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Neonatal Nursing Congress 2019: Women’s decision-making processes and the influences on their mode of birth following a previous caesarean section in Taiwan: a qualitative study- Shu Wen Chen-University of Nursing and Health Science

Shu Wen Chen

Vaginal birth after cesarean (VBAC) is another opportunity for women who have had an earlier cesarean section (CS); though, uptake is limited because of worry about the risks of uterine rupture. The objective of this study was to explore women’s decision-making courses and the influences on their mode of birth following a previous CS. A qualitative approach was used. The research comprised three stages.

Involved of naturalistic observation at 33-34 weeks’ gestation. Involved interviews with pregnant women at 35-37 weeks’ gestation. Consisted of interviews with the same women who were interviewed postnatal, 1 month after birth.

The inquiry was conducted in a private medical center in northern Taiwan. Using purposive sampling, 21 women and 9 obstetricians were recruited. Data collection complex in-depth talks, observation, and field notes. Constant comparative analysis was employed for data analysis. Ensuring the protection of the mother and baby was the attention of women’s decisions. Women’s decision-making effects involved earlier birth experience, concern about the risks of vaginal birth, valuation of the mode of birth, current pregnancy situation, information resources, and health assurance. In communicating with obstetricians, some women complied with obstetricians’ recommendations for repeat cesarean section (RCS) without being informed of alternatives. Others used four-step decision-making processes that included searching for information, listening to obstetricians’ professional judgment, evaluating alternatives, and making a decision regarding mode of birth. After birth, women imitated their choices in three aspects:

• A reflection on birth choices

• Reflection on factors influencing decisions

• Reflection on outcomes of decisions

The health and wellbeing of mother and baby were the main concerns for women. In answer to the decision-making effects, women’s connections with obstetricians about birth choices varied from passive decision-making to shared decision-making. All women have the right to be learned of alternative birthing decisions. Routine providing of clarifications by obstetricians about risks linked with alternate birth options, in addition to financial coverage for RCS from National Health Insurance, would care women’s decision-making. Formation of a website to provide women with reliable data about birthing choices may also assist women’s decision-making.

Methods:

Using a qualitative approach, the research encompassed three stages.

Stage 1- Involved in the naturalistic opinion of obstetric consultations to know how obstetricians assisted women to make their birth choices. Stages 2- Involved interviews with pregnant women to explore their perceptions of the influences on their preferences for mode of birth. Stage3- Consisted of interviews in the postnatal period with the same women who were interviewed in stage 2. The determination of the stage 3 interview was to capture women’s reflections about the effects on their decisions regarding mode of birth, and the relationship between their choices and the actual birth mode outcome.

The study was conducted in a private, tertiary teaching

medical centre in northern Taiwan. At the hospital, there

were between 350 and 450 births per month and the CS

rate varied between 34% and 38%, consistent with Tai-

wan’s overall CS rates [19]. A purposive sampling ap-

proach was used in this study. Pregnant women who

had undergone a previous CS were eligible to be in-

cluded. Inclusion criteria were: women who were aged

18-45 years of age, fluent in Mandarin or English, 30-

32 weeks’gestation, and had experienced a previous CS.

Exclusion criteria included women with a multiple preg-

nancy, a previous classic CS or myomectomy, and/or

high-risk pregnancies (for example, women who had risk

factors such as threatened premature labour, hyperten-

sion, heart disease, diabetes, epilepsy, or another pre-

existing medical problem)

The study was conducted in a private, tertiary teaching

medical centre in northern Taiwan. At the hospital, there

were between 350 and 450 births per month and the CS

rate varied between 34% and 38%, consistent with Tai-

wan’s overall CS rates [19]. A purposive sampling ap-

proach was used in this study. Pregnant women who

had undergone a previous CS were eligible to be in-

cluded. Inclusion criteria were: women who were aged

18-45 years of age, fluent in Mandarin or English, 30-

32 weeks’gestation, and had experienced a previous CS.

Exclusion criteria included women with a multiple preg-

nancy, a previous classic CS or myomectomy, and/or

high-risk pregnancies (for example, women who had risk

factors such as threatened premature labour, hyperten-

sion, heart disease, diabetes, epilepsy, or another pre-

existing medical problem)

Two interviews of women were conducted to elicit their

perspectives, preferences regarding birth choice before

and birth reflections afterwards. A semi-structured inter-

view guide was used for the interview to cover key issues

for women participants.

Ethics approval was obtained from the university and

hospital Human Research Ethics Committee. Prior to

commencement, participants gave written informed con-

sent for participation and the audio-recording of the in-

terviews. The researcher invited eligible women to

participate in the study when they attended the registra-

tion counter for their prenatal examination at the 33-

34 weeks’gestation visit in the Outpatient Department

of Obstetrics and Gynaecology. Interactions between the

consulting obstetrician and the pregnant woman were

observed and field notes were recorded.

Two interviews of women were conducted to elicit their

perspectives, preferences regarding birth choice before

and birth reflections afterwards. A semi-structured inter-

view guide was used for the interview to cover key issues

for women participants.

Ethics approval was obtained from the university and

hospital Human Research Ethics Committee. Prior to

commencement, participants gave written informed con-

sent for participation and the audio-recording of the in-

terviews. The researcher invited eligible women to

participate in the study when they attended the registra-

tion counter for their prenatal examination at the 33-

34 weeks’gestation visit in the Outpatient Department

of Obstetrics and Gynaecology. Interactions between the

consulting obstetrician and the pregnant woman were

observed and field notes were recorded.

Two interviews of women were showed to elicit their perspectives, preferences concerning birth choice before, and birth reflections afterward. A semi-structured interview guide was used for the interview to cover key issues for women participants. Ethics consent was got from the university and hospital Human Research Ethics Committee. Prior to commencement, participants gave written informed consent for participation and the audio-recording of the interviews. The researcher asked eligible women to share in the study when they joined the registration security for their prenatal examination at the 33- 34 weeks’ gestation stays in the Outpatient Department of Obstetrics and Gynaecology.

Connections between the consulting obstetrician and the pregnant woman were experiential and field notes were logged. A prenatal interview with the woman was scheduled to coincide with the woman’s next visit to the obstetrician. The right face-to-face interview was held at 35- 37 weeks’ gestation when the women stayed their obstetrician. The quiet waiting room of the Outpatient Department of Obstetrics and Gynaecology was used to conduct the interview while the women waited for their obstetrician appointment. Interviews initiated with a key query, “Could you tell me what is your birth plan regarding the mode of birth?” Following the provision before the birth of the child of the signed agreement for the postnatal interview, and at about 1 month after birth, a portable text message requesting a postnatal interview was allotted to the women to check their intention to join in the interview. The face-to-face interviews were conducted in the waiting room of the Outpatient Department of Obstetrics and Gynaecology or the Neonatal Department after the postnatal women attended their routine follow-up postnatal appointment. A total of 24 pregnant women decided to participate in the study and providing signed agreement. Three women were included from the study with two women who moved to another hospital located in southern Taiwan and one woman who miscarried before the prenatal meeting. In entire, nine obstetricians and 21 pregnant women joined in the study. Women completed a survey to provide their demographic characteristics. Opinion of consultation among obstetricians and pregnant women of the 21 pregnant women who joined in the study, only nine were experiential during the consultation with their obstetrician. A total of 12 pregnant women were not detected because their obstetricians did not approve to participate in the study. Interactions between obstetricians and pregnant women were detected through discussions in the Outpatient Department of Obstetrics and Gynaecology when women were 33-34 weeks ‘gestation. Observational data were recorded and field notes were collected. During the consultation, women seldom asked questions. In most discussions obstetricians providing women with routine antenatal examinations such as checking the fetal heartbeat and gaging the fundal height of the uterus. They did not provide any counselling regarding mode of birth. On average, each consultation was complete within 5-8 min.

Note: This work is partly presented at 31^st Global Experts Meeting on Neonatal Nursing and Maternal Healthcare, May 08-09, 2019 Tokyo, Japan