Complexities of Choice after Prior Cesarean:A Narrative Analysis

Allison Shorten, RN RM MSc PhD FACM, Brett Shorten, BA MCom,and Holly Powell Kennedy, CNM PhD FACNM FAAN

ABSTRACT: Background: High rates of primary cesarean internationally continue to createdecision dilemmas for women and practitioners about birth in subsequent pregnancies. Thisarticle explores values and expectations that guide women during decision making about the nextbirth after cesarean and identifies factors that influence consistency between women’s choices andactual birth experiences. Methods: Narrative analysis was used to identify key themes indecision-making experiences of women who were facing a choice about mode of birth aftercesarean. A sample of 187 women provided qualitative data about their choices for birth at36–38 weeks. At 6–8 weeks after the birth, 168 also wrote about their experiences of birth andthe process of making the decision. Results: Decision making about birth after cesarean wascomplex and difficult for many women; strong emotions were expressed as they weighed birthoptions. Fear and anxiety were articulated as women explained their choices and expectations.Avoidance of the previous cesarean experience, an expectation of a “better” or “faster”recovery, and issues around “safety” for the baby were common reasons given for wantingeither vaginal or cesarean birth. Practitioner preferences were influential and women’s need forinformation about their options underpinned their confidence or certainty about their decision.Conclusions: Strategies are needed to support practitioners to expand discussions beyondclinical algorithms about physical risks and benefits of birth options and to actively integratewomen’s values and preferences into decisions about birth. (BIRTH 2014)

Key words: birth choices, choice complexity, narrative analysis, previous cesarean, trial oflabor (TOL), vaginal birth after cesarean (VBAC)

Around 1.3 million women experience cesarean surgeryfor birth each year in the United States (32.8% of allbirths in 2011) (1). Cesarean delivery in a previouspregnancy continues to create a significant decisiondilemma for women and their care practitioners in theUnited States, with fewer than 10 percent experiencingvaginal birth after cesarean (VBAC) in subsequentpregnancies (2–4). This uncertainty is despite clear evi-dence that confirms the safety of trial of labor (TOL)for the majority of women as an alternative to repeatcesarean surgery (3) and mounting evidence of inferioroutcomes with repeat cesarean (3,5).

As part of an effort to improve VBAC utilization,the National Institutes for Health (NIH) has called forresearch to promote better communication between cli-nicians and women about risks and benefits of VBACand repeat cesarean (4). The 2010 NIH VBAC Consen-sus development conference highlighted the importanceof women being supported as they share decisionsabout mode of birth with practitioners (4). This spot-light heralded a change in the direction of innovationaround this issue with movement toward shared deci-sion making and use of decision aids to assist practitio-ners as they communicate with women.

Allison Shorten is an Associate Professor, Yale University School ofNursing; Holly Powell Kennedy is Executive Deputy Dean and HelenVarney Professor of Midwifery, Yale University School of Nursing,West Haven, Connecticut, USA; Brett Shorten is a freelance dataanalyst and research consultant, Guilford, Connecticut, USA.

Address correspondence to Allison Shorten, Yale University School ofNursing, P.O. Box 27399 West Haven, CT 06516-7399, USA.

Accepted November 8, 2013

© 2014, Copyright the AuthorsJournal compilation © 2013, Wiley Periodicals, Inc.

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Shared decision making is the process wherebypatients and health care practitioners share informationwith each other and work together to make a health caredecision (6–8). The notion of “no decision about mewithout me” speaks to the importance of patients aspartners in decision making rather than passive recipi-ents of care (9). Shared decision making is particularlyimportant when there are no clear “best” options andwhere decisions are value laden and complex, such as inthe case of birth after cesarean. Women’s values andattitudes not only influence birth choices but are likelyto influence birth outcomes. Therefore, strategies toaddress the complexities in decision making, and toincorporate women’s values into the process, are impor-tant (10).

Clinical research has focused on physiological risksand benefits to mothers and babies resulting fromattempted VBAC or elective repeat cesarean delivery(ERCD). Less attention has been given to broader psy-chological aspects of women’s experiences of decisionmaking or how practitioners can use decision science toimprove the quality of care. Qualitative studies holdcapacity to reveal the psychological processes womenundergo when facing birth after cesarean and factorsthat influence how they make decisions. Women’s per-ception of personal risk, knowledge of birth options,attitudes and opinions of family and friends, memoriesof previous birth experiences, and practitioner patternsof practice all factor into the decision (11–18). Greaterinsight into these factors is required for the developmentof effective tools and strategies to assist practitioners incaring for this population (17). Prospective studies capa-ble of capturing women’s experiences as they occur arenecessary to strengthen our evidence base and to pro-vide a clearer picture of what women value at differentpoints in time, accounting for the influence of newexperiences and contextual factors (10).

This study used a qualitative approach to deepen ourunderstanding of key drivers for women’s decisionmaking, through an analysis of the experiences of preg-nant women as they interacted with information, com-municated with practitioners, and were immersed in thechallenge of decision making about their birth.

Methods

This analysis represents one segment of a randomizedcontrolled trial (RCT) that tested a decision aid forwomen’s choice of birth mode after a prior cesareandelivery (19). The broad aim of this study was to explorewomen’s values and expectations during their process ofdecision making about the next birth. The research ques-tions guiding the qualitative segment of the study were:1) what reasoning underpins women’s choice about

method of birth after cesarean; 2) what do women valueand expect from their birth choices after cesarean; and 3)what factors influence consistency between choice andoutcome? Approval for the study was obtained from thehuman research ethics committees of The University ofWollongong, University of Sydney, and participatinghospitals. This analysis of de-identified qualitative datawas granted institutional review board exemption under45 CFR 46.101(b) (4) by Yale University Human Sub-jects Committee (Protocol No: 1010007545).

Research Design

Narrative analysis was chosen as the method to bestcapture women’s stories of making choices about modeof birth after a prior cesarean delivery. Narratives, orstories, are socially shared and provide a way for peo-ple to make sense and share meanings about events intheir lives (20). They help to expose beliefs and valueswithin society and agency within an event.

Sample and Setting

The study enrolled 227 women at 12–20 weeks ofpregnancy who were medically eligible to choosebetween TOL and ERCD (19). Women were random-ized to receive a decision-aid booklet about BirthChoices after cesarean (n = 115) or usual antenatal care(n = 112). Demographic characteristics for the RCT arereported elsewhere (19). After study attrition (n = 34)and missing data (n = 6), a total of 187 women(n = 93 experimental group; n = 94 control group) pro-vided qualitative data. The study took place in twostudy sites (Area Health Services) within New SouthWales, Australia.

Data Collection

Data were collected by means of open-ended questionsin written surveys. At 36–38 weeks’ gestation womenwere asked to indicate the mode of birth they had cho-sen and then to explain the choice they had made. At6–8 weeks postpartum they were asked to write adescription of how they felt about their choice and expe-rience. Data were de-identified, transcribed, cleaned, andentered into Atlas.ti (ATLAS.ti Scientific SoftwareDevelopment, Corvallis, Oregon, USA), a qualitativesoftware program to organize, manage, and code data.

Codes were developed through in-depth analysis ofthe transcripts. Each researcher conducted a preliminaryanalysis, developing codes independently. Initial com-parison of coding was very similar and consensus was

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achieved with discussion. Once all data were codedthey were again examined for depth, breadth, similari-ties, and divergence. These were clustered into themesand in-depth memos were written to represent the nar-rative messages provided by the women. Inferred rela-tionships were mapped across the codes and themes toprovide a conceptualization of the complexities of mak-ing decisions about birth after a prior cesarean.

Results

The mean age of women studied was 32 years withtwo-thirds Australian born and three-fourths having post-secondary education (Table 1). Over three-fourths previ-ously experienced emergency cesarean; over one-halfhad TOL as their initial preference (56%), 26 percent

preferred ERCD, and 18 percent were unsure. Overall,112 of 143 women (78.3%) who either chose TOL orERCD (and whose birth information was available)experienced their chosen birth mode. Achievement ofchoice was strongly influenced by study site (19).

Women’s narratives revealed complexities in decisionmaking. Table 2 summarizes women’s reasons for theirchoice. The decision-making process was influenced bymultiple factors and choice was facilitated or preempteddepending on how these factors aligned. Interestingly,there was crossover on several of these factors, meaningthat women who chose TOL or ERCD sometimes usedsimilar rationales for their decisions. This crossovermade thematic analysis challenging; for example, whatwas perceived as “best for the baby” or best for them-selves led to different decisions. Findings are presentedin four broad categories to best portray the complexityand similarities in decision making among women.These include: a) the decision-making process; b) emo-tions; c) choice of TOL; and d) choice of ERCD.

The Decision-Making Process

Decisions were contextual and multifactorial. Decisionmaking was challenged by contradictory information,family pressures and/or needs, medical practitioners notsupportive of TOL, and conflicting perceptions of theircapacity to birth. Many women relied on medicaladvice; for some, this was their most trusted source ofinformation, and mostly the case for those who choseERCD or were still unsure. Women clearly needed toresolve what happened with their previous labor and toplace it within the context of the current situation; itwas helpful if they could do that with their health carepractitioner.

I am frightened this might happen again if my blood pressuremeans that labour has to be artificially started and our baby istoo high up. Therefore, I am now a little confused at what isthe best option for us and I think we’ll go on the doctor’sadvice (P190) [P# = participant ID].

However, for other women there existed differingopinions about the best way forward or about capacityto have a vaginal birth. In the following narrative,information was both critical and conflicting.

When I recounted my past labour to [obstetrician at first birth]he confidently (as only a doctor can) stated that I would behaving a planned caesarean this time, and was surprised whenI said that that hadn’t been the plan, that in fact we were plan-ning a pelvimetry to make sure there was nothing black andwhite (i.e., enormous baby, tiny pelvis) and if there wasn’t wewere going to trial VBAC. He seemed to think it was obviousI had a small pelvis (even though he couldn’t remember meor my labour!) … [and said] rather flippantly “you’ll be back

Table 1. Characteristics of Women Who Provided Quali-tative Responses

Variable No. (%) or [mean]

Age 187 [31.9]

Parity* 184 [1.16]

Previous cesarean

Elective 44 (23.5)

Emergency 143 (76.5)

Australian born†

Yes 120 (66.7)

No 60 (33.3)

Mode of care

Midwives clinic 56 (29.9)

Team midwifery 26 (13.9)

GP shared care 58 (31.0)

Public OB/GYN 7 (3.7)

Private OB/GYN 40 (21.4)

Education

< Grade 12 33 (17.6)

Grade 12 15 (8.0)

Cert./Diploma 64 (34.2)

Bachelors/higher 75 (40.1)

Employment

Full-time 28 (15.0)

Part-time 65 (34.8)

Home duties 84 (44.9)

Other 10 (5.3)

Initial birth preference

TOLAC 105 (56.1)

Elective cesarean 49 (26.2)

Unsure 33 (17.6)

*Parity not available for three women; †Place of birth not availablefor seven women.

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for this next time”… He reluctantly agreed for me to go aheadwith the pelvimetry …. I cried for about 24 hours after thisappointment … (P163).

She eventually went on to have a successful VBACafter a pelvimetry showed a roomy pelvis.

For many women who chose ERCD, the ability toplan or perhaps predict the birth experience was cru-cial; this power added to a sense of peace about theirdecision. Women who expressed regret about theirdecision were more likely to have had a TOL thatended in another cesarean delivery. Thus, after theuncertainty, they ended up with what they did not wantcoupled with the pain of labor.

Emotions

Emotions factored considerably in choosing birth mode.Fear and anxiety led to uncertainty and diminishedwomen’s confidence, knowing problems could happenregardless of the decision. Emotions reflected priorexperiences, conflicting information, and family/others’opinions, and needed resolution. Given the combinationof uncertainty, anxiety, and fear, it appeared that manywomen chose ERCD as one way to control at leastsome aspects of the process.

I am finding it difficult to know what is best to do. I haven’treally got an understanding of how safe a trial of vaginal birthis … I feel very inconfident since last time. The scariest thingabout a placental abruption was that I felt fine and it happenedso suddenly without any forewarning … it would be reassur-ing to know a given time for the birth instead of having thewaiting and wondering (P81).

Anxiety and fear of danger to the baby was amajor reason to avoid TOL. However, other medicalconditions or life factors added to the overlyinganxiety.

Very scared of vaginal birth as I am scared my baby will die.Can’t deal with that as I have lost my mother not too longago (P8).

In contrast to the women who were fearful and anx-ious, there was another group who used information toenhance their confidence for a vaginal birth. Mostwomen whose comments were coded as [+ confidence]chose a TOL. Some expressed general confidence intheir bodies and others talked about the importance ofthe information they received.

The midwives and doctors were very supportive of my wishesbut explained what difficulties may/could arise as I was aTOS [trial of scar]. I did read information and research onTOS births. Being informed made all the difference but some-times also made me a bit anxious about the negative side andcomplications. I put total faith into my mind and body andbelieved I could deliver naturally and now feel very contentwith my birth experience & baby (P149).

This group of women also seemed satisfied withtheir decision and proud of their accomplishment, evenif they did not achieve vaginal birth.

I feel extremely satisfied and proud of myself … I feel veryglad and pleased that I stuck to my birth choice as I did get alot of pressure and negativity from family and friends aboutmy decision to have a vaginal birth (P112).

The Choice for an Elective Repeat Cesarean Delivery

“I just don’t want to take the risk” sums up why manywomen chose ERCD. Several reasons were cited compris-ing the avoidance of risk, an obstetrical indication includ-ing concern about the size of the baby, prior experiencewith labor and emergency cesarean, ability to plan thebirth, influence of others (family pressure), and a percep-tion that the recovery would be better. Of these, the per-ception of ERCD as less risky than TOL was dominant.

Table 2. Reasons Given for Choice of Birth at 36–38 Weeks

Reasons for choiceChoice TOL

n = 89Choice ERCD

n = 64Unsuren = 34

Total (%)n = 187

Ease/speed of recovery 40 (44.9) 2 (3.1) 4 (11.8) 46 (24.6)

Doctor/medical advice 4 (4.5) 21 (32.8) 13 (38.2) 38 (20.3)

Safety/risk to baby 10 (11.2) 25 (39.1) 3 (8.8) 38 (20.3)

Vaginal birth is natural/normal 24 (27.0) 0 (0.0) 2 (5.9) 26 (13.9)

Previous experience 5 (5.6) 16 (25.0) 0 (0.0) 21 (11.2)

Wants to experience labor 18 (20.2) 0 (0.0) 1 (2.9) 19 (10.2)

Need more information 0 (0.0) 1 (1.6) 12 (35.3) 13 (7.0)

Planning/convenience 0 (0.0) 11 (17.2) 1 (2.9) 12 (6.4)

Avoid emergency cesarean section 0 (0.0) 7 (10.9) 0 (0.0) 7 (3.7)

TOL = Trial of labor; ERCD = Elective repeat cesarean delivery. Women often gave more than one reason and therefore columns do not sum to100%.

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Women worried about uterine rupture and potentialfor their baby to be hurt; “Not willing to put my child’slife in danger” (P7). Other reasons included baby’ssize, maternal conditions, avoiding pressure on thebaby, worry about complications of labor and vaginalbirth (stitches tearing, stillbirth), breech presentation,and the desire to avoid an emergency cesarean thatmany had experienced in the past. Consistent phrasessuggested worry and fear about damage to the baby(highest) and themselves. Many women justified theirdecision; it was important to have a reason to make thischoice. Some indicated a preference for TOL and vagi-nal birth, but these comments were in the minority ofthe women who made the choice for ERCD. Somewomen were able to articulate that although theybelieved vaginal birth might be better, their fear aboutthe risks prevailed, even when the physician recom-mended TOL.

When I was 38+ weeks, I was worried about my birth choice.I then asked the doctor to send me for a C-T scan to measuremy pelvis and my baby’s head so after my scan they stillwanted me to have a trial before taking me for a c-section.The decision by the doctors – I wasn’t happy with it becauseI didn’t want to take the risk of having a ruptured uterus, etc.So, when I went in, I asked the doctor straight away for ac-section, and explained to him how I felt. He then examinedme; I was already 8-1/2 cm dilated. So he wanted me to havea trial for 1 hour. Nothing happened and at the end I had thec-section. I am now very healthy and happy. My son ishealthy too (P4).

Although uterine rupture dominated women’s fearsand worries, other conditions were mentioned as rea-sons to choose ERCD. Some of these were perceivedas preventing the woman from having the strength toendure labor.

The baby also has complications so I don’t want to put itthrough any other undue pressure that may happen with a vag-inal birth. And because I have Thallasaemia minor my haemo-globin has been dropping. I feel quite weak to deliver withvaginal birth (P22).

Interestingly, discussions about the placenta did notalways seem definitive; rather, they hinted at possiblerisk. “I have chosen caesarean because I might haveplacenta praevia and I do not want to take any unneces-sary risks” (P64). Size of the baby became a focal pointfor many women; if the baby was deemed “large” then avaginal birth seemed almost unattainable, thus the riskseemed stronger. “Baby is already big. Very highchances of having caesarean anyway … don’t want tohave another emergency one, rather planned” (P11).

Women’s prior labor experience and a need for con-trol with the upcoming birth factored clearly in theirdecision. Women described long labors ending in cesar-

ean and simply did not want to go through it again, andespecially did not want to repeat the “emergency” sce-nario. As they weighed their options they worried aboutgoing through the effort for nothing.

No one could predict the outcome of my labour, so I wish toavoid potential stress and anxiety and have a planned caesar-ean (P62).

Recovery after cesarean was overwhelmingly per-ceived as easier than after labor. This comprehensionmay have been because of a previous long labor endingin cesarean delivery and thus a painful, difficult, orexhausting recovery.

This time we organised for my husband to take 1 month offwork to help care for me and the children. This made a huge dif-ference to my recovery and I think this is part of the reason I’mso well… I feel I’ve had the best birth experience yet (P1).

Women did not make decisions in isolation—part-ners, family members, and friends all provided opinionsand varying degrees of pressure. Sometimes this deter-mination was about risk perception, planning and con-trol, and at times body image, “having had caesareanpreviously can’t help but think ‘already damaged’”(P188).

The Choice for Trial of Labor

The need to experience labor and the idea that vaginalbirth is natural, normal, and generally better wasexpressed by many women who chose TOL. “This isthe way we were designed to give birth” (P86). Thesewomen perceived that vaginal birth would result in aquicker recovery compared with ERCD. Specifically,they felt it would enable them to return to normal tasksof motherhood without the burden of postsurgical painand limitations on activity. Key aspects of recoveryincluded shorter hospital stay, avoiding complicationssuch as infection, less difficulty breastfeeding, andavoiding incision pain.

There was clear anticipation that their new motheringrole would include simultaneously caring for the babyalong with other children, and a vaginal birth wouldmake this easier.

Already having a small toddler, I wish to be able to comehome and continue as “normally” as possible and not have anextended hospital stay or recovery process (P134).

The ability to breastfeed was important to somewomen who explicitly included this as a personal goal,in addition to avoiding separation from the baby afterthe birth.

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I was not able to breastfeed properly, baby was not given to meimmediately and also because of stitches I had pain (P 99).

Women also felt that TOL would provide activeinvolvement in the birth and therefore a greater level ofpersonal control. Some women explicitly desired theexperience of labor, labor pain, and vaginal birth. “Ialso really want to experience what thousands of othershave” (P112).

Some women expressed not feeling “present” duringthe previous birth, perhaps as a result of general anes-thetic, or that they were not active in the process ofbirthing the baby. Many described a sense of loss afterthe previous cesarean experience and expressed a per-sonal need to remedy this feeling through a betterexperience in the next birth.

I need to feel a sense of achievement. After an emergencycaesarean I felt I had failed, I felt cheated of the childbirthexperience I had wanted (P131).

There was also a sense that the body is capable ofvaginal birth and that TOL is an opportunity to demon-strate capacity as a woman. This feeling of inadequacyfrom previous cesarean carried over to the subsequentpregnancy. The ability to give birth vaginally was asso-ciated with a significant achievement and it seemed thatdespite the presence of the healthy child, the vaginalbirth itself was associated with adequacy as a woman.“I still occasionally feel inadequate for not ever havinggiven birth naturally. Although I have 2 perfect littlegirls” (P98).

Choice of TOL helped these women gain control andmanage fear and anxiety in a different way than womenwho gained control by planning ERCD. “Would like thebaby to decide when to come, feel this is a better optionfor the baby and myself. Feel I have more control overthe birth” (P124). Women also talked about avoiding theprevious fear associated with birth or the negative experi-ence they remember. “I feel like the traumatic experienceof my last birth has left me feeling very vulnerable”(P81). There was a general recognition among the womenwho preferred TOL that vaginal birth was “better” forthem and also their babies. This feeling related both tosafety for the baby and a quicker recovery for them. Somewomen had formed their impressions after talking withother women who had experienced vaginal birth. Othershad previously experienced vaginal birth before cesareanand reflected on that experience.

Discussion and Conclusions

This article responded to the call for evidence aboutwhat is important to women in making birth decisions(6). We learned that past experience with labor and

cesarean strongly influenced the woman’s choice forfuture birth and in particular ERCD, but did not neces-sarily predict the choice. Other factors added to theequation, including emotions of fear, anxiety, anduncertainty, a desire to control what happened in thenext birth, and the influence of practitioners and signifi-cant others. For women who chose ERCD the percep-tion of risk with TOL and potential scar ruptureoverrode personal desires for vaginal birth. Womenwho chose TOL seemed more confident in their bodyand valued vaginal birth for both them and their babyas a way to achieve a quicker recovery and return totheir role as a mother.

Women in both groups valued safety for their babyover their own needs, although this reason for choicewas more commonly noted for those who preferredERCD. Interestingly, few discussed “labor” as an eventthat might have positive health effects for the baby. Asinformation and options were weighed, factors accumu-lated. Thus, a prior negative or emergent prior cesar-ean, combined with a difficult recovery, breastfeedingproblems, practitioner or significant other lack of enthu-siasm for TOL, desire for planning, and/or fear andanxiety seemed to have a cumulative effect more likelyto lead to ERCD as the choice. Both groups seemedsatisfied with their decisions, although women whochose TOL ending in another cesarean were less satis-fied (21). It is possible that women who chose ERCDto avoid emergency cesarean were anticipating futuredecision regret and ERCD helped them cope with theuncertainty of TOL (22,23).

Benchmarks for decision making are important forfuture study, including 1) prior experience such as fac-tors in the emotional sequela of the event and carefulevaluation of potential to improve TOL success; 2) per-sonal knowledge (including significant others) of bene-fits and potential harms of TOL versus ERCD; 3)identifying need for control and how that can be man-aged with both TOL and ERCD; and 4) how thewoman and the practitioner discuss planning for thefuture birth.

This study was limited by including only the voicesof the women. Their narratives were not countered withothers involved in their story such as practitioners orsignificant others. These were also written responses ona survey that was collecting data for the RCT. Individ-ual interviews may have provided longer narratives.However, strength lies in the study retention rate of 85percent through the postpartum period and the inclusionof women who chose different modes of birth.

Practitioners, and the health care culture within whichthey work, have a strong influence on women’s birthexperiences. A recent United States study that examinedthe degree to which women were informed about theiroptions for birth after cesarean also found that practi-

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tioner preference was a strong predictor of choice.When patients perceived their practitioner preferredERCD they were more likely to choose this option(86%), and when practitioners were thought to preferTOL, 78 percent chose TOL. If there existed no obviouspractitioner preference the choice was 50:50 (24). It wasinteresting that many women were not sufficientlyinformed about the physiological risks and benefits ofTOL versus ERCD. Information gaps included under-standing their chance of VBAC success, uterine rupturerisk, length of recovery, maternal risk, and neonatalsafety (risk of demise). These key information pointsintersect with women’s values as they weigh pros andcons of TOL versus ERCD. Information about likeli-hood of success is critical for women who need to avoidemergency cesarean, information about length of recov-ery is necessary for women who value speedy return to“normal” roles, and neonatal risk information is impor-tant for women who place the perception of safety forthe baby over all else. These data underline the impor-tance of achieving a broader approach to informationsharing. Shared decision making requires practitionersto push beyond clinical algorithms about physical risksand benefits to develop and use strategies that effec-tively acknowledge and actively incorporate women’svalues and preferences into decisions about birth.

Funding

Medical Benefits Fund provided funding for the datacollection.

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