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o BIOETHICS AND BIRTHINSIGHTS ON RISK DECISION-MAKING FOR AN ELECTIVECAESAREAN AFTER A PRIOR CAESAREAN DELIVERY

Pam McGrath, CQUniversityEmma Phillips, CQ University

This article presents thefindings ofqualitative research which explored, from themothers' per­spective, the process of decision-making about mode of delivery fora subsequent birth after aprevious Caesarean Section. Incontradiction to the clinical literature, themajority ofmothers inthis study were strongly of the opinion that a vaginal birth after caesarean (VBAC) posed ahigher risk than an elective caesarean (EC). From themothers' perspective, risk discussions wereprimarily valuable forgaining support fortheir pre-determined choice, rather than obtaining in­formation. The findings posit ethical concerns withregards to informed consent and professionalobstetric practice ata time when there isadocumented and worrying trend towards an increaseinbirths by caesarean section (CS).

INTRODUCTIONThe risks of elective caesarean (EC) and vaginal birth after caesarean (VBAC) are heavily

debated in the medical and nursing literature; however, the perspective of pregnant women

regarding birth risks following a prior caesarean section (CS) birth is not well understood.This article seeks to address this gap by presenting a sub-set of findings on the level of

knowledge about birth risks among women who have had a prior caesarean and, of thesect of these women who choose EC, the extent to which this knowledge informed birth

choice.The findings are from a qualitative study designed to explore, from the mothers'

perspective, the decision-making experience with regards to subsequent birth choice forwomen who had previously delivered by caesarean. The majority of mothers in the study

chose EC. This article presents their beliefs about the risks of EC and their reception toinformation presented by health practitioners. The findings posit ethical concerns with

regards to informed consent and professional obstetric practice at a time when there is

a documented and worrying trend towards an increase in the incidence of births by CS.In the case of the present findings, the mothers indicated that their birthing choice

was informed by psycho-social factors such as a sense of control and professional support,

rather than rational clinical indications of risk to themselves or their babies. The psycho-

22.1 MONASH BIOETHICS REVIEW, VOLUME 28, NUMBER 3,2009 MONASH UNIVERSITY EPRESS

social aspects of decision-making need to be understood and factored into any clinical

reflection of the rising CS rates. Yet to date, there is scant research on this aspect ofbirthing choice.

LITERATURE REVIEWConcern about the rising rates of caesarean delivery worldwide in the past decade hasled to much debate about the factors driving this trend. Caesarean births now accountfor 23.3% of all births in Australia (AIHW 2004), 21.5% in the United Kingdom (Thomaset al. 2001) and 31.1 % in the United States (Hamilton et al. 2007). The caesarean rateis highest among women who have experienced prior caesarean delivery (Dodd et al.2004). In the late 1990s the EC rate declined somewhat with the endorsement by theAmerican College of Obstetricians and Gynecologists supporting VBAC as a "safe andacceptable option" (ACOG 1999), but this trend has since reversed and the EC rate for

multiparous women continues to climb (Dodd et al. 2004).A recent systematic review considered the impact of strategies aimed at reducing the

EC rate after a prior caesarean birth (Horey et al. 2008) . Neither prenatal education and

support, nor cognitive therapy to reduce fear of giving birth, impacted upon clinicaloutcomes (Horey et al. 2008). Furthermore, a multicentre Randomised Clinical Trial(RCT) in Australia of 227 women that compared the effects of a decision-aid booklet

describing risks and benefits of both EC and VBAC showed little evidence that increasedknowledge about birth choices translates into a reduced caesarean rate (Shorten et, al.2005). Another information-based intervention for pregnant women aimed at reducingthe rates of caesarean section found not only that provision of information had little effecton women's birth choice, but that one in five women reported being distressed by some

of the information (Walker et. al. 2005).The rise in the caesarean rate has been partially attributed to maternal request, al­

though the evidence for this is contradictory (Declercq et al. 2006; Gamble et al. 2000;Hildingsson er. al. 2002; McCourt et. al. 2007; Menacker er al. 2006) . Although ECsfor pr imiparas is still ethically controversial except when medically indicated (Minkoff& Chervenak 2003), most health practitioners support maternal request for caesareanin women who have experienced prior emergency caesarean. Women prefer EC or VBACfor a variety of reasons, including prior birth experiences, personal expectations of the

birth process, family and social influences and medical recommendations (Hildingssonet al. 2002; Eden et al. 2004 ; Gamble et al. 2001; Shorten et al. 2004; Weaver et al.2007).

BIDETHICS ANDBIRTH ARTICLES 22.2

The publication of risks of EC and VBAC in the medical literature and popular mediahas created confusion among health practitioners and mothers alike. Well documentedrisks of ECs include prolonged recovery, delayed breastfeeding, bleeding, infection andneonatal breathing difficulties (Declercq et al. 2006) . As the number of repeat caesareansincreases, there is the possibility of reduced fertility, increased likelihood of abnormal

placentation and surgical difficulties due to adhesions (Dodd et al. 2004; Gilliam 2006).VBAC is also not without risks. Emergency caesarean following unsuccessful trial of la­bour is a real possibility, and although uncommon, life threatening complications suchas uterine rupture and perinatal death may occur (Dodd et al. 2004; Landon et al. 2004).

There is insufficient data in the literature that examines the mothers' perspective ofbirth risks following prior caesarean. However, as can be seen by the following studies,there is evidence from the mothers' perspective of inadequate preparation and knowledge

about birth risks. Gamble & Creedy (2001) found that 90% of women could name anadvantage of EC, but few knew about the risks to themselves (40%) or their baby (5%);furthermore, any risks of EC were seen as minor (Gamble et al. 2001). Weaver et al.(2007) found that a woman's fears and needs playa major part in the decision-making

process and that most women perceived EC as a safer birth choice for the baby.

METHODS

THE RESEARCH

The study was conducted by a senior research fellow at the CQUniversity in associationwith a Director of Obstetrics and Gynaecology (0 & G) at Redland Hospital, Queensland.The aim of the research was to explore from the mothers' perspective the process of de­cision-making about mode of delivery for a subsequent birth after a previous caesarean.

The research project was initiated by the then Director of O&G who was interested toexplore in-depth the subtleties of the mothers' experience with birth decision-making.The records from the Hospital Obstetric department echo the worldwide trend towardsa decreasing number of women undergoing VBACs. Indeed, the majority of mothers inthis study chose EC. Thus, the ethical imperative driving the research was a desire to

understand the mothers' perspective on birth decision-making. This imperative was furtherstrengthened by the fact there is very little literature available on the mothers' perspective.

The findings from the study are rich and dense and are being published separatelyas a number of articles (McGrath and Ray-Barreul, 2009; McGrath et al., 2009; McGrarhand Phillips, 2009; Phillips et al., 2009). The findings presented in th is article are fromthe data that describes the perspective of the mothers who underwent an EC on risks

22.3 BIOETHICS ANDBIRTH ARTICLES

associated with the delivery modes of VBAC and EC, and their experience discussingsuch risks with the health professionals who provided their obstetric care.

Ethical consent to conduct the study was obtained from both CQUniversity EthicsCommittee and the Redland Hospital Ethics Committee. Participants were verbally in­formed of their research rights and written consent was obtained for participation in the

research.

METHODOLOGY

Descriptive phenomenology was chosen as the theoretical framework as it underpins aresearch method that explores the "lived experience" of people from the "inside" per­spective of the individuals involved in the experience (Holloway 2008). As Spiegelberg

(1975) explains, descriptive phenomenology is the "direct exploration, analysis, anddescription of particular phenomena, as free as possible from unexamined presuppositions,aiming at maximum intuitive presentation." In this case, the phenomenon was mothers'lived experience as regards decision-making about the mode of delivery for a subsequent

birth following a CS. The discussion of decision-making extended to immediate birthingissues such as bonding and breast feeding. As inductive, phenomenological, qualitativework, the reporting of findings is based on a commitment to the participants' point ofview with the researcher playing the role of co-participant in the discovery and under­standing of what the realities are of the phenomena studied (Sorrell & Redmond 1995;

Streubert & Carpenter 1995).

PARTICIPANT GROUP

The sub-section of findings presented in this article are from interviews with 20 women,consecutively enrolled from RH hospital list, who had all had a previous caesarean andhad a subsequent birth at RH six weeks prior to the interviews, which were conducted

in June 2008. Of these twenty women, two gave birth by VBAC, two attempted VBACand 16 chose Ee. It is the findings from the 16 mothers who chose to birth by EC that

are presented in this article.Of the twenty mothers, thirteen (n=13) had an emergency caesarean for their prior

birth and seven (n=7) had Ee. At the time of the interview, all of the women had twochildren with the exception of two mothers who had three children and one mother who

had four children. All participants were either married or in a de-facto relationship atthe time of the birth. The participants' mean age was 32 years with an age range from26 to 38 years old. All of the women lived in the geographical catchment area of RH.

BIDETHICS AND BIRTH ARTICLES 22.4

INTERVIEWS

Data collection was conducted th rough an iterative, phenomenological, qual itative re­search methodo logy using open- end ed interviews conducted at the time and locationchosen by each participant. The inte rviews were conducted by an experienced researcheremployed by CQU and thus independent of RH. The interviews were informed by thepr inciples of "phenomenological reflection " as outlined in the work of Van Manen(1990). The line of questioning included the techn iques of probing, paraphrasing andsilence to explore the participant's experience. The interviews lasted for approximatelyone hour and were audio-recorded. Th e interviews were transcribed verb atim by a uni ­versity research assistant independent of RH .

ANALYSIS

The language texts were then entered into the QSR NUD*IST computer program and

analy sed thematically. All of the participants' comments were coded into "free nodes"wh ich are category files that have not been pre-organised but are "freely" created fromthe data. Thus the data analysis is driven by all of the participants' insights not by selected

pre-as sumptions of the coders. The research team did not mediate the findings but ratherdeveloped code titles that directly reflect the participants' sta tements ensuring the final

analysis directly describes the phenomenon (birth decision-making) from the participants'

perspective. The coding was established by an experienced qual itativ e researcher andcompl eted by a research assistant with extensive experience with cod ing qualitative data.There was complete agreement on the cod ing and emergent them es. Th e list of codeswas then transported to a Word Computer Program (Word XP) and organized under

thematic headings. The finding s presented in this article are from the data that describesthe perspective of the mothers who chose EC on risks associated with the delivery modesof VBAC and EC and their experience with discussing such risks with the health profe s­sionals who provide their obstetric care . As will be outl ined in the finding s, the data from

the EC mothers shared a common perspective and hence is being publ ished together.The data from the mothers who attempted or achieve a VBAC was quite different andis thu s the subject of different publications. Therefore, it is important to emphasise that

the following discussion is not repre sentative of the full sample of moth ers but only thosemothers who chose to birth by EC.

22.5 BIOETHICSANDBIRTH ARTICLES

RESULTS

THE RISK - VBAC VERSUS EC

One of the concerns that mothers confront in making birthing choices after a priorcaesarean is the issue of risk associated with either mode of delivery (VBAC or EC). Themajority of mothers who chose EC strongly believed that VBAC carried the highest risk,as the following stat ements exemplify:

Oh yeah the riskiest approach was to try a vaginal delivery. Yeah, no

I wouldn't have even attempted it. And everything I read backed that

up, yes.

And you know they say it's not very safe but I just saw as a woman

that's her decision to make. The caesarean is safer, yes, well yes. We'll

just have a caesarean because it's safer.

Yeah, I would choose Caesar over a natural birth . I know a natural

birth is a higher risk of things going wrong, whereas a caesarean is

really very low risk. Low risk to baby, low risk to mum. So a caesarean

is the way to go for that reason and there's lots of pluses for caesareans.

The key concern for the mothers was expressed to be the risk of rupture of the scarfrom the previous CS:

Basically I guess the main [concern] would be the fact that my Caesar

sca r, there's always that risk of it splitting...

The risk of tearing was what scared me the most .

Further reducing the mot~ers' sense of risk is confidence in the skill of the operatingteam, who were seen as' experienced and unlikely to make a mistake:

And I mean the only other complication that come out of C section

because the y do it every day so as far as them cutting through this ,

that or nicking a bowel or something; I was, you know, pretty confid­

ent with it.

The perception of the minimal risk associated with an EC was further reinforced by theknowledge that staff will be available and focused on the birth :

BIOETHICS AND BIRTH ARTICLES 22.6

We both thought, you know, nice and calm and on a set day and all

sort of, you know, all the staff already there and on hand. It sounded

more sensible.

The predictability of booking in for the EC and not being open to the unpredictability

of a natural delivery was also considered safer by this group of EC mothers:

I wouldn't say easier, it's still an operation and it still has its downside,

but I would say that I felt safer, the situation that I could be booked

in. That I didn't have to be at home and fall into labour and go through

that .

Only one mother who chose an EC viewed caesareans as more risky than a VBAC:

I think there's more risk in Caesars. There's probably more risk in

Caesars, I would think, because it's an operation.

However, one mother who chose an EC noted that there are just as many risks with both

options:

I mean, obviously you think about that you've had a caesarean. A

vaginal birth after that can have some risks to rupturing the scar. But

you just sort of take it all, I guess, with a grain of salt and know that

whichever you do there is generally some kind of risk anyway. And

just hope that that doesn't happen.

And another indicated she did not even consider the risks:

The risks didn't really enter my head.

RISK DISCUSSIONS WITH HEALTH PROFESSIONALS

The participants who chose an EC spoke in detail about their discussions of risk with

the health professionals who cared for them.

A CAVEAT - PRE-DETERMINED ATTITUDE NOT INFORMATION UNDERPINS CHOICE

With regard to the risks associated with different modes of delivery, the process was not

simply one of the health professional providing information that was absorbed and acted

on by the mother. Some mothers reported that the health professionals presented the

risks associated with both birthing choices without favour ing either choice:

22.7 BIOETHICS ANO BIRTH ARTICLES

No, they didn 't say one was preferable over the other.

However, such a balanced discussion did not necessarily inform the mothers' perceptionof risk:

Yes, yes, talked about risk issues. The y said that there are risk facto rs

in both vaginal birth s and Caesars. Just two different types of risks.

So it was up to me which one I chose, but I already had my mind made

up .. .

Moth ers may not even read the information provided if thei r minds are already madeup:

At one stage the hospital were actually very good, they gave me a lot

of inform ation to go both ways . And I was sort of reluctant to look

at it because I knew the decision I had made.

The health professional may not even offer information if they think the mother is pre­determined in her choice :

No information about trying a VBAC versus having a second caesarean,

there wasn' t any of that kind of information. But becau se maybe I'd

already made my mind up [to have an EC] they might have just not

given it to me.

Thu s, from the EC mothers' perspect ive a key factor is not the information content, butrather the support for their pre-det ermined choice. Th is theme is echoed in the findingsin regard to the specific health professiona ls: general practitioner, obstetrician and mid­wife.

GENERAL PRACTITIONERS (GPS)

For one group of mothers who chose an EC, the GP wa s the key health profess ionaloutside the hospital providing information and support for their birthing choice. Parti­cipants made clear statements that their GPs took time to discuss the birthing choice andwere supportive of the ir decisions. However, even when the GP provided informationon both options (EC and VBAC) it wa s the support for the mother's pre-determinedchoice that was cons idered most important:

BIDETHICSANDBIRTHARTICLES 22.8

The GP laid our the pros and cons and said ' if that's your choice that's

fine, and it's quite understandable'.

Support from the GP for a birthing option could be expressed in statements indicatingthat an EC was the only option:

When I told the GP why, he was like, ' oh well you 've really got no

choice have you?' Yeah, he was good .

Alternatively, the GP could project their personal preferences onto the mother in a waythat was deemed supportive by the mother:

She [GP] was actuall y supportive of a caesarean from the day that I

found out that I was pregnant. Yes, she was like, 'well I would be

having a Caesar if I was you '.

The mothers expressed satisfaction with this support for their pre-determined choice andexpressed that it was this support, rather than information or discussing on different

risks for alternative options, that was sought from the GP.

HOSPITAL OBSTETRICIANS

The same theme permeated the data on risk discussions with hospital obstetricians.

SUPPORTIVE OF EC

Many of the mothers in research did not consider opting for a VBAC and, from the startof the pregnancy, had made a decision to have an EC. Hospital staff were supportive ofthis decision:

[Interviewer, summin g up the interview so far: Would it be fair com­

ment to say right from the beginning you decided that you were going

for an elective Caesar and that was the end of it?] Yes, that's it. [Inter­

viewer: And that the doctors supp orted you in that and under stood

that ?] A hundred percent , yes. It was just a date, come in, have the

baby then .

A few of the participants noted that the hospital obstetricians did present the option

of VBAC positively and sensitively. As one mother explained:

22.9 BIOETHICS ANO BIRTHARTICLES

Yeah, I think they were pretty fair in that. They certainly .. . they don't

push vaginal births but they certainly try and encourage people and

say ' look we can do this' you know, probably right, fair enough, be­

cause nobody should be going through major surgery unless they have

to .

Again, the important point from the perspective of this group of mothers, who werecommitted to having an EC, is that it was not the information per se but rather the wayit was communicated that affirmed the mother 's pre-determined choice:

They were quite supportive. They did say to me that I had the option

of going for a vaginal delivery, but I was quite adamant that I didn't

want to . And then at my following appointment they did offer that to

me again and I was once again quite adamant that I wanted to proceed

with the Caesar. And they just said that they wanted to make sure that

I was 100% comfortable with that, and they were supportive, so we

did that.

Central to this was the obstetrician's acceptance of the mother's choice of EC:

And that even though some of the doctors would say 'have a go at a

vaginal birth ', they were supportive once you decided you wanted a

caesarean.

One mother feared her request for an EC would not be heeded because of a previous

difficult experience at another hospital, so she sought additional support in her approach

to the hospital doctors:

It was a lot better. It was a lot easier to .. . because I mean they already

had all my file with the information that they needed straight up and

they listened to me, and I think also a little bit of weight was thrown

behind me because I'd come from the Diabetes Clinic. And the diabetes

specialists were saying 'yes, that's how it is' . I felt that gave me a little

bit more weight in their minds.

Other mothers reported that they experienced strong discouragement from consideringa VBAC. There were many clinical reasons why women believed it was not possible toengage in a VBAC without the birth ending in an emergency caesarean. As discussed

BIOETHICS ANDBIRTH ARTICLES 22.10

elsewhere in full, many of the women had lost confidence in their body's ability to givebirth naturally (McGrath, Phillips & Vaughan, 2009). Advice against a VBAC wascouched in positive terms of the convenience of an EC:

But they could pretty much guarantee me that it wasn't going to work,

so it was like, 'do you really want to go through all that just to find

that you've got to have an emergency caesarean anyway? When you

could be put in and we can give you a date and then you'll be in a

more relaxed frame of mind '. And so that's what we did .

Mothers did not necessarily understand the clinical reasons for the EC:

I don't know [clinical reason]. I really don 't know because I didn't get

to talk too much about it this time.

If the doctor had a reputation for being supportive of VBACs then the recommendationagainst a VBAC was trusted:

He did guide me when I went for the last check up. He said he thinks

it would be better if I have a Caesarean and I know he'd know, he's

pro-natural. So when he said .. . then I thought 'okay if you say so,

I'll trust him' , 'I'll do it'.

When a doctor recommends an EC, mothers worry that to go against the advice is

to take on too much risk:

I could have had a go [at VBAC]. But I didn 't really want to risk it. It

was a hard decision because I needed to put what I wanted to do first

or the risks. He [doctor] said to me, 'You can do it [VBAC] if you

want to', but he just said 'I recommend it [EC]'. So 1 said, 'okay if

that's your medical reason, then do it' .

If the doctor recommends an EC, it is very difficult for mothers to go against this advice:

I definitely feel that it 's very hard for mothers to say 'no', because

there is that fear factor, that if a doctor has recommended it, it's

probably necessary.

22.11 BIOETHICS ANO BIRTH ARTICLES

MIDWIVES

The mothers in the study were predominantly followed up by the midwives at the hos­pital :

1saw a doctor 1think it was at twelve weeks and a doctor at 34 weeks

and the rest of the time it was midwives .

Overall, the midwives were seen as supportive of the mother's desire for an EC:

1th ink they were, all the midwives were, pretty supportive actually in

that when they heard the reasons 1 think they were like, 'yeah, 1 can

see why you want to go that route'.

Some of the midwives even used their own experience to affirm the choice of an EC:

Whereas even the midwife 1 had on the day that 1went in to have the

caesarean she was like, 'Oh, a caesarean... you 're doing the best thing'.

She said, 'I had four Caesareans' [laughs).

At the same time, there is ample evidence that the midwives are proactive in positing

the idea of the value of attempting a VBAC without unduly pressuring the mothers:

So certainly early on before it was decided 1 was definitely going to

have a Caesar 1 can remem ber two or three midwives mentioning to

me that, you know, 'recommend that you try for a vaginal birth',

'they've got a great success rate', and you know , blah, blah , blah , you

know, all the positives, so they certainly .. . 1 wouldn 't say they leant

on me, that wouldn 't be fair, but they cert ainly made sure the idea

was in my head that I cou ld go down the natural route if that's what

1wanted.

DISCUSSION

Despite ample evidence that VBAC is predominantly safe for mother and baby (Maconeset at. 2005) and associated with improved physical and emotional outcomes and fewerlong-term consequences (Fenwick et at. 2007), the majority of mothers in this study werestrongly of the opinion that VBAC poses a higher risk than EC because of the risk ofrupture of the scar from the previous caesarean. Such a belief is in contradiction to theclinical literature that posits VBAC as the 'safe and acceptable option' (ACOG 1999)

BIOETHICS ANOBIRTH ARTICLES 22.12

and uterine rupture as an uncommon possibility (Dodd et aI. 2004; Landon et aI. 2004).However, for the mothers, the planned nature of the EC, confidence in the skill and ex­perience of the operating team and the controlled nature of the experience reinforces thenotion that EC is a safer option than a VBAC. Of the few EC mothers who differed fromthis opinion, one perceived EC as more risky because it involved an operation, one be­

lieved both modes of delivery had risks and one did not cons ider risks at all. It is importantto note that many of these mothers had previously delivered by emergency caesareanand were unwilling to risk the uncertainty of a vaginal delivery. The find ings resonatewith the work of Gamble & Creedy (2001) who have also documented that women are

unaware of the risks of EC to themselves or their babies, and view EC risks as minor.The important point is that mothers are informing their choice on psycho -social factorssuch as a sense of control and professional support, rather than on clinical indications.

Thus, the psycho-social aspects of decision-making need to be understood and factoredinto any clinical reflection of the rising CS rates, yet, to date, there is scant research onthis aspect of birthing choice .

The participants spoke in detail about their discussions on the issue of risk with the

health profess ionals who cared for them . Significantly, many of the mothers in the studybrought to these discussions of risk a pre-determined choice for EC and were not really

open to the information presented. Mothers may not even read the information on risk

provided by health professionals, or the health professional may not even offer risk in­formation if the mother holds a strong pre-determined choice.

The participants' comments regarding discussions of risk with their GP and hosp italobstetricians were couched in term s of the doctor's support or otherwise for their birthdelivery preference. As many of the mothers had firmly decided to birth by EC, there

were favourable comments on the pro-EC support provided. Some hospital obstetriciansdid present the option ofVBAC in positive terms, while sensitively respecting the mother'spreference for EC. One mother feared her request for EC would not be listened to becauseof a previous difficult experience at another hospital, so she sought add itional supportin her approach to the hospital doctors. Some of the mothers reported that the hospitalobstetricians discouraged VBAC for reasons that an attempt would end in an emergencycaesarean and it would be more convenient to opt for EC. The mothers did not necessarilyunderstand the clinical reasons for this. If the doctor had a reputation for being supportiveof VBAC then the recommendation against VBAC was viewed as trusted advice. A majorconcern for the mother when the doctor recommends EC is the worry that to go against

the advice is to take on too much risk. Indeed, it is seen as very difficult to go against

22.13 BIDETHICS AND BIRTH ARTICLES

such clinical advice, especially as many of the women had lost confidence in their abilityto birth naturally as a consequence of a previous birthing experience.

The routine care and follow-up of the mothers at the hospital was provided by hos­pital midwives. Overall, the midwives were seen as supportive of the mothers ' desire forEC, with some midwives even using their own experiences to affirm the EC choice. At

the same time, there is ample evidence that the midwives are proactive in positing theidea of the value of attempting a VBAC without unduly pressuring the mothers awayfrom their choice of EC.

These findings add a valuable perspective to the EC versus VBAC ethical debate. Themajority of mothers in this study who chose EC did so because they believed it was thesafer option. They were reluctant to receive knowledge contradictory to their birth choice

and primarily sought support for their decision, rather than information, from healthpractitioners.

AN ETHICAL DILEMMA - RESPECT FOR AUTONOMY VS BENEFICENCEA key finding from the research is that, from the perspective of this group of mothers,

risk discussions are not important in terms of clinical information-gathering but arerather valued for gaining psycho -social support for their pre-determined birth choice.Professional obstetric and mid-wife support for such pre-determined choice resonates

with the ethical pr inciple of respect for autonomous choice. However, in view of thebenefits of VBAC and the ongoing angst about the worrying trend of increasing unneces­sary ECs, from a professional perspective support for such pre-determined choice chal ­lenges the principle of beneficence. Further findings from the study indicate that the ex­per ience of VBAC mothers is that the obstetric system is predominantly pro-caesareanand that VBAC mothers have to work hard against a hosp ital risk-management culture

to achieve their desired outcomes. In short, the ethical dilemma posited by these findingsis that, in a pro-CS hospital sub-culture, the fostering of the pre-determined autonomouschoice for ECs may be contributing to negative outcomes in terms of an unacceptablerise in EC rates and the development of a risk-averse subculture that is not supportiveof the difficult choice made by women who opt for a VBAC.

The limitation that this initial data were collected from participants from one hospitalis acknowledged. However, the insights are important and indicative of a productivenew direction in exploring the eth ical concerns about rising CS rate s. The strong recom­mendation from the research is that there needs to be a paradigmatic shift in the approachto exploring and documenting the ethical concerns about mode of birth delivery that

BIOETHICS ANOBIRTH ARTICLES 2214

incorporates a strong psycho-social , rather than purely clinical or abstract philosophical,

approach. The recommendation resonates with the ongoing discussion in the bioethicalliterature that crit iques the role of the philosophically-based, predominantly abstract,rationalistic mode of Principlism as the central mode of reasoning in bioethics (Alderson1991; Bauman 1993; Clouser & Gert 1990; De Grazia 1992; McGrath 1998; McGrathet al. 2006; Nicholson 1994; Tong 1996). Gilligan (1982), an early leader contributing

to the new direction, has highl ighted that the rationality of abstract philosophy leavesout important non-rational factors associated with the social context and relationshipsinforming the ethical decision-making. Similarly, Alderson (1991) simply states that ab­

stract bioethics ignores human emotions.The findings clearly indicate that bioeth ical reflection on this dilemma needs to take

into consideration the psycho-social aspects of decision-making for the mother and sub­culture issues from the perspective of the hospital. At present the deliberation aboutethical aspects of the rising CS rates are set in the clinical literature and posit factorssuch as maternal age as key causative factors (Smith et al. 2008). As Smith (2009), aProfessor of Obstetrics and Gynaecology at the University of Cambridge, UK, argues in

relation to rising caesarean rates: ' the first thing is that faced with any sort of publichealth problem, the way to begin to address it is to understand biologically what's hap ­

pening'. There is an exten sive obstetric and midwifery clinical literature based on th isassumption. In contrast, there is scant research that explores the 'psycho-social factorscontributing to the ethical concerns about increasing rates of birth by CS. The insightsprovided by the mothers in the research reported in this article are important as theyindicate the reverse. The mothers' decision-milking was not informed by clinical consid­erations, indeed the mothers were poorly informed of the clinical/biological implications

of their choice.The doctrine of informed consent is founded on the notion that the individual has

sufficient information about the options available so as to enable a rational choice to bemade (Johnstone 2004). The key requirements for the giving of informed consent arefull disclosure of all relevant information; comprehension and understanding of that in­formation; freedom or voluntariness; and competence in decision-making, with the co­

existence of all requirements recorded by a written expression of consent (McGrath2000; Lovat & Mitchell 1991) . Clearly, for this group of mothers who had all providedwritten consent for their CS operations, the informed consent issues were not met. Im­portantly, issues of relevant information, comprehension and understanding of that in­formation were not prioritised. The ethical imperative in relation to autonomy for thisgroup of women was support for their pre-determined choice. The important point is

22.15 BIOETHICS ANDBIRTH ARTICLES

that psycho-social knowledge of the dynamics of decision-making casts a very differentlight on the factors contributing to conserit to birthing choice. Thus, it is strongly arguedthat the way forward in understanding and resolving the ethical concerns about risingCS rates lies in further investment in psycho-social research to deepen our collective un­derstanding of the factors actually contributing to this health care dilemma. Clinical

knowledge and abstract reflection make a contribution but are only part of the solution.As scant research has been completed on this topic, the findings are offered with the

hope and expectation that the insights will make a contribution to deepening our under­standing of the ethical issues associated with birth decision-making for mothers for asubsequent birth after a prior CS.

CONCLUSIONIn contradiction to the clinical literature, the majority of mothers interviewed for this

study believed that VBAC carries a higher risk than repeat caesarean. Although mostmothers reported that their doctor had discussed the risks and benefits of each mode ofdelivery, the findings strongly affirm that most mothers have already made up their minds

about birth options following a prior caesarean delivery and seek psycho-social supportin their decision, rather than detailed clinical information about risks and benefits, fromtheir health practitioners. The insights from the study are offered as a contribution to

enriching our understanding of the complexity of ethical issues informing the increasingconcern about the rising rates of EC.

ACKNOWLEDGMENTThe study was funded by a collaborative Industry Grant between CQUniversity and theRedland Hospital.

REFERENCESAlderson, P. 1991 . Abstract bioethics ignores human emotions. Bulletin ofMedical Ethics 68 (May)

13-21.American College of Obstetricians and Gynecologists. 1999. ACOG Practice Bulletin: vaginal birth

after previous cesarean delivery. Clinical Management Guidelines. International Journal ofGynecology and Obstetrics 66 (2): 197-204.

Australian Institute of Health and Welfare. 2004 . Australia's Health 2004 . Canberra: AIHW.Bauman, Z. 1993. Postmodern Ethics . Oxford: Blackwell.

BIOETHICS ANDBIRTH ARTICLES 22.16

Clouser, K. & Gert, B. 1990 . A critique of Principlism . [ournal of Medicine and Philosophy 15:219-236.

De Grazia, D. 1992. Moving forward in bioethical theory : Theories, cases and specified principlism.Journal of Medicine and Philosophy 17: 511-539.

Declercq, E.; Sakala, C., et al. 2006 . Listening to Mothers II: The Second National U.S. Survey of

Women 's Childbearing Experiences. [internet). New York: Childbirth Connection. Accessed31 July 2008 . Available from: http://www.childbirthconnection.org/listeningtomothers.

Dodd, ./.; Crowther, c.,et al. 2004 . Planned elective repeat caesarean section versus planned vaginalbirth for women with a previous caesarean birth (Review). Cochrane Database SystematicReuieun 4.

Eden, K.; Hashima, ] ., et al. 2004. Childbirth preferences after Cesarean birth : A review of theevidence . Birth 31 (1): 49-60.

Fenwick., ] .; Gamble,] ., et al. 2007. Believingin birth - choosing VBAC:The childbirth expectationsof a self-selected cohort of Australian women . journal of Clinical Nursing 16: 1561-1570.

Gamble, j.; Health, M., et al. 2000. Women's request for a cesarean section: A critique of theliterature. Birth 27:256-263.

Gamble, ].; Health, M., et al. 2001. Women's preference for a cesarean section: Incidence andassociated factors. Birth 28: 101-110.

Gamb le, j. and Creedy, D. 2001. Women's preference for caesarean section: Incidence and associatedfactors . Birth 28 (2): 101-10.

Gilliam, M. 2006. Cesarean delivery on request: Reproductive consequences. Seminars in Perinatology30: 257-260.

Gilligan, C. 1982 . In a different voice: Psychological Theory and Womell's Development. Cambridge,Mass .: Harvard University Press.

Hamilton, B.; Martin, j., et al. 2007. Births : Preliminary Data for 2006. Centers for Disease Controland Prevention Division of Vital Statistics. National Vital Statistics Report 57 (7).

HiJdingsson, I.; Radestad, I., et al. 2002 . Few women wish to be delivered by caesarean section .B./OG: International journal of Obstetrics and Gynaeeology 109: 618-623.

Holloway, I. 2008. A-Z of Qualitatille Research in Healtbcare. 2nd ed. Oxford: Blackwell.Horey, D.; Weaver,.J., et al. 2008. Information for pregnant women about caesarean birth (Review).

Cochrane Library Systematic Review. 3.

Johnstone, M-] . 2004 . Bioethics: A Nursing Perspective. Sydney: Churchill Livingston.Landon, M .; Hauth, ] ., et al. 2004 . Maternal and perinatal outcomes associated with a trial of labor

after prior cesarean delivery. The New England [ournal of Medicine 351 (25): 2581-2589.Lovat, T. & Mitchell, K. 1991. Bioethies for Medical and Health Professionals . New South Wales:

Social Science Press, New South Wales.Macones, G.; Peipert . ] ., et al., 2005 . Maternal complications with vaginal birth after cesarean

delivery: A multicenter study. American journal of Obstetrics & Gynecology 193:

1656-1652.McCourt, c.;Weaver, ] ., er aI., 2007. Elective caesarean section and decision making : A critical

review of the literature. Birth 34 (1): 65-79.

22.17 BIDETHICS AND BIRTH ARTICLES

McGrath, P. 1.998. Autonomy, discourse, and power : A postmodern reflection on principlism andbioethics. The Journal of Medicine and Philosophy, 23 (5): 516-532.

McGrath, P. 2000. Informed consent to peripheral blood stem cell transplantation. Cancer Strategy

2: 44-50.McGrath, P.and Ray-Barreul, G. 2009 . The easy option? Australian findings on mothers' perception

of Elective Caesar as a birth choice after a prior Caesarean Section. International Journal

of Nursing Practice 15 (4): 271-279.McGrath P.; Phillips E. (2009). The breast or bottle? Women's infant feedings choices in a subsequent

birth after a previous Caesarean Section. Australian Journal of Advanced Nursing 27 (1):37-47.

McGrath, P.; Henderson, D.; Holewa, H. 2006. Patient -centred care : Qualitative findings on healthprofessionals' understanding of ethics in acute medicine. Journal of Bioethcial Inquiry 3

(3): 149-60.McGrath P.;Phillips E.; Vaughan G. 2009 [in press]. Speaking out! Qualitative insights on the

experience of mothers who wanted a vaginal birth after a birth by Caesarean Section The

Patient: Patient-Centered Outcomes Research.

Menacker, E; Declercq, E., et al. 2006 . Cesarean delivery: Background, trends, and epidemiology.Seminars in Perinatology 30:235-241.

Minkoff, H. & Chervenak, E 2003 . Elective primary cesarean delivery. The New England Journal

of Medicine 348 (10): 946-950.Nicholson , R. 1994. Limitations of the four principles. In R. Gillon (ed.). Principles of Health Care

Ethics (pp. 267-275). Chichester: Wiley.Phillips E.; McGrath P.;Vaughan G. 2009 [in press]. ' I wanted desperately to have a natural birth':

Mothers' insights on VBAC. Contemporary Nurse.

Shorten, A.; Chamberlain, M., et al. 2004. Making choices for childbirth: Development and testingof a decision-aid for women who have experienced previous caesarean. Patient Education

and Counseling 52: 307-313.Shorten , A.; Shorten, B., et al. 2005. Making choices for childbirth: A randomized controlled trial

of a decision-aid for informed birth after cesarean . Birth 32 (4): 252-261.Smith, G. 2009 . Rise in caesarean section. The Health Report, Australian Broadcasting Commission,

Radio National http://www.abc.net.aulrnlhealthreportlstories/2009/2708388.htm#transcript.Accessed 20th October 2009.

Smith, GCS., et al. 2008 . The effect of delaying childbirth on primary caesarean section rates . PLoSMedicine 5 (7): el44.

Sorrell, J.; Redmond, G. 1995. Interviews in qualitative nursing research: Differing approaches forethnographic and phenomenological studies .Journal ofAdvanced Nursing 21:1117-1122.

Spiegelberg, H. 1975. Doing Phenomenology, The Hague : Nijhoff.Streubert, J.;Carpenter, D. 1995. Qualitative Research in Nursing: Advancing the Humanistic

Imperative. New York: Lippincott.Thomas, J,; Paranjothy, S., et al. 2001. National Sentinel Caesarean Section Audit Report. London:

Royal College of Obstetricians and Gynaecologists Press.

BIOETHICS ANOBIRTH ARTICLES 22.18

Tong, R. 1996. Feminist approaches to bioethic s. In S. Wolf {ed.}.,Feminism and Bioethics : Beyond

reproduction (pp , 67-94) Oxford: Oxford University Press.Van Marien, M. 1990. Researching Lived Experience. Ontario: State University of New York Press.Walker, R.; Turnbull, D., et al. 2005. The development and process evaluation of an

information-b ased intervent ion for pregnant women aimed at addressing rates of caesareansection. B]OG : International Journal of Ob stetrics and Gynaecology 112:1605-1614.

Weaver, ]. ; Statham, H., et al. 2007 . Are there "unnecessary" cesarean sections? Perceptions ofwomen and obstetr icians about cesarean sections for nonclinical indicat ions. Birth 34 (I) :32- 41.

Cite this articleas:McGrath, Pam; Phillips, Emma. 'Bioethics andbirth:Insights onriskdecision­making for anelective caesarean after a prior caesarean delivery'.Monash Bioethics Review28 (3): pp. 22.tto 22.19. 001: 10.2104/mber0922.

22.19 BIDETHICS AND BIRTH ARnClES