aim of ensuring the safety of mother and infant.45 The guidelines issued in 2011 state that if the request is due to anxiety about childbirth, then a referral should be made to a health care professional with expertise in perinatal mental health support to address this.46 If, after discussion, vaginal birth is still not acceptable then planned cesarean should be offered. The most common reason identified for CDMR in this review was tocophobia. It is therefore essential that clinicians focus on the underlying reasons behind tocophobia and offer measures, such as labor support classes, to support women faced with this decision.8 A recent study found that after receiving intervention counseling, 86% of women with tocophobia elected to give birth vaginally.47 Counseling should be

tailored to each woman depending on the level of anxiety and reasons underlying her fears. Finally, high-quality antenatal education should not be underestimated, as it can affect the process and outcome of childbirth.48 CDMR rates show a distinct socioeconomic gradient with higher rates observed in private hospitals, compared with the public system.39,49 There are clear financial incentives promoting CDMR, including insurance coverage for childbirth, patient costs, and provider revenues.4 Given the potential financial incentives to health care providers, it is important this area is better regulated as ultimately the provision of safe, effective, and evidence-based care is paramount.9

4.1 | Strengths and limitations This systematic review is the most recent comprehensive attempt to examine women’s preferences for CDMR, regardless of geographic or economic context. The quality of studies was assessed using the standardized CASP checklist, meaning that greater importance was placed on the conclusions from those studies deemed to be of a higher quality. Thematic synthesis provided a useful and robust framework to synthesize qualitative data. This enabled similarities to be identified, which were not recognized in single studies, and integrate them into major themes to gain a more comprehensive understanding of CDMR. With regard to study limitations, the exclusion of studies published in languages other than English makes the review prone to language bias. This is particularly unfortunate, given the high rate of cesarean deliveries in Central and South America, where the predominant languages are Spanish and Portuguese. The synthesis of findings was used in a reductive manner: overarching concepts were developed to encompass all aspects women felt were important when choosing CDMR.50 Therefore, some of the meaning of key concepts may have been lost during synthesis, when themes were translated across studies to identify meta-themes.51 This was minimized by transparent data extraction from the authors, who ensured all concepts were accompanied by a narrative memo about how they were developed and connected. Despite an extensive search of gray literature sources the review only contains peer-reviewed studies found in databases. Due to a limited number of publications, no studies were excluded on the basis of poor or poorly described methodology. Generalizability of the synthesis is limited, as samples were small and often self-selected, resulting in participation bias. Furthermore, these findings are often deeply contextualized and include “information rich” cases. Hence, it is difficult to transfer from one setting to another. Only two studies reported ethnicity of women. This is important, since previous studies have demonstrated higher cesarean rates in the black population.52 A further

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sub-analysis by ethnicity would have been an important area to investigate.53 A further disadvantage of all studies, except those by Fenwick and Moffat, was the use of only one method of data collection, rather than the use of mixed methodologies. Finally, because of a review by McCourt et al., in 2007, this review was limited to the years of 2006 through 2016. Given the influence family and social contexts have on women’s preferences for CDMR, it would be pertinent to explore these issues in future research. This would enable health care professionals to better understand the complex underlying social networks that impact on the decisions behind CDMR.

4.2 | Conclusions The reasons behind CDMR are multifactorial and complex. Situation-specific cultural factors, along with previous experience and interactions with health care professionals, are likely to have led to the increase in CDMR. To address these issues and conform to WHO guidelines, it will be important to facilitate an environment that emphasizes and educates health care providers and women of the benefits of vaginal delivery.54 It is essential that obstetricians establish the underlying reasons behind CDMR to provide clear, evidence- based information on a case-by-case basis.55 It is crucial that upstream determinants, including social norms, are considered and interventions targeting mothers, health care workers and systems are implemented both at the individual and population levels. ACKNOWLEDGMENTS We thank Dr. Ipek Gurol for supervision and guidance while completing this work. We also thank the women who took part in the original studies which have been included in this review. This work was not supported by any grants. ORCID Charles O’Donovan http://orcid. org/0000-0003-4416-5037 R E F E R E NC E S 1. Lumbiganon P, Laopaiboon M, Gulmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007- 08. Lancet. 2010;375:490‐499. 2. OECD. OECD Caesarean sections (indicator). 2011; https://data. oecd.org/healthcare/caesarean-sections.htm. 3. Cavallaro FL, Cresswell JA, Franca GV, Victora CG, Barros AJ, Ronsmans C. Trends in caesarean delivery by country and wealth quintile: cross- sectional surveys in


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SUPPORTING INFORMATION Additional Supporting Information may be found online in the supporting information tab for this article. How to cite this article: O’Donovan C, O’Donovan J. Why do women request an elective cesarean delivery for non-medical reasons? A systematic review of the qualitative literature. Birth. 2017;00:1‐11. https://doi.org/10.1111/birt.12319