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It is concerning that the rate of caesarean sections is increasing worldwide. Results from the World Health Organization (WHO) worldwide survey showed that the overall rate of caesarean sections was 25.7% in 2004-2008 (Souza et al., 2010). Gibbons et al. (2012) reported the number of caesarean sections performed in 137 countries in 2008 and indicated that 50.4% of the countries had caesarean section rates greater than 15%. The WHO also conducted a global survey on Maternal and Perinatal Health between 2004 and 2008 and indicated that 1) the incidence rate for severe maternal complications associated with elective caesarean section was about three times greater than that associated with normal spontaneous delivery (4.2% and 1.5%, respectively); 2) when an elective caesarean section was performed before the onset of labor, the risk of short term adverse outcomes was nearly six fold compared with normal spontaneous delivery; 3) when an elective caesarean section was performed after the onset of labor, the risk of short term adverse outcomes was 14 times above the level of risk for normal spontaneous delivery (Souza et al., 2010).
Research also has shown evidence that newborns delivered by elective caesarean section have an increased risk of morbidity. For example, the prospective survey that was conducted by the Medical Birth Registry of Norway compared normal spontaneous delivery and elective caesarean section on newborn health outcomes, and they indicated elective caesarean sections increased transfer rates to the neonatal intensive care unit from 5.2% to 9.8% and the risk for pulmonary disorders from 0.8% to 1.6%, compared with normal spontaneous delivery (Kolas, Saugstad, Daltveit, Nilsen, & Oian, 2006). Furthermore, the increasing rate of caesarean sections raises other concerns, such as increased cost and utilization of public resources. It has been estimated that more than $2.5 billion would have been saved if the rate of caesarean section in America in 2006 had been 15%, rather than the actual rate of 31.1% (Sakala & Corry, 2008). Hence, it is important to better understand the psychological factors (beliefs and attitudes) that influence pregnant women’s decisions to undergo elective caesarean section in order to propose evidence-based behavior change strategies to amend the significant maternal-child health problem.
The theory of planned behavior (TPB) (Ajzen, 1985) is the most widely studied social cognition theory to predict and elucidate human behavior (Hardeman et al., 2002). The efficacy of the theory in predicting and modifying individual health-related behaviors has been demonstrated in several systematic reviews (Armitage & Conner, 2001; Godin & Kok, 1996; Hausenblas, Carron, & Mack, 1997). The TPB posits that mother’s intention/decision is influenced by her attitudes toward the two delivery options, her self-efficacy related to childbirth, and her beliefs regarding what her family and friends may think of her choice.
Therefore, this pilot study examined the acceptability, feasibility, and preliminary validity of a theory-based questionnaire, the Childbirth Delivery Options questionnaire (CDOQ) that has potential as an instrument for pregnant women’s decisions regarding their childbirth delivery options in diverse clinical settings.
Methods:
This pilot study used a mixed method approach to pretest and refine the CDOQ. Participants who must be pregnant women aged 18 or older were recruited from two sites to confirm the feasibility of the procedure. First, the study was described and consent obtained from those who were interested. Second, participants were given a choice to complete the questionnaire on paper-and-pencil or tablet. Third, participants were asked to complete the questionnaire and to provide comments about the questionnaire. The cognitive interviewing approach provided the feedback obtained from these respondents to revise the questionnaire. Finally, all participants were asked to rate their overall impression of the questionnaire; and this will permit comparison of the two methods (p&p vs. tablet) of administration.
Results:
A total of 61 participants were recruited in this pilot study from two clinical sites. Depending on where the participants were recruited, the majority of participants from Site A were single (never married) (79.3%), African Americans (41.4%) with a mean age of 23 years (SD = 4.93). About 72.4% of the respondents had a high school diploma with Medicaid health insurance; in contrast, participants from the other site (Site B), were married (71%) and significantly older with a mean age of 26 (SD = 3.88; t = 2.88, p < .01). In addition, they were predominately white (80.6%) having a bachelor’s degree (54.8%) with private health insurance at the time of the interviews (67.7%). With regard to childbirth delivery options, even though both groups preferred the vaginal birth method, Site A had a stronger preference toward vaginal birth whereas the other group tended to respond neutrally. In particular, participants recruited from Site A had a statistically stronger preference towards vaginal birth and believed that vaginal birth was more convenient (t = 7.04, p < .01) and meaningful (t = 4.61, p < .01) when compared to their counterpart. In addition, participants from Site A were more confident with delivery through vaginal birth method (t = 2.57, p < .05) and perceived less social pressure (t = 4.17, p < .01) when compared to participants recruited from the Site B clinic. Interestingly, when they were asked whether their decisions were entirely up to them, both groups did not show a significant difference in either vaginal birth method (t = 1.04, p > .05) or schedule cesarean section (t = .03, p > .05). When it comes to their support system, although participants’ mothers and partners all played a significant role in both sites, Site A’s participants believed that vaginal birth was more meaningful for their significant others when compared to the other group (t = 2.20, p< .05).
For the second part of the study, participants’ comments on the CDOQ were generally positive with a mean score of 2.71 on a scale ranging from -4 (terrible) to 4 (excellent). Respondents thought that the items on the CDOQ were easy to read and comprehend; they reported favorably on the wording and formatting. Their overall impression of the questionnaire was no significant difference between the two methods (p&p vs. tablet) of administration, and the CDOQ only took participants on average 10 minutes to complete.
Conclusion:
This study is grounded on well established and extensively tested theory—the theory of planned behavior— and responds to the globally increasing rate of caesarean sections. The current study exposes feasibility issues based on the study that may be useful to scientific communities interested in improving maternal-child care. Given that caesarean sections are increasing worldwide, participants from both groups all preferred to deliver their babies by the vaginal birth method. In addition, a difference in socioeconomic status emerged between these two groups; participants with higher socioeconomic status had relatively less preference regarding their delivery options when compared to their counterpart. In particular, they have less confidence to deliver vaginally. Interestingly, in accordance with the theory of planned behavior hypothesizing that their significant others may influence their decisions, in terms of delivery options, pregnant women’s partners or mothers seem to not play an important role influencing their decisions. Although it has been known that the vaginal birth method benefits pregnant women and their babies more when compared to caesarean sections, it is still necessary for clinicians to promote vaginal birth for women with less confidence as well as their support system. The results from this pilot study will be used to inform a larger study with a bigger sample size to improve the contemporary maternal-child health promotion environment.
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