Caesarean section on maternal request : Personality, fear of childbirth and signs of depression among first-time mothers

University dissertation from Stockholm : Karolinska Institutet, Department of Clinical Sciences

Abstract: Aim The overall aim of this thesis was to study healthy first-time mothers requesting and undergoing an elective caesarean section (CS) and to compare these to healthy first-time mothers planning a vaginal delivery. The focus was socio-demographic factors, personality, depression, expectations and experience of birth. Sample The cohort consisted in total of 558 healthy first time-mothers. Participants were recruited to the trial in late pregnancy and divided into three different groups; women requesting CS in the absence of medical or obstetrical indication, women having an elective CS on indication breech presentation and women planning a vaginal delivery. The focus in this thesis has mainly been to compare two of the groups, namely women requesting a CS and women planning a vaginal birth. Method The participants completed four different self-assessment questionnaires. At inclusion, they received the first questionnaires concerning socio-demographic background, self-estimated health and family planning, and a personality inventory, Karolinska Scales of Personality (KSP) and a questionnaire revealing their expectancies on the forthcoming delivery, Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). At two days postpartum, they were given a questionnaire concerning initiation of breastfeeding, self-estimation of pain and experience of the delivery. At three months after birth, they received a posted questionnaire concerning breastfeeding, sexual life, experience of birth (W-DEQ) and a questionnaire measuring signs of depression, Edinburgh Postnatal Depression Scale (EPDS). At nine months after birth, they received the last questionnaires concerning breastfeeding, sexual life, birth experience, health and the personality inventory (KSP). Results A significant difference in age was found between the CS and the vaginal group (mean age 33.9 yrs vs.30.8). Analysis of personality traits showed that the subscales Monotony Avoidance and Socialization differed between women requesting CS and women planning a vaginal delivery. It was found that both groups increased their Impulsivity scores and women in CS group lowered their Detachment scores from late pregnancy to nine months after birth. Women requesting CS experienced their health as poorer compared to women planning a vaginal birth and were more often planning for one child only. They often reported anxiety for lack of support during labour, for loss of control and concern for fetal injury/death. At three months after birth they were breastfeeding to a lesser extent than women planning a vaginal delivery. There were no differences in signs of postpartum depression between the groups three months after birth. Mothers requesting a CS had more negative expectancies of a vaginal delivery and 43% in this group showed a clinically significant fear of delivery. Conclusion Women requesting a CS in the absence of obstetric/medical indication differ in several aspects from those who plan a vaginal delivery. This finding highlights the need for an individual response to a request for CS where obstetricians very carefully weigh and balance outcomes in different ways. For any decision, factors such as age, family plans for the future, psychological factors and medical risks both in CS and in planned vaginal delivery must be considered.

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