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The preferred mode of delivery of medical professionals and non-medical professional mothers-to-be and the impact of additional information on their decision: an online questionnaire cohort study

  • Maternal-Fetal Medicine
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

It was the aim to evaluate the personal preference of mode of delivery and to analyze differences between medical professionals and non-medical professionals. Interest in participating in a risk stratification system was evaluated. We hypothesized that gaining information about risk stratification provided in the survey could potentially change participants’ decision regarding the preferred mode of delivery; therefore, subjects were asked twice (before and after providing information).

Methods

Five cohorts [four professionals (MP) including participants of the German Urogynecology Congress 2017, employees of two major university hospitals in Germany, and members of the German Society of Gynecology and Obstetrics, and one non-professional group (NP) including pregnant women] were invited online to participate in this survey.

Results

Vaginal delivery was the preferred mode of delivery in both groups (MP 90.4% vs. NP 88.8%; p = 0.429). MP are more likely to opt for CS due to concerns regarding pelvic floor disorders (MP 56.6% vs. NP 9.1%; p < 0.001). Likewise, parity and prior experienced CS (pCS) had a significant impact on the decision towards vaginal delivery (parity MP OR 7.5 95% CI 4.6–12.3, NP OR 9.3 95% CI 1.9–44.2; (pCS) MP OR 0.12 95% CI 0.07–0.19, NP OR 0.05 95% CI 0.01–0.25). There is great interest in participating in risk stratification systems in the majority of participants (68.9%).

Conclusions

MP and NP prefer vaginal birth for themselves or their partners. Within the group that opted for CS, MP were significantly more often concerned about pelvic floor disorders. Future prevention aspects might include education about pelvic floor disorders.

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Acknowledgements

The authors acknowledge all midwives, nurses, physicians, general OB/GYN practitioners as well as the German Association for Urogynecology and Pelvic Floor Reconstruction (AGUB) and the Coma UG Congress Management for their support.

Author information

Authors and Affiliations

  1. Department of Womenʼs Health, University Hospital of Tuebingen, Tuebingen, Germany

    Julia Bihler, Christl Reisenauer, Jan Pauluschke-Froehlich, Philipp Wagner, Harald Abele, Katharina K. Rall, Sara Y. Brucker & Markus Huebner

  2. Department of Urogynecology, German Pelvic Floor Centre, St. Hedwig Hospital, Berlin, Germany

    Ralf Tunn

  3. Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

    Giselle E. Kolenic

  4. Department of Gynecology and Obstetrics, Helios Hospital Erfurt, Erfurt, Germany

    Gert Naumann

  5. Department of Gynecology and Obstetrics, University Hospital of Heidelberg, Heidelberg, Germany

    Stephanie Wallwiener, Markus Wallwiener & Christof Sohn

  6. Women’s Center Bern, Lindenhofgruppe, Bremgartenstr 117, 3001, Bern, Switzerland

    Markus Huebner

Authors
  1. Julia Bihler
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  2. Ralf Tunn
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  4. Giselle E. Kolenic
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  5. Jan Pauluschke-Froehlich
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  6. Philipp Wagner
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  14. Markus Huebner
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Contributions

JB project development, questionnaire programming, data acquisition, statistical analysis, data interpretation, manuscript writing/editing. RT project development, data interpretation, manuscript editing. CR project development, data interpretation, manuscript editing. GK statistical analysis, data acquisition, data interpretation, manuscript writing/editing. JP-F project development, data interpretation, manuscript editing. PW project development, data interpretation, manuscript writing/editing. HA project development, data interpretation, manuscript editing. KR project development, data interpretation, manuscript writing/editing. GN project development, data interpretation, manuscript editing. SW project development, data interpretation, manuscript editing. MW project development, data interpretation, manuscript editing. CS project development, data interpretation, manuscript editing. SB project development, data interpretation, manuscript writing/editing, supervision. MH project development, data collecting, questionnaire programming, data acquisition, data interpretation, manuscript writing/editing, supervision.

Corresponding author

Correspondence to Markus Huebner.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Study was approved by the local ethics committee of the University of Tuebingen (Ethic Committee Eberhard-Karls-University Tuebingen, Germany, 91/2017BO2, 02/28/2017)

Informed consent

Informed consent was obtained from all individual participants included in the study.

Appendix: Questionnaire

Appendix: Questionnaire

In the appendix we present a translated and combined questionnaire in order not to overload the manuscript. Questions that have been asked medical professionals only have been marked. In the original German language, careful attention had been paid to keep the language understandable for non-professionals. These differences in the language are lost due to the translation process.

DECISION-Study

Personal preference regarding mode of delivery-a prospective, online-based, informative questionnaire Survey

First, we would like to ask a few personal questions:

figure a
figure b

Over 20 years ago 282 Obstetricians in the UK were asked about their preferred mode of delivery, assuming an uncomplicated pregnancy. (Al-Mufti 1996) Now we would like to ask the same question.

figure c

The previously mentioned study revealed that 17% of the 282 obstetricians opted for Cesarean section (31% of the women and 8% of the men for their partners).

As the main reason for this decision, 80% stated to be afraid of a pelvic floor disorder while 58% feared restriction on sexual activity. The fear for harming the child is only mentioned in third place with 39% of the respondents, while 27% mentioned the better predictability of a C-Section. (Al-Mufti 1996).

Today we know that this was not a representative group. Other surveys indicated lower rates of personal preferred Cesarean section.

One reason to opt for a Cesarean section could be the fear of pain. In this regard there are different options to reduce pain during labour, such as epidural anaesthesia.

figure d

Some information about epidural anaesthesia:

Meanwhile there is a good evidence about epidural anaesthesia. It is effective in pain relief and does not lead to a higher rate of Cesarean sections. First stage of labour might be a little shorter, second stage a little longer, however, this does not bring any negative consequences. Regarding the pelvic floor, there is evidence that epidural anaesthesia has protective effects on both the levator ani muscle and the anal sphincters.

Some facts about a risk-stratification system:

Over the last 20 years we have learned much about anatomical and physiological aspects of the female pelvic floor. Today we know more about the effects of pregnancy and delivery on the female pelvic floor, as compared with the time when the UK obstetricians were asked about their preferred mode of delivery. Furthermore, we expect that only a very small group of women is likely to benefit from a Cesarean section due to specific factors, whereas the majority of women are unlikely to have any advantage from a Cesarean section and could safely give birth vaginally.

It is a challenge to identify this small group of women. The procedure for this is called risk-stratification. Different factors such as height, weight, age, estimated fetal weight, genetic factors, prevalence of incontinence and other factors were analysed. There is evidence that women who are less then 160 cm tall while carrying a baby with an estimated fetal weight of more than 4 kg might benefit from a Cesarean section.

The aim of the risk-stratification is to identify pregnant women who will have a measurable benefit from a Cesarean section. Other women could be approved to deliver their child vaginally.This risk-stratification would take place during a visit to your obstetrician where those parameters can be identified. This is an additional visit; however, it is covered by your insurance (at least in Germany).

figure e

Assuming the risk stratification reveals a very low risk for you (or your partner) we would like to ask the same question from the beginning:

figure f

The postpartum period is an important time for pelvic floor recovery. Those exercises are necessary to prevent long term consequences like incontinence or prolapse.

figure g

There is an assumption that a postpartum pessary therapy might support pelvic floor recovery. It contains a ring or cube pessary made of silicone, which is inserted vaginally to decrease tension on the connective tissue of the pelvic floor. There is not much experience regarding this therapy, however, in theory it could be beneficial to the postpartum recovery.

figure h

Thank you for your time to participate in our survey!

Literature:

Al-Mufti R, McCarthy A, Fisk NM (1996) Obstetricians’ personal choice and mode of delivery. Lancet 347:544.

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Bihler, J., Tunn, R., Reisenauer, C. et al. The preferred mode of delivery of medical professionals and non-medical professional mothers-to-be and the impact of additional information on their decision: an online questionnaire cohort study. Arch Gynecol Obstet 299, 371–384 (2019). https://doi.org/10.1007/s00404-018-4970-7

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