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Decision Making for Primary Cesarean Delivery: The Role of Patient and Provider Preferences
Decision Making for Primary Cesarean Delivery: The Role of Patient and Provider Preferences Anjali J. Kaimal, MD, MAS,* and Miriam Kuppermann, PhD, MPH†,‡ Primary cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the range of contexts in which decision making takes place and the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate that are safe and acceptable to both patients and providers. We conducted a review of the literature on patient and provider preferences and obstetrical decision making in the context of primary cesarean delivery, and offer recommendations for future research directions, including potential interventions that may impact the patient and provider factors affecting the primary cesarean rate. Semin Perinatol 36:384-389 © 2012 Elsevier Inc. All rights reserved. KEYWORDS cesarean delivery, patient-provider communication, shared decision making
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he cesarean rate in the United States reached an all time high of 32% in 2007, representing more than 1 million births per year and reflecting a 53% increase since 1996.1 This increase has been attributed to many factors, including changes in patient characteristics, provider practice patterns, and patient and provider preferences for a particular mode of delivery based on clinical circumstances such as prior cesarean delivery, breech presentation, and multiple gestation. Changing rates of cesarean delivery absent medical or obstetric indication may also have contributed to the recent rise. The dramatic reduction in vaginal birth after cesarean delivery —a reduction influenced both by availability of providers and centers supporting a trial of labor after cesarean delivery and patient preference—means that reducing the primary cesarean rate offers the best opportunity to impact the cesarean delivery rate as a whole, and understanding how patient
*Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA. †Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA. ‡Department of Epidemiology and Biostatistics, University of California, San Francisco, CA. Address reprint requests to Miriam Kuppermann, PhD, MPH, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, 3333 California Street, Suite 335, San Francisco, CA 941430856. E-mail: [email protected]
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and provider preferences affect decision making for primary cesarean delivery is an important part of this effort.
Decision Making Regarding Cesarean Delivery in Context As with any medical procedure, cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. However, the dynamic nature of decision making for cesarean delivery during the course of pregnancy, and particularly during labor, is unique, and the relative importance of patient and provider factors affecting this decision may vary depending on the specific circumstances. Part of the context for decision making arises from the distinction between planned delivery approach and eventual delivery mode. While a patient may express a preference for a particular delivery mode, providers can only offer a particular delivery approach, and must acknowledge that while in general, if a cesarean delivery is planned, then a cesarean birth will occur, for those who plan a vaginal delivery, either a vaginal birth or a cesarean birth may result. Considering primary cesarean deliveries specifically, a distinction can be made between an elective cesarean, in which there is a choice of delivery approach, and an indicated cesarean, in which a specific delivery approach is favored and
Decision making for primary cesarean delivery recommended given the clinical situation as assessed by the provider. In addition, some indications may be present before labor, allowing for an indicated cesarean delivery to be planned, whereas others only arise or become apparent during the course of labor, which will clearly affect the timing of decision making and planning for cesarean delivery. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate, which are safe and acceptable to both patients and providers.
Shared Decision Making in Obstetrics Shared decision making has been defined as a process in which decisions are shared by patients and health care providers, informed by the best evidence available and weighted according to the specific characteristics and values of the patient.2,3 Although the shared decision-making model has been endorsed for some clinical contexts in obstetrics and gynecology,4 mode of delivery decisions, particularly in a first pregnancy, are more frequently viewed as opportunities for education and consensus building, with a specific approach being recommended based on the medical scenario, and the provider offering education and guidance to help the patient understand the reasons for this recommendation and agree to provide informed consent to proceed. Returning to the contrast of delivery approach and delivery mode, if there are some contexts in which either approach is reasonable, then these may be seen as opportunities for shared decision making. However, if one approach is in the best interest of the patient and/or the fetus, the provider’s role is to educate the patient and elicit and allay her concerns. Overall, one may consider a continuum of situations in which cesarean delivery is the planned approach, ranging from the most elective, cesarean delivery on maternal request (CDMR), to perhaps the most indicated, complete placenta previa; in the case of a planned vaginal delivery, cesarean deliveries performed during labor require a decision to change the delivery approach and are generally thought of as indicated, but a continuum of patient and provider influence may still exist (Fig. 1). Most of the published studies examining patient and provider preferences regarding mode of delivery have focused on the context of elective planned cesarean deliveries, particularly CDMR and elective repeat cesarean delivery. These are situations in which patient preferences play a primary role, but optimally, assessment of risks and benefits by both patient and provider helps to inform these preferences. Therefore, examination of data from studies regarding these planned cesarean deliveries may provide information regarding how patient and provider preferences are formed and affect decision making for primary cesarean delivery in this as well as other contexts.
385
Figure 1 The spectrum of contexts for decision making regarding cesarean delivery.
CDMR and Beyond: The Impact of Patient Preference CDMR is defined as a planned primary cesarean delivery in the absence of any medical or obstetrical indication. Significant media attention has been devoted to this entity, and in the context of the rising cesarean rate, attempts have been made to quantify the impact of CDMR on the cesarean rate as a whole. Unfortunately, it is difficult to accurately assess the rate of CDMR based on research studies, coding, or reimbursement information.5 Surveys of obstetrical providers indicate that although CDMR is performed, it does not seem to make up a significant proportion of cesarean deliveries; estimates range from 4% to 18% of all cesarean deliveries, corresponding to approximately 2% of all births.6 While CDMR may not comprise a large percentage of primary cesarean deliveries, examining the reasons why patients report that they would choose a primary cesarean in the absence of medical or obstetric indications offers interesting insight into the possible determinants of patient preference for mode of delivery in other contexts. Commonly stated reasons include a belief that the cesarean delivery is safer for the baby, fear of labor or the process of childbirth, in particular related to prior trauma, and concerns about the impact of vaginal delivery on sexual function and urogynecologic outcomes.6-8 Less frequently stated in the literature is the concern that attempting vaginal birth is not the same as achieving vaginal birth, and for some women, a cesarean delivery performed before labor may be preferable to a labor that ends in a cesarean delivery. Given the uncertainty in fetal as well as maternal outcome that is inherent in any labor, but particularly salient in a first labor, strength of preference for a vaginal delivery and the level of tolerance for uncertainty or maternal or fetal risk that is perceived to be associated with labor may combine to result in varying preferences for a particular delivery approach.9 For some women, tolerance for uncertainty and strength of preference for vaginal delivery may be low enough to lead to a preference for elective cesarean delivery so as to avoid having a planned vaginal delivery end in cesarean delivery. For others with a stronger preference for vaginal delivery, a greater willingness to tolerate uncertainty, or a lower perceived risk associated with labor, labor would be
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preferable even if the likelihood of success is predicted to be low. For the patient who requests a primary cesarean delivery before labor, the strength and direction of her preference is clear; for a patient undergoing labor, the direction of the preference at the start of labor is usually clear, but the strength is much more difficult to assess, and the way that this strength impacts decision making during the dynamic process of labor and delivery is even more difficult to quantify. Weaver et al10 assessed the perceptions of patients and providers regarding mode of delivery and found that 73% of primiparous women stated that they would prefer vaginal birth at the start of pregnancy, whereas 23% of the women who were undecided stated that they would want whatever was “safest for the baby,” suggesting that a desire to reduce perceived risk may be a key factor in determining patient preference for mode of delivery. In further support of this hypothesis, a mixed methods study by Kingdon et al11 followed women from pregnancy through the postpartum period and found that while most women stated a preference for vaginal delivery throughout their pregnancy, most also felt that the decision for cesarean during labor should be based on health risks and benefits, which they knew to be dynamic, and that they relied on their provider to make this assessment. While decision making regarding mode of delivery after cesarean does not involve all of the same issues as in a first delivery, discussion of what is important to women contemplating repeat cesarean also offers insight into patient priorities and echoes the finding that reduction in risk is seen as the key factor. Women choosing a trial of labor and those choosing an elective repeat cesarean delivery both see their choice as the safer option.12-14 Individual patient experience and risk assessment has been reported to be an influential factor in several studies: women who believe they have a high likelihood of successful vaginal delivery are more likely to report a preference for trial of labor.15-17 Conversely, convenience, desire to avoid labor pain, and fear of failed trial of labor have repeatedly been identified as reasons for preferring an elective repeat cesarean delivery.13,15,16,18-20 Because, by definition, individual patient experience is lacking in a first labor, how women assess their own likelihood of vaginal delivery and how this informs their preferences as the events of labor unfold remain unclear; it seems likely that provider assessment and counseling may play a role in women’s understanding of the risks and benefits of a particular course, even prior to the recommendation for a particular delivery mode.
tient and the provider, cesarean deliveries performed during labor for the indications of active phase arrest or nonreassuring fetal heart tracing depend more on provider judgment of the clinical situation and assessment/inclusion of patient preference as they see fit. A recent study by Barber et al21 found that the number of cesarean deliveries performed for nonreassuring fetal heart tracing and arrest of dilation at their institution increased significantly over time, accounting for 50% of the increase in their primary cesarean rate; decision making for delivery in these situations relies heavily on the provider’s clinical assessment, which may be influenced by the provider’s attitudes as well as those of the patient, in addition to the provider’s and the patient’s tolerance for uncertainty. As with nearly all decisions in obstetrics,22 the assessment of the need for cesarean delivery for the indications of nonreassuring fetal heart tracing or arrest of dilation requires a balancing of maternal and fetal benefits and risks, as well as a discussion with the patient. Fetal heart rate monitoring was introduced as a method of identifying fetuses at risk of death or neurologic compromise in whom expeditious delivery will improve outcome. However, continuous fetal heart rate monitoring in particular has been associated with an increase in operative delivery without an effect on neonatal outcome. Despite the attempt by the National Institute of Child Health and Human Development to standardize fetal heart interpretation,23 the fact that most fetal heart tracings fall into category II (indeterminate) means that performing a cesarean delivery for this indication requires subjective assessment by the provider not only of the information contained in the fetal heart tracing but also of the a priori risk of fetal compromise and the likelihood of vaginal delivery as well as the expected time course to delivery based on the clinical scenario. Similarly, labor management can vary widely between providers, and the frequency of examinations and the tendency toward or against intervention by the patient and provider in the setting of a slowly progressing labor may result in variation in the timing of a decision for cesarean delivery because of active phase arrest. This may be particularly true in the setting of induction of labor, which comprises more than 20% of all deliveries.24 Allowing for more extended time to document progress increases the number of patients who will have a vaginal delivery,25 but whether and when extending the time allowed before proceeding with cesarean delivery is appropriate depends on the comfort of the patient and the provider as well as the presence of other risk factors for maternal or fetal compromise.
Primary Cesarean Delivery Performed During Labor: Decision Making Under Uncertainty
The Impact of the Provider on Decision Making for Primary Cesarean Delivery
In contrast to cesarean deliveries performed before labor, where clinical indications such as breech presentation, placenta previa, or multiple gestation are clear to both the pa-
Given the priority that patients give to provider assessment of benefits and risks of a particular mode of delivery, as well as the inescapable fact that providers make the recommendation for cesarean delivery during labor, it is intuitive to think
Decision making for primary cesarean delivery that provider attitudes and differences in management style may explain some of the increase in cesarean rate. Analysis of the strength of indication for a primary cesarean delivery showed that in one sample, patients who were older, white, privately insured, and cared for by a private practice group were more likely to undergo cesarean delivery for arrest of dilation, whereas patients cared for by a resident practice group were more likely to have a “strong” indication for cesarean delivery at the time of the procedure as assessed by independent observers.26 Furthermore, while the ability to predict who will have a first cesarean remains poor, risk prediction models for cesarean delivery have shown that including a physician level factor in the model increases the predictive power.27-29 Looking more specifically at intrapartum cesarean deliveries, Kalish et al30 found that in 422 women who eventually underwent indicated cesarean delivery during labor, 13% were offered cesarean delivery before the indication developed, and an additional 8% of patients requested a cesarean delivery before the indication was clear, providing evidence that the patient and provider preferences influence outcome. It also seems clear that the context in which the provider is assessing the patient may affect the outcome. In one study, Shen et al31 presented theoretical cases to providers and found that the cases presented immediately before an ambiguous case had a significant impact on the practitioner’s assessment of need for cesarean delivery in that ambiguous case. Specifically, if the prior cases were abnormal, the ambiguous case seemed more normal, and obstetricians were less likely to intervene; if the prior cases were normal, the ambiguous one seemed more grave. How this type of framing effect may impact real world labor and delivery decisions remains unclear. Perhaps reflecting a similar effect of context or individual practice style, Li et al32 found that physicians who tended to perform more cesareans performed more cesareans for every indication, but the variation in cesarean delivery rates was highest for subjective indications such as active-phase arrest or nonreassuring fetal heart tracing. In this study, lower rates of primary cesarean delivery were primarily associated with reduction in the number of cesareans performed for activephase arrest. Finally, an analysis of physician treatment styles with regard to cesarean delivery found that 30% of variation was explained by “time-invariant, physician-specific factors separable from observed physician characteristics, training, and region”; the question remains as to what these factors may be, how they can be measured, and whether they can be intervened upon.33
Management of Uncertainty in Obstetrics Evidence regarding the subjectivity of decision making in the case of primary cesarean delivery highlights the uncertainty that is inherent in the labor and delivery process, particularly for women experiencing their first labor. Uncertainty has been defined as a form of metacognition or a
387 “knowing about not knowing”; in health care decision making, the patient, the provider, or both may be uncertain. In the era of evidence-based medicine, shared decision making, and patient-centered care, the management of uncertainty has been recognized as an important issue34 and examination of decision making for primary cesarean delivery highlights this. There are numerous sources of uncertainty that arise in a first labor, and how these are interpreted by the patient and provider directly impacts the risk– benefit calculus that underlies decision making for delivery. First and foremost, outcomes of mode of delivery decisions are never certain until delivery is achieved—so the probability, or indeterminacy, of benefit from a particular delivery plan is always present. Second, there is significant ambiguity or conflicting opinion about the impact of certain clinical decisions, ranging from the specific short- and long-term maternal and fetal outcomes of the eventual delivery mode to the impact of the obstetrical interventions, such as induction of labor, on the likelihood of vaginal delivery in different contexts. Finally, complexity, referring to the multiplicity of causal factors resulting in a particular outcome, is inherent in the simultaneous assessment of maternal and fetal well-being as well as likelihood of successful vaginal delivery as perceived by the patient and provider during labor. Setting the stage for optimal management and decision making regarding primary cesarean delivery requires determining whether any of these sources of uncertainty can be reduced through improvement in clinical evidence, and determining how patients and providers can best tolerate the uncertainty that remains inherent to a first labor.
Interventions to Reduce the Primary Cesarean Rate Given that the interaction between the patient and the provider remains central in decision making regarding primary cesarean deliveries, interventions to reduce the cesarean rate must target both patients and providers. All preferences are not informed preferences, and both patients and providers bring their biases to decision making. Educational tools may be helpful to allow both patients and providers define their priorities and cope with the uncertainty that is inherent in a first labor. Besides educational resources, decision support tools may help patients think through their preferences and engage in informed shared decision making when planned cesarean delivery and planned vaginal delivery are both reasonable options. In terms of interventions targeting providers, Abenhaim et al35 analyzed patients who were delivered by an on-call doctor rather than their primary obstetrician and found that those who were delivered by the on-call obstetrician were significantly more likely to have a cesarean delivery for fetal indications in the first stage of labor. The authors hypothesized that this could be due to a lack of rapport between patient and provider and the difficulty in communication that it may cause. Interventions to improve communication
A.J. Kaimal and M. Kuppermann
388 on labor and delivery may help to mitigate this type of effect. Evidence also indicates that having a second provider review decision making for cesarean delivery before the procedure may also help to reduce the intrapartum cesarean rate, perhaps by removing some of the individual bias and subjectivity from the decision.36 Beyond this real time interaction with colleagues, peer review at an individual or institutional level may also be helpful to raise awareness of these issues, and clinical guidelines may be useful to ensure that indicated cesarean deliveries meet a minimum criteria; however, limited implementation of these types of interventions has not been successful thus far, indicating that novel approaches are necessary.37
Future Research Directions In sum, despite evidence suggesting that patient and provider preferences play key roles in how decisions for primary cesarean delivery are made, data from large prospective studies among sociodemographically diverse pregnant women outside the context of CDMR are lacking. Ideally, future studies should assess the strength of patient preference for a particular delivery mode, including the dynamic nature of preferences through both the course of antenatal care and labor, and also should measure changes in provider assessment of likelihood of successful vaginal birth and recommendations for management based on these assessments. In addition, continued investigation regarding the clinical determinants of primary cesarean delivery is needed to provide the best evidence possible to patients and providers regarding the likely outcome of different management options for different populations of women. At the same time, more information is needed regarding how best to communicate the ambiguity that is inherent in translating these population risks into an individual outcome, as well as how to deal with the irreducible uncertainty that is encountered in every labor.
References 1. Menacker F, Hamilton BE: Recent trends in cesarean delivery in the United States. NCHS Data Brief 35:1-8, 2010 2. Légaré F, O’Connor AC, Graham I, et al: Supporting patients facing difficult health care decisions: Use of the Ottawa decision support framework. Can Fam Physician 52:476-477, 2006 3. Stewart BM, Weston W, McWhinney I, et al: Patient-Centered Medicine: Transforming the Clinical Method. London, Sage Publications, 1995 4. ACOG Committee on Practice Bulletins: ACOG Practice Bulletin No. 77: Screening for fetal chromosomal abnormalities. Obstet Gynecol 109:217-227, 2007 5. Viswanathan M, Visco AG, Hartmann K, et al: Cesarean delivery on maternal request. Evid Rep Technol Assess (Full Rep) 133:1-138, 2006 6. Wax JR, Cartin A, Pinette MG, et al: Patient choice cesarean: An evidence-based review. Obstet Gynecol Surv 59:601-616, 2004 7. Dursun P, Yanik FB, Zeyneloglu HB, et al: Why women request cesarean section without medical indication? J Matern Fetal Neonatal Med 24:1133-1137, 2011 8. Wiklund I, Edman G, Andolf E: Cesarean section on maternal request: Reasons for the request, self-estimated health, expectations, experience
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of birth and signs of depression among first-time mothers. Acta Obstet Gynecol Scand 86:451-456, 2007 Turner CE, Young JM, Solomon MJ, et al: Vaginal delivery compared with elective caesarean section: The views of pregnant women and clinicians. Br J Obstet Gynaecol 115:1494-1502, 2008 Weaver JJ, Statham H, Richards M: Are there “unnecessary” Cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications. Birth 34:32-41, 2007 Kingdon C, Neilson J, Singleton V, et al: Choice and birth method: Mixed-method study of caesarean delivery for maternal request. Br J Obstet Gynaecol 116:886-895, 2009 Eden KB, Hashima JN, Osterweil P, et al: Childbirth preferences after cesarean birth: A review of the evidence. Birth 31:49-60, 2004 Moffat MA, Bell JS, Porter MA, et al: Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study. Br J Obstet Gynaecol 114:86-93, 2007 Angeja AC, Washington AE, Vargas JE, et al Chilean women’s preferences regarding mode of delivery: Which do they prefer and why? Br J Obstet Gynaecol 113:1253-1258, 2006 Emmett C, Shaw A, Montgomery A, et al: Women’s experience of decision making about mode of delivery after a previous caesarean section: The role of health professionals and information about health risks. Br J Obstet Gynaecol 113:1438-1445, 2006 Kirk EP, Doyle KA, Leigh J, et al: Vaginal birth after cesarean or repeat cesarean section: Medical risks or social realities? Am J Obstet Gynecol 162:1398-1403, 1990; discussion 403-405 Martin JN Jr, Harris BA Jr, Huddleston JF, et al: Vaginal delivery following previous cesarean birth. Am J Obstet Gynecol 146:255-263, 1983 McClain CS: Why women choose trial of labor or repeat cesarean section. J Fam Pract 21:210-216, 1985 McClain CS: Patient decision making: The case of delivery method after a previous cesarean section. Cult Med Psychiatry 11:495-508, 1987 McClain CS: The making of a medical tradition: Vaginal birth after cesarean. Soc Sci Med 31:203-210, 1990 Barber EL, Lundsberg LS, Belanger K, et al: Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 118:29-38, 2011 Berghella V, Blackwell SC, Ramin SM, et al: Use and misuse of the term “elective” in obstetrics. Obstet Gynecol 117:372-376, 2011 Macones GA, Hankins GD, Spong CY, et al: The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: Update on definitions, interpretation, and research guidelines. Obstet Gynecol 112:661-666, 2008 Simon CE, Grobman WA: When has an induction failed? Obstet Gynecol 105:705-709, 2005 Rouse DJ, Owen J, Hauth JC: Active-phase labor arrest: Oxytocin augmentation for at least 4 hours. Obstet Gynecol 93:323-328, 1999 Peipert JF, Hogan JW, Gifford D, et al: Strength of indication for cesarean delivery: Comparison of private physician versus resident service labor management. Am J Obstet Gynecol 181:435-439, 1999 Luthy DA, Malmgren JA, Zingheim RW: Cesarean delivery after elective induction in nulliparous women: The physician effect. Am J Obstet Gynecol 191:1511-1515, 2004 Luthy DA, Malmgren JA, Zingheim RW, et al: Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol 188:1579-1585, 2003; discussion 1585-1587 Peaceman AM, Feinglass J, Manheim LM: Risk-adjustment of cesarean delivery rates: A practical method for use in quality improvement. Am J Med Qual 17:113-117, 2002 Kalish RB, McCullough L, Gupta M, et al: Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol 103:1137-1141, 2004
Decision making for primary cesarean delivery 31. Shen O, Rabinowitz R, Geist RR, et al: Effect of background case characteristics on decisions in the delivery room. Med Decis Making 30: 518-522, 2010 32. Li T, Rhoads GG, Smulian J, et al: Physician cesarean delivery rates and risk-adjusted perinatal outcomes. Obstet Gynecol 101:1204-1212, 2003 33. Epstein AJ, Nicholson S: The formation and evolution of physician treatment styles: An application to cesarean sections. J Health Econ 28:1126-1140, 2009 34. Han PK, Klein WM, Arora NK: Varieties of uncertainty in health care: A conceptual taxonomy. Med Decis Making 31:828-838, 2011
389 35. Abenhaim HA, Benjamin A, Koby RD, et al: Comparison of obstetric outcomes between on-call and patients’ own obstetricians. Cmaj 177: 352-356, 2007 36. Althabe F, Belizán JM, Villar J, et al: Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: A cluster randomised controlled trial. Lancet 363:1934-1940, 2004 37. Khunpradit S, Tavender E, Lumbiganon P, et al: Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 6:CD005528, 2011
T
he cesarean rate in the United States reached an all time high of 32% in 2007, representing more than 1 million births per year and reflecting a 53% increase since 1996.1 This increase has been attributed to many factors, including changes in patient characteristics, provider practice patterns, and patient and provider preferences for a particular mode of delivery based on clinical circumstances such as prior cesarean delivery, breech presentation, and multiple gestation. Changing rates of cesarean delivery absent medical or obstetric indication may also have contributed to the recent rise. The dramatic reduction in vaginal birth after cesarean delivery —a reduction influenced both by availability of providers and centers supporting a trial of labor after cesarean delivery and patient preference—means that reducing the primary cesarean rate offers the best opportunity to impact the cesarean delivery rate as a whole, and understanding how patient
*Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA. †Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA. ‡Department of Epidemiology and Biostatistics, University of California, San Francisco, CA. Address reprint requests to Miriam Kuppermann, PhD, MPH, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, 3333 California Street, Suite 335, San Francisco, CA 941430856. E-mail: [email protected]
384
0146-0005/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2012.04.024
and provider preferences affect decision making for primary cesarean delivery is an important part of this effort.
Decision Making Regarding Cesarean Delivery in Context As with any medical procedure, cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. However, the dynamic nature of decision making for cesarean delivery during the course of pregnancy, and particularly during labor, is unique, and the relative importance of patient and provider factors affecting this decision may vary depending on the specific circumstances. Part of the context for decision making arises from the distinction between planned delivery approach and eventual delivery mode. While a patient may express a preference for a particular delivery mode, providers can only offer a particular delivery approach, and must acknowledge that while in general, if a cesarean delivery is planned, then a cesarean birth will occur, for those who plan a vaginal delivery, either a vaginal birth or a cesarean birth may result. Considering primary cesarean deliveries specifically, a distinction can be made between an elective cesarean, in which there is a choice of delivery approach, and an indicated cesarean, in which a specific delivery approach is favored and
Decision making for primary cesarean delivery recommended given the clinical situation as assessed by the provider. In addition, some indications may be present before labor, allowing for an indicated cesarean delivery to be planned, whereas others only arise or become apparent during the course of labor, which will clearly affect the timing of decision making and planning for cesarean delivery. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate, which are safe and acceptable to both patients and providers.
Shared Decision Making in Obstetrics Shared decision making has been defined as a process in which decisions are shared by patients and health care providers, informed by the best evidence available and weighted according to the specific characteristics and values of the patient.2,3 Although the shared decision-making model has been endorsed for some clinical contexts in obstetrics and gynecology,4 mode of delivery decisions, particularly in a first pregnancy, are more frequently viewed as opportunities for education and consensus building, with a specific approach being recommended based on the medical scenario, and the provider offering education and guidance to help the patient understand the reasons for this recommendation and agree to provide informed consent to proceed. Returning to the contrast of delivery approach and delivery mode, if there are some contexts in which either approach is reasonable, then these may be seen as opportunities for shared decision making. However, if one approach is in the best interest of the patient and/or the fetus, the provider’s role is to educate the patient and elicit and allay her concerns. Overall, one may consider a continuum of situations in which cesarean delivery is the planned approach, ranging from the most elective, cesarean delivery on maternal request (CDMR), to perhaps the most indicated, complete placenta previa; in the case of a planned vaginal delivery, cesarean deliveries performed during labor require a decision to change the delivery approach and are generally thought of as indicated, but a continuum of patient and provider influence may still exist (Fig. 1). Most of the published studies examining patient and provider preferences regarding mode of delivery have focused on the context of elective planned cesarean deliveries, particularly CDMR and elective repeat cesarean delivery. These are situations in which patient preferences play a primary role, but optimally, assessment of risks and benefits by both patient and provider helps to inform these preferences. Therefore, examination of data from studies regarding these planned cesarean deliveries may provide information regarding how patient and provider preferences are formed and affect decision making for primary cesarean delivery in this as well as other contexts.
385
Figure 1 The spectrum of contexts for decision making regarding cesarean delivery.
CDMR and Beyond: The Impact of Patient Preference CDMR is defined as a planned primary cesarean delivery in the absence of any medical or obstetrical indication. Significant media attention has been devoted to this entity, and in the context of the rising cesarean rate, attempts have been made to quantify the impact of CDMR on the cesarean rate as a whole. Unfortunately, it is difficult to accurately assess the rate of CDMR based on research studies, coding, or reimbursement information.5 Surveys of obstetrical providers indicate that although CDMR is performed, it does not seem to make up a significant proportion of cesarean deliveries; estimates range from 4% to 18% of all cesarean deliveries, corresponding to approximately 2% of all births.6 While CDMR may not comprise a large percentage of primary cesarean deliveries, examining the reasons why patients report that they would choose a primary cesarean in the absence of medical or obstetric indications offers interesting insight into the possible determinants of patient preference for mode of delivery in other contexts. Commonly stated reasons include a belief that the cesarean delivery is safer for the baby, fear of labor or the process of childbirth, in particular related to prior trauma, and concerns about the impact of vaginal delivery on sexual function and urogynecologic outcomes.6-8 Less frequently stated in the literature is the concern that attempting vaginal birth is not the same as achieving vaginal birth, and for some women, a cesarean delivery performed before labor may be preferable to a labor that ends in a cesarean delivery. Given the uncertainty in fetal as well as maternal outcome that is inherent in any labor, but particularly salient in a first labor, strength of preference for a vaginal delivery and the level of tolerance for uncertainty or maternal or fetal risk that is perceived to be associated with labor may combine to result in varying preferences for a particular delivery approach.9 For some women, tolerance for uncertainty and strength of preference for vaginal delivery may be low enough to lead to a preference for elective cesarean delivery so as to avoid having a planned vaginal delivery end in cesarean delivery. For others with a stronger preference for vaginal delivery, a greater willingness to tolerate uncertainty, or a lower perceived risk associated with labor, labor would be
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preferable even if the likelihood of success is predicted to be low. For the patient who requests a primary cesarean delivery before labor, the strength and direction of her preference is clear; for a patient undergoing labor, the direction of the preference at the start of labor is usually clear, but the strength is much more difficult to assess, and the way that this strength impacts decision making during the dynamic process of labor and delivery is even more difficult to quantify. Weaver et al10 assessed the perceptions of patients and providers regarding mode of delivery and found that 73% of primiparous women stated that they would prefer vaginal birth at the start of pregnancy, whereas 23% of the women who were undecided stated that they would want whatever was “safest for the baby,” suggesting that a desire to reduce perceived risk may be a key factor in determining patient preference for mode of delivery. In further support of this hypothesis, a mixed methods study by Kingdon et al11 followed women from pregnancy through the postpartum period and found that while most women stated a preference for vaginal delivery throughout their pregnancy, most also felt that the decision for cesarean during labor should be based on health risks and benefits, which they knew to be dynamic, and that they relied on their provider to make this assessment. While decision making regarding mode of delivery after cesarean does not involve all of the same issues as in a first delivery, discussion of what is important to women contemplating repeat cesarean also offers insight into patient priorities and echoes the finding that reduction in risk is seen as the key factor. Women choosing a trial of labor and those choosing an elective repeat cesarean delivery both see their choice as the safer option.12-14 Individual patient experience and risk assessment has been reported to be an influential factor in several studies: women who believe they have a high likelihood of successful vaginal delivery are more likely to report a preference for trial of labor.15-17 Conversely, convenience, desire to avoid labor pain, and fear of failed trial of labor have repeatedly been identified as reasons for preferring an elective repeat cesarean delivery.13,15,16,18-20 Because, by definition, individual patient experience is lacking in a first labor, how women assess their own likelihood of vaginal delivery and how this informs their preferences as the events of labor unfold remain unclear; it seems likely that provider assessment and counseling may play a role in women’s understanding of the risks and benefits of a particular course, even prior to the recommendation for a particular delivery mode.
tient and the provider, cesarean deliveries performed during labor for the indications of active phase arrest or nonreassuring fetal heart tracing depend more on provider judgment of the clinical situation and assessment/inclusion of patient preference as they see fit. A recent study by Barber et al21 found that the number of cesarean deliveries performed for nonreassuring fetal heart tracing and arrest of dilation at their institution increased significantly over time, accounting for 50% of the increase in their primary cesarean rate; decision making for delivery in these situations relies heavily on the provider’s clinical assessment, which may be influenced by the provider’s attitudes as well as those of the patient, in addition to the provider’s and the patient’s tolerance for uncertainty. As with nearly all decisions in obstetrics,22 the assessment of the need for cesarean delivery for the indications of nonreassuring fetal heart tracing or arrest of dilation requires a balancing of maternal and fetal benefits and risks, as well as a discussion with the patient. Fetal heart rate monitoring was introduced as a method of identifying fetuses at risk of death or neurologic compromise in whom expeditious delivery will improve outcome. However, continuous fetal heart rate monitoring in particular has been associated with an increase in operative delivery without an effect on neonatal outcome. Despite the attempt by the National Institute of Child Health and Human Development to standardize fetal heart interpretation,23 the fact that most fetal heart tracings fall into category II (indeterminate) means that performing a cesarean delivery for this indication requires subjective assessment by the provider not only of the information contained in the fetal heart tracing but also of the a priori risk of fetal compromise and the likelihood of vaginal delivery as well as the expected time course to delivery based on the clinical scenario. Similarly, labor management can vary widely between providers, and the frequency of examinations and the tendency toward or against intervention by the patient and provider in the setting of a slowly progressing labor may result in variation in the timing of a decision for cesarean delivery because of active phase arrest. This may be particularly true in the setting of induction of labor, which comprises more than 20% of all deliveries.24 Allowing for more extended time to document progress increases the number of patients who will have a vaginal delivery,25 but whether and when extending the time allowed before proceeding with cesarean delivery is appropriate depends on the comfort of the patient and the provider as well as the presence of other risk factors for maternal or fetal compromise.
Primary Cesarean Delivery Performed During Labor: Decision Making Under Uncertainty
The Impact of the Provider on Decision Making for Primary Cesarean Delivery
In contrast to cesarean deliveries performed before labor, where clinical indications such as breech presentation, placenta previa, or multiple gestation are clear to both the pa-
Given the priority that patients give to provider assessment of benefits and risks of a particular mode of delivery, as well as the inescapable fact that providers make the recommendation for cesarean delivery during labor, it is intuitive to think
Decision making for primary cesarean delivery that provider attitudes and differences in management style may explain some of the increase in cesarean rate. Analysis of the strength of indication for a primary cesarean delivery showed that in one sample, patients who were older, white, privately insured, and cared for by a private practice group were more likely to undergo cesarean delivery for arrest of dilation, whereas patients cared for by a resident practice group were more likely to have a “strong” indication for cesarean delivery at the time of the procedure as assessed by independent observers.26 Furthermore, while the ability to predict who will have a first cesarean remains poor, risk prediction models for cesarean delivery have shown that including a physician level factor in the model increases the predictive power.27-29 Looking more specifically at intrapartum cesarean deliveries, Kalish et al30 found that in 422 women who eventually underwent indicated cesarean delivery during labor, 13% were offered cesarean delivery before the indication developed, and an additional 8% of patients requested a cesarean delivery before the indication was clear, providing evidence that the patient and provider preferences influence outcome. It also seems clear that the context in which the provider is assessing the patient may affect the outcome. In one study, Shen et al31 presented theoretical cases to providers and found that the cases presented immediately before an ambiguous case had a significant impact on the practitioner’s assessment of need for cesarean delivery in that ambiguous case. Specifically, if the prior cases were abnormal, the ambiguous case seemed more normal, and obstetricians were less likely to intervene; if the prior cases were normal, the ambiguous one seemed more grave. How this type of framing effect may impact real world labor and delivery decisions remains unclear. Perhaps reflecting a similar effect of context or individual practice style, Li et al32 found that physicians who tended to perform more cesareans performed more cesareans for every indication, but the variation in cesarean delivery rates was highest for subjective indications such as active-phase arrest or nonreassuring fetal heart tracing. In this study, lower rates of primary cesarean delivery were primarily associated with reduction in the number of cesareans performed for activephase arrest. Finally, an analysis of physician treatment styles with regard to cesarean delivery found that 30% of variation was explained by “time-invariant, physician-specific factors separable from observed physician characteristics, training, and region”; the question remains as to what these factors may be, how they can be measured, and whether they can be intervened upon.33
Management of Uncertainty in Obstetrics Evidence regarding the subjectivity of decision making in the case of primary cesarean delivery highlights the uncertainty that is inherent in the labor and delivery process, particularly for women experiencing their first labor. Uncertainty has been defined as a form of metacognition or a
387 “knowing about not knowing”; in health care decision making, the patient, the provider, or both may be uncertain. In the era of evidence-based medicine, shared decision making, and patient-centered care, the management of uncertainty has been recognized as an important issue34 and examination of decision making for primary cesarean delivery highlights this. There are numerous sources of uncertainty that arise in a first labor, and how these are interpreted by the patient and provider directly impacts the risk– benefit calculus that underlies decision making for delivery. First and foremost, outcomes of mode of delivery decisions are never certain until delivery is achieved—so the probability, or indeterminacy, of benefit from a particular delivery plan is always present. Second, there is significant ambiguity or conflicting opinion about the impact of certain clinical decisions, ranging from the specific short- and long-term maternal and fetal outcomes of the eventual delivery mode to the impact of the obstetrical interventions, such as induction of labor, on the likelihood of vaginal delivery in different contexts. Finally, complexity, referring to the multiplicity of causal factors resulting in a particular outcome, is inherent in the simultaneous assessment of maternal and fetal well-being as well as likelihood of successful vaginal delivery as perceived by the patient and provider during labor. Setting the stage for optimal management and decision making regarding primary cesarean delivery requires determining whether any of these sources of uncertainty can be reduced through improvement in clinical evidence, and determining how patients and providers can best tolerate the uncertainty that remains inherent to a first labor.
Interventions to Reduce the Primary Cesarean Rate Given that the interaction between the patient and the provider remains central in decision making regarding primary cesarean deliveries, interventions to reduce the cesarean rate must target both patients and providers. All preferences are not informed preferences, and both patients and providers bring their biases to decision making. Educational tools may be helpful to allow both patients and providers define their priorities and cope with the uncertainty that is inherent in a first labor. Besides educational resources, decision support tools may help patients think through their preferences and engage in informed shared decision making when planned cesarean delivery and planned vaginal delivery are both reasonable options. In terms of interventions targeting providers, Abenhaim et al35 analyzed patients who were delivered by an on-call doctor rather than their primary obstetrician and found that those who were delivered by the on-call obstetrician were significantly more likely to have a cesarean delivery for fetal indications in the first stage of labor. The authors hypothesized that this could be due to a lack of rapport between patient and provider and the difficulty in communication that it may cause. Interventions to improve communication
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388 on labor and delivery may help to mitigate this type of effect. Evidence also indicates that having a second provider review decision making for cesarean delivery before the procedure may also help to reduce the intrapartum cesarean rate, perhaps by removing some of the individual bias and subjectivity from the decision.36 Beyond this real time interaction with colleagues, peer review at an individual or institutional level may also be helpful to raise awareness of these issues, and clinical guidelines may be useful to ensure that indicated cesarean deliveries meet a minimum criteria; however, limited implementation of these types of interventions has not been successful thus far, indicating that novel approaches are necessary.37
Future Research Directions In sum, despite evidence suggesting that patient and provider preferences play key roles in how decisions for primary cesarean delivery are made, data from large prospective studies among sociodemographically diverse pregnant women outside the context of CDMR are lacking. Ideally, future studies should assess the strength of patient preference for a particular delivery mode, including the dynamic nature of preferences through both the course of antenatal care and labor, and also should measure changes in provider assessment of likelihood of successful vaginal birth and recommendations for management based on these assessments. In addition, continued investigation regarding the clinical determinants of primary cesarean delivery is needed to provide the best evidence possible to patients and providers regarding the likely outcome of different management options for different populations of women. At the same time, more information is needed regarding how best to communicate the ambiguity that is inherent in translating these population risks into an individual outcome, as well as how to deal with the irreducible uncertainty that is encountered in every labor.
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