Obstetric providers willing to accept women's preferences for mode ofdelivery.

Abstract

Access to a safe caesarean delivery is a cornerstone of comprehensive and quality reproductive healthcare. And yet, when performed for non-medically indicated reasons, caesarean delivery has been associated with higher rates of infection, haemorrhage, surgical injury and death (Vogel et al. BJOG 2014;121:76–88). As outlined by Rivo et al., Latin American and Caribbean countries have the highest caesarean delivery rates globally, with over 40% of women delivering by caesarean. To supply some insight into these rates, Rivo et al. present a well-designed prospective survey exploring delivery preferences among obstetrical providers in Argentina and their association with provider characteristics, preferences and attitudes. In their survey, the authors draw from a diverse sample across two public and two private institutions and include both obstetricians and certified nurse midwives. Rivo et al. document some important findings: although over 90% of providers prefer a vaginal route as the mode for their patients, close to three-quarters support a woman's right to choose the mode of delivery; in the absence of medical indication for caesarean, two-thirds would agree to perform a caesarean delivery at maternal request. Interestingly, the authors also demonstrate a disconnect between what providers think their patients want, i.e. 30% of providers believing women prefer a caesarean delivery, compared with >90% of women preferring a vaginal delivery in studies from the same country. Despite complex aetiologies for rising caesarean delivery rates, ranging from cultural beliefs to financial incentives, organisational policies and legal ramifications, ultimately, as the interface between many of these complexities and pregnant women, providers have a critical role to play in the decision for a woman to undergo a caesarean delivery. As providers, our counselling to patients during decision-making is rarely purely impartial. Counselling is more often directive, based on our analysis of the risks and benefits of a decision to perform a caesarean delivery. Our perception of what our patient's desires are, can often have a role this and we may unwittingly drive a decision towards a caesarean delivery if we believe that is what women want. To make progress in optimising caesarean delivery rates, which in many regions means a reduction, we must understand more about the provider role, the interface between providers and their patients and how to create a shared decision-making model that optimises caesarean delivery rates. Interventions focusing on providers, such as peer review, audit and feedback, mandatory second opinions and targeted clinical training, have had mixed success (Chaillet et al. Birth 2007;34:53–64). Given that Rivo et al. demonstrate that the majority of providers wish to do what their patients want and, as they document, studies have shown that most women prefer a vaginal delivery, future strategies might yield more benefit by strengthening a woman's role in a shared decision-making model. This requires a culture shift, but given that women after all bear the burden of rising caesarean rates, bolstering their voice and agency might bring about the changes we have been unable to achieve to date. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.