Using data from the population-based Listening to Mothers in California Survey of women who had hospital births in 2016, we further analyzed the 1,964 women without a prior cesarean birth who did not have a planned cesarean birth. Our goal was to identify factors associated with reduced likelihood of unplanned primary cesarean birth using the broader range of variables available in woman-reported survey data. We examined in bivariate analyses the role of demographic variables; of women’s behaviors, preferences, knowledge and beliefs; and of characteristics of intrapartum care, including labor management practices. We then entered significantly related or theoretically important variables into multivariable analyses. While women’s personal views, preferences and behaviors related to care arrangement had little relationship with their likelihood of cesarean birth, we identified many aspects of their intrapartum care that were related to their mode of birth.
The use of survey data to understand factors associated with cesarean birth enabled us to explore whether the beliefs, preferences, knowledge and behaviors of women themselves play a role in their likelihood of having a cesarean. We found that most survey participants agreed either strongly (47%) or somewhat (27%) with the statement that “childbirth is a process that should not be interfered with unless medically necessary,” while just 8% disagreed. And although few actually used midwifery care and had doula support, and all gave birth in hospitals, they expressed a high degree of interest (i.e., they would definitely want or would consider) in these high-touch, low-tech forms of care should they give birth in the future: midwife (56%), doula (59%) and birth center births (41%). Further, almost one respondent in three (30%) sought information about cesarean rates of prospective hospitals, with the great majority of these finding this information. And about one in three correctly understood that the quality of care varies across both obstetricians and hospital maternity units [28]. However, we found no association between having a cesarean and agreeing that unneeded childbirth interventions should be avoided, seeking cesarean rates of prospective facilities, understanding that quality varies by obstetrician and by facility, or feeling that the intrapartum staff had accorded autonomy. Women with a cesarean were less likely to be interested in a future birth center birth, possibly because they correctly understood that many care providers encourage hospital birth and repeat cesareans for women with a previous cesarean. It is not possible to take women’s own perspectives into account in analyses limited to administrative, clinical or vital records data sources.
Engaging patients and their family members and caregivers in their health care is a growing policy priority, as reflected in the United States National Quality Strategy’s priority of “Ensuring that each person and family is engaged as partners in their care” [32]. However, our results suggest that women’s behaviors relating to making care arrangements and their preferences and views have virtually no impact on whether they experience an unplanned primary cesarean, and are no match for the institutional care practices they encounter. A consensus Blueprint for Advancing High-Value Maternity Care recommends many resources and supports to foster engagement of childbearing women during pregnancy, childbirth and the postpartum period. These include better performance measures and user-friendly, evidence-based public reporting of results of performance measurement. Currently, there are no woman-reported nationally-endorsed measures of the experience or outcomes of maternity care. There are no endorsed measures of care coordination or shared decision making in maternity care, nor any endorsed measures of physiologic childbirth or vaginal birth after cesarean.
Development and routine use of high-quality, evidence-based, up-to-date decision aids would also provide essential support to childbearing women. Care navigators can help women understand how to find and interpret comparative performance information, develop care plans, work through decision aids, and complete surveys to collect information about their experience and outcomes of care [33]. Also foundational are women’s access to basic informational resources about cesarean birth [34, 35], including the My Birth Matters campaign in the state where this survey was conducted [36]. Creating and reliably using such resources and supports might help close the gap between the care many women desire and the care they receive. It may be unrealistic to expect childbearing women to be drivers of higher-value maternity care and of achieving many of their own care goals without implementing more substantial ways of supporting their engagement in their care.
By contrast, we identified demographic characteristics, provider behaviors and labor management practices that were clearly associated with mode of birth. The finding of higher cesarean rates for Black mothers is consistent with prior research [37,38,39], though the differences identified here (aOR 2.40) after adjustment are greater than in those studies. Likewise, the finding of higher cesarean rates for older [40] and less educated mothers has been regularly confirmed [41]. The positive relationship between age and cesarean birth appears to be well-established [18]. However, whether some older women experience avoidable cesareans due to age-related professional expectations, and whether the other subgroups are experiencing biased care and a greater burden of iatrogenic harm are a priority for future research, given the growing recognition that structural racism and both explicit and implicit bias adversely impact the life circumstances, health and quality of care of Black and other disadvantaged groups [42,43,44]. Providing higher quality care to women from these groups may offer important opportunities for safely reducing the cesarean rate. As hospital maternity units examine the impact of their highly variable unit culture [27] on cesarean rates and other birth outcomes, ensuring respectful, evidence-based care for all women can improve birth outcomes, reduce disparities and reduce costs.
Type of insurance payer, while trending toward significance with higher rates for women with private insurance, did not achieve statistical significance. An earlier study likewise found differences by payer type in unadjusted rates, but no differences after adjustment [45]. More importantly, we identified a number of modifiable labor management practices that were related to the likelihood of an unplanned primary cesarean, specifically attempted induction, labor augmentation and early admission to the hospital [12]. We included as a covariate in our adjusted analysis any pregnancy or labor and birth complication on the participant’s birth certificate to adjust for a factor that might have influenced both these labor practices and cesarean mode of birth.
Our results suggest that opportunities currently exist for reducing cesarean use through broad implementation of evidence-based labor management practices. The Blueprint for Advancing High-Value Maternity Care identifies payment and delivery system reform, performance measurement and accountability, consumer engagement, movement toward interprofessional education and team-based care, attention to workforce composition and distribution, and filling priority research gaps as promising strategies for maternity care transformation and reliable delivery of appropriate care for childbearing women and newborns [33].
Consistent with other research [12], we found increased likelihood of cesarean birth with early versus delayed hospital admission (aOR 2.85) among the 68% of our study sample who could recall cervical dilation at their first vaginal exam after hospital admission. The relationship was limited to nulliparous mothers (aOR 5.53). As just 24% of women had initial dilation of 5 or more centimeters, delayed admission appears to be an underutilized practice for cesarean reduction.
Some studies have found midwifery care to be associated with reduced likelihood of cesarean birth [14]. As we only collected the type of intrapartum provider who delivered the baby, we could not examine the role of the type of maternity care provider during labor before any decision for an unplanned, physician-attended primary cesarean. Having a midwife as the primary prenatal care provider was not associated with reduced likelihood of unplanned primary cesarean. The exclusion of women with a planned primary cesarean and women with a history of cesarean in this secondary analysis appears to have masked differences between midwifery and obstetrical care. With our entire survey sample, we found that women with obstetrician-led prenatal care were more likely to have a cesarean birth (32%) than women with midwifery-led prenatal care (18%) (p < .01). When we further limited the comparison to lower-risk first-birth (NTSV) cesareans, notable differences persisted: 28% with obstetrician-led care versus 17% with midwifery-led care (p < .01). Prenatal provider differences were also great when we looked at vaginal birth after cesarean rates, which were 14% among women with obstetrician-led care versus 33% among women with midwifery-led care (p < .02) [30].
The relationship between attempted labor induction and cesarean birth is uncertain. Although the large ARRIVE trial found reduced cesarean birth with routine induction at 39 weeks [46], questions have been raised about this trial’s external validity and relevance to other populations and care settings and practices [47, 48]. Our survey-based results found that women with attempted labor induction were more likely to have an unplanned primary cesarean than women with spontaneous onset of labor (aOR 2.07). Similarly, the relationship between epidural analgesia and cesarean birth has been controversial. Unfortunately, our data do not enable us to distinguish between epidural use in labor that may have contributed to an unplanned cesarean compared to epidural use as an anesthetic for a cesarean procedure, further complicated by the practice of encouraging epidural placement if a cesarean might be anticipated. Hence, we did not include this practice in the multivariable model that is presented. The relationship between labor augmentation with synthetic oxytocin and cesarean birth has also been variable [49]. We found that such labor augmentation was associated with having an unplanned primary cesarean.
Some of our labor management results differ from best available evidence. Intermittent auscultation versus continuous electronic fetal monitoring has been found to be associated with vaginal birth [9]. However, just 3% of survey participants said they had been monitored solely with a handheld device. The present analysis was based upon those with any intermittent auscultation, most of whom also used electronic fetal monitoring (16% in our study population). While the direction of effect was as expected, the difference was small and a much larger sample would have been necessary to explore this difference, and especially use of intermittent auscultation alone, in a multivariable model. We were puzzled to find in the bivariate relationship that women who reported being upright and ambulatory for some period of time during labor versus laboring in bed after hospital admission were more likely to have an unplanned cesarean, but that relationship did not continue in the multivariable analysis [11]. Best evidence suggests that labor support in a doula role reduces the likelihood of cesarean birth [7], though our analysis found no difference in cesarean rates between women who did and did have labor support. Some of the discrepancy may be explained by the fact that we excluded women with previous cesareans, who may seek labor doulas to help achieve their goal of a vaginal birth after cesarean.
The largest adjusted odds ratio in our multivariable model, 7.45, compared women who did and did not report experiencing pressure from a health professional for cesarean birth, with experience of pressure strongly associated with having an unplanned primary cesarean. While provider pressure was likely, in some cases, the result of a concern with a medical condition, this was a low-risk population and variables for pregnancy complications and labor and birth complications (one or more item selected from either category of the participant’s birth certificate) were included as covariates in the model.
There is strong rationale, from Listening to Mothers survey data and other sources, for including the pressure variable in our model and thus concluding that many women experience pressure for cesarean birth that is not synonymous with provider recommendations for indicated cesarean birth. First, many women with unplanned primary cesareans did not report experiencing pressure, suggesting that they concurred that cesarean was an appropriate clinical decision. Second, rates of cesarean for subjective indications (e.g., non-reassuring fetal heart tracings, arrest of dilation, suspected large baby) vary widely, have contributed to the trend of increased national cesarean rates, and suggest a considerable amount of discretion in commonly identified indications [50]. Notably, a secondary analysis of this item in the third national Listening to Mothers survey found that women who had cesareans without medical indication were more likely to report experiencing pressure than women with cesareans for standard indications [51]. Another secondary analysis of data from that survey found that providers’ discussions of mode of birth among women with one or two prior cesareans pushed the decisions toward repeat cesareans in providing strikingly more information in support of having a cesarean rather planning a vaginal birth and in providers’ tendency to recommend repeat cesarean, suggesting poor conformity with standards of shared decision making [52]. Another secondary analysis from the same survey found that women’s reported perception of experience of pressure was highly associated with breakdowns in communication, specifically among the four in ten women who reported having held back from asking questions due to perceiving that clinicians were rushed, awareness of a discrepancy between their own care preferences and that of their providers, and/or fear of being perceived as difficult [53].
Given broad recognition that many cesareans can and should be safely avoided and widespread agreement about the importance of safely lowering the cesarean rate in many settings [2,3,4], it is likely that many women who reported feeling “pressure from any health professional” to have a cesarean experienced this as coercion and suspected the procedure may not have been needed. This was confirmed in some open-ended comments we received when asking about the worst aspect of participants’ hospital experience. Examples include “I felt rushed to deliver or else have a c-section,” the worst part was “encouraging c-section,” and “I didn’t like that they pressured me into having a c-section when I clearly wanted a natural birth. There was nothing wrong with my baby.” By contrast, we believe that many women who concurred with professional guidance to have a cesarean birth would have understood their provider’s position as a recommendation reflecting wise judgment and not “pressure.” For example, one participant wrote, “I personally felt pressured to have a C-section at first until they told me what the baby weighed. Then I was ok with it.”
The revision and validation of the Labor Culture Survey was carried out among 110 California hospitals, and found that the hospital unit NTSV rate over 2015–2016 was associated with a series of dimensions of hospital maternity unit culture, such as unit microculture, fear of vaginal birth, physician oversight, and maternal agency [27]. Bivariately, we compared participants’ birth hospital units meeting and not meeting the national consensus NTSV target rate of 23.9%, and found that our survey participants’ likelihood of having an unplanned primary cesarean trended toward their birth hospital unit not meeting the NTSV target, although this did not reach significance. In the multivariable model, hospitals in the highest quartile trended toward significantly higher cesarean rates, suggesting a potential role for hospital unit culture; however, we again did not find significant differences among the quartiles.
Areas for future research include examining the relationship between labor practices and unplanned primary cesarean birth with larger samples and studies that better capture timing and rationale for use of the practices. There is also a need to better understand ways to increase women’s agency and engagement in their care to the extent that their values and preferences affect the care they receive. Lastly, the small number of multiparous mothers who, by definition had given birth vaginally in the past and this time experienced a cesarean, were particularly likely to report having experienced pressure. This may be a productive area for future research on cesarean decision making with larger samples.
Limitations of our study include lack of power, as discussed above, to measure some labor management practices that have clearly been associated with cesarean birth in other studies. The relatively small number of multiparous mothers in our sample who had a primary cesarean also limited our ability to analyze their experiences. We also did not have information concerning timing of decisions that would allow a more nuanced analysis. For example, we could not determine whether midwives provided care during labor prior to an obstetrician-attended cesarean birth and which maternity care provider made the decision for a cesarean, nor could we distinguish epidural use for pain relief during labor versus its initiation as an anesthetic for surgery. We were unable to determine whether women who entered the hospital with less cervical dilation might have been experiencing less productive labor. Although previous analyses of survey questions about experiencing pressure to have interventions suggest that experience of “pressure” discriminates from concurring that provider recommendations are indicated, we have not systematically asked survey participants about their interpretation of these items. We also did not know the extent to which the index birth experience influenced women’s postpartum attitude toward intervention in childbirth and whether that attitude was held prior to the birth. Further, this secondary analysis of a cross-sectional design may not have adjusted for some relevant confounders, including some related to risk and complications. For example, we adjusted for any pregnancy and labor and birth complication identified on participants’ birth certificates, yet cannot be certain that this corrected for early hospital admission or labor induction associated with conditions that increase the likelihood of cesarean birth.
