Caesarean section as an informed choice in the UK: a systematic review
Despite the steady increase in the number of women giving birth via caesarean section in the UK, little is understood about how shared decision making is implemented in obstetrics or what this means for women that have given birth via caesarean. The aim of this review is to assess narratives of women's experiences of caesarean birth as an informed choice and their involvement in this process.
A number of databases were searched, including MEDLINE via EBSCO, EMBASE via OVID, MIDIRS via OVID, Scopus, Wiley Online Library, Google Scholar and Ethos, as well as the reference sections of the included studies. Primary studies published between 1990–2020 were included and quality was assessed using the critical appraisal skills programme tool. Findings were analysed using a thematic synthesis framework to elicit higher order interpretations.
A total of 11 studies were included in the final review. Quality assessment indicated the studies were generally of good quality, with the main limitations being in methodology quality indicators. Thematic synthesis identified eight subthemes within three main themes: ‘patient-doctor relationships’, ‘decision making as an emotional journey’ and ‘caesarean not really an informed “choice”’. The role of healthcare providers in promoting women's agency via patient-centred care was a prominent theme in women's narratives.
Women's decision making in consent to undergo caesarean births is a complex, emotionally driven process that can have a significant long-term psychological impact.
The continual increase in caesarean section rates in the UK has been recognised as a public health issue because of a lack of evidence that caesarean section generates better (or at least equitable) mother–infant outcomes compared to vaginal delivery (D'Souza and Arulkumaran, 2013; D'Souza, 2013; Wise, 2018). The World Health Organization emphasises that caesarean section rates over 15%, such as in the UK where the rate is currently 26.2%, is indicative of unnecessary and therefore unethical surgical intervention (Betrán et al, 2016; Wise, 2018).
The National Institute for Health and Care Excellence (NICE, 2013) guidelines state informed choice/consent is the pinnacle in enabling women to act as equal partners in deciding their mode of birth in a clinical environment. Informed choice is achieved by maternity care providers supplying women with impartial, evidence-based information (D'Souza, 2013; NICE, 2013; Moore, 2016). The long-term benefits of shared decision making in obstetrics are widely recognised and include increased equity in care, decreased litigation because of improved patient satisfaction and better patient outcomes resulting in reduced post-care complications (Gee and Corry, 2012). Results from international studies identify that UK providers score highly in indicators of supporting women's rights to caesarean section as an informed choice (Habiba et al, 2006; Betrán et al, 2016). However, shared decision making and informed choice are misunderstood by healthcare providers and are mostly comprised of a shallow process of decanting knowledge to lay persons in order to obtain a consent signature (Begley et al, 2019).
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