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Exploring factors influencing Chinese women's decision to have elective caesarean surgery
Exploring factors influencing Chinese women’s decision to have elective caesarean surgery LindaY|n King Lee, Eleanor Holroyd and ChunYuen Ng Objectives: to identify the factors that in£uence Hong Kong Chinese women’s decision to have an elective caesarean section.To explore Chinese women’s perceptions of their autonomous involvement in childbirth decision-making. Design: a qualitative exploratory design. Setting: a postnatal ward of a private hospital in Hong Kong. Participants: a purposive sample of six postnatal women who had undergone an elective caesarean section. Findings: four thematic categories were identi¢ed including: avoiding fetal and maternal risks, exercising autonomy to make an independent choice,Chinese belief systems, and rejoicing and regretting. Key conclusions and implications for practice: we propose the provision of a ‘named’ midwife and continuity of care. Improving the availability of information on caesarean sections, accommodating a Chinese belief system in the planning of midwifery services at the international level and establishing post caesarean section peer support groups are recommended. & 2001 Harcourt Publishers Ltd
LindaY|n King Lee RN, RM, BN (Hons), MNurs Lecturer (Nursing), The Open University of Hong Kong, 30 Good Shepherd Street, Ho ManT|n, Kowloon, Hong Kong, E-mail: [email protected] Eleanor Holroyd RN, RM, BN, M Mid, PhD (Medical Anthropology) Associate Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong ChunYuen Ng RN, RM, BN (Hons) Nursing O⁄cer, Maternity Unit, Hong Kong Baptist Hospital, 222 Waterloo Road, KowloonTong, Kowloon, Hong Kong (Correspondence to LYKL) Received: 6 July 2000 Revised: 20 December 2000; 27 March 2001 Accepted: 28 March 2001
INTRODUCTION Requesting an elective caesarean section for an uncomplicated pregnancy has been an increasing trend in the Asian region, particularly in Hong Kong and China. This trend has been fuelled by the diminishing birth rate in Hong Kong. From the statistical data, Hong Kong’s birth rate in 1998 dropped to 4.9/10 000 compared with 5.1/ 10 000 in 1989 (Hong Kong Department of Health 1999). Other factors such as the desire to ensure a perfect birth outcome, the cultural valuing of medicalisation as a sign of affluence, concern over neonatal morbidity and a belief system based on fortune attributable to correct birth and birth data have also contributed to this trend. In addition, Asian women are increasingly aware of their rights for choice and involvement in the childbirth decision, and choose to exercise these rights. Elective caesarean sections are perceived to be associated with safety in Asian societies in which childbirth has historically been linked to danger and disfigurement (Simkin 1996, Sultan 1997, Paterson-Brown & Amu Midwifery (2001) 17, 314 ^322 & 2001 Harcourt Publishers Ltd doi:10.1054/midw.2001.0274, available online at http://www.idealibrary.com on
1998, VandeVusse 1999). It has recently been suggested by Yeung (1999) that requests for elective caesarean section on auspicious dates or for social reasons are not uncommon among Chinese families. Such practice leads to a high rate of elective caesarean section in the private sector. Recently, a growing body of literature has pointed to the high elective caesarean section rate in Western countries (Simkin 1996, Schimmel et al. 1997, Jackson & Irvine 1998, Paterson-Brown & Amu 1998). Yet relatively little is known about the factors which go into making this decision. In particular, there is little empirical work on how this phenomenon can be contextualised in Chinese society.
Choice of a Caesarean section With the popularity of pre-pregnancy counselling, antenatal screening and prenatal diagnosis, the desire to promote a ‘designer baby’ has become increasingly apparent in Asian societies (Paterson-Brown & Amu 1998). In the past,
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vaginal delivery was the legitimate choice for giving birth (Flint 1987). Nowadays, fear of perineal damage, delayed onset of childbearing among professional women and spouses’ influence have been major factors associated with an increased demand for caesarean section (Al-Mufti et al. 1996). International studies have indicated that some women regard the experience of labour pain as unnecessary (Simkin 1996, Jackson & Irvine 1998), and were therefore reluctant to undergo it. In addition, women undergoing vaginal deliveries have reported concerns regarding damage to the pelvic floor, stress incontinence, and birth trauma such as fractured bones and cerebral palsy to the baby. Neonatal morbidity or mortality associated with previous vaginal delivery were also factors that informed the decision to request elective caesarean sections (Jackson & Irvine 1998). An opinion survey conducted with female obstetricians showed that 31% would choose an elective caesarean section for themselves despite the absence of clinical complications (Al-Mufti et al. 1996).
Maternal choice and the opportunity for decision-making Traditionally, maternity services have been dominated by the bio-medical model. Women have little or no chance to be involved in decision-making (Hickling 1999). VandeVusse (1999) has argued that women prefer an open flow of communication with health professionals. They are dissatisfied with lack of autonomy and being controlled by doctors. Educated, middle-class women have been shown to express a strong desire to control their childbirth (Fox 1999). The importance of sharing information and sharing control over childbirth decisions on the delivery mode has been repeatedly emphasised in a number of recent studies (Green et al. 1994, Paterson-Brown & Amu 1998, Hickling 1999, VandeVusse 1999). Such a situation parallels Hong Kong, where an increase in awareness of patients’ rights is advocated in response to the recent publication of the ‘Patient Charter’ (Ko 1999).
The in£uence of Chinese traditional folk beliefs on childbirth practice Pregnancy and childbirth are significant life events that are accorded with special rituals and customs in all cultures (Flint 1987). The doctrine of yin-yang-wu-hsing and the calendrical cycles inform Chinese cultural beliefs, and serve as a major theoretical framework of living (Ng 1998). It is well recognised that individual health behaviour is embedded in cultural patterns of exchange (Leninger 1991). Goodkind
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(1996) reported that lunar birth fluctuations have been documented among a variety of Asian societies with Confucian belief origins. Many Chinese societies throughout the world exhibit birth fluctuations during significant lunar zodiac years. ‘Baby booms’ in an auspicious year, such as that of the ‘Dragon’, has resulted from the Chinese cultural belief that babies born in such years will have health, dynastic nobility, and longevity. Such a baby-boom was exhibited in Hong Kong in 1988 (Year of the Dragon). According to the Hong Kong Department of Health (1999), the total number of registered live births was 75 412 in 1988, whereas the number was 69 958 in 1987 and 69 621 in 1989. An additional 5000 babies were born in 1988, when compared with the years of 1987 and 1989. Within auspicious years, such as the Chinese lunar Year of the Dragon, particular days are considered to be ‘lucky days’. It is common to find that more elective caesarean sections are scheduled on these ‘lucky days’ (Goodkind 1996). In recent years, lunar birth timing is manifested more clearly as recent family size has declined and the parents have more concerns for promoting the health of the fewer and more highly prized children.
METHODS An exploratory cross-sectional study using a qualitative approach was used, with the study objectives being: 1. to identify the factors that specifically influence Hong Kong Chinese nulliparous women when choosing an elective caesarean section; 2. to explore Chinese women’s perceptions of their autonomous involvement in childbirth decision making.
Sampling A purposive sample of six Chinese women was selected from the maternity unit of a 500-bed private hospital in Hong Kong. A private setting was chosen because women in the public hospitals are not allowed to request caesarean births without clinical indications. Due to the difference in hospital policy, women who purposely seek to undergo caesarean section for personal reasons and can afford to do so usually have their operations done in the private hospitals. The selection criteria for the study were Chinese nulliparous women with a single fetus who had requested a caesarean section, without maternal and/or fetal complications, and were able to speak Cantonese.
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Ethical considerations Ethical approval was obtained from the Open University of Hong Kong Research Ethics Committee. Permission from the Deputy Medical Superintendent of the study hospital was sought for access to undertake the study. In order to gain access to the sample, the names of all women who had delivered two days prior were made available from the hospital record. Women who fulfilled the sample selection criteria were invited to participate. The purpose and nature of the study was explained to each woman, and they were assured of confidentiality and anonymity. Written consent was then obtained from each participant. The interview process was piloted with one woman, and modifications in interviewing skills were made as a result of the feedback obtained.
of the other three women were high diploma, bachelor and masters degree respectively. The women’s total family incomes ranged between HK$240,000 to HK$1 200 000 per year. Five women had full-time work (secretary, beautician, clerk, university lecturer, and assistant manager) and one woman was a housewife. Five of the women had undergone an elective caesarean section on a self-selected date, and one woman, because of the sudden onset of labor, had received an emergency caesarean section before her original scheduled date. All the caesarean sections were performed under general anaesthesia. There was no significant obstetric birth or postnatal complication among these women. Neonatal morbidity was not detected in any of the babies.
Categories Data collection procedures Semi-structured interviews were conducted to obtain information regarding why women requested caesarean sections, and their perceptions. Such methods also enabled the researcher to gain a description of the phenomenon and to elicit detail. On average, the interviews lasted about 45 minutes. The interviews took place in hospital, two days after the women’s caesarean sections. Interviews were so arranged in order to allow women some time to adjust to the demands of motherhood, and prior to discharge. An interview guide was derived from the literature, and it served to enhance the reliability of the interview. In addressing threats to the validity of the study, all interviews were tape-recorded and field notes of observations were recorded. The interview tapes were transcribed verbatim and translated from Chinese into English and back translated to check for accuracy in the interpretation. Interpretations of the findings were given to the women as a means of cross-checking the data.
Data analysis The transcribed and translated data were coded and then analysed using content analysis, constant comparative techniques, and a code-mapping category. Categories and themes were generated.
FINDINGS Sample characteristics The six women ranged in age from 26 to 35 years, with a mean age of 29.5 years. All of the women were married. Three women had attained secondary education level. The education levels
After content analysis on the interview data, four major categories were identified. These categories were: avoiding fetal and maternal risks, exercising autonomy to make a choice, Chinese belief systems, rejoicing and regretting. The following quotations are reported as direct translation to convey the expression, hence may not always present as grammatically adequate.
Promoting a quick recovery of mother and baby While all the women felt that a vaginal birth was more desirable from the women’s perspective, there were some common elements that led these women to select caesarean section as a preferred mode of delivery. All these women thought that caesarean section could help to ensure the baby’s safety, to avoid personal risk, to avoid painful labour, and to avoid damage to the body and loss of figure. Ensuring the baby’s safety – Five of the six women mentioned that their main concern was to guarantee the baby’s safety. Mrs Y had experienced infertility for some years before she became pregnant. She treasured this baby very much and claimed that most probably it would be her only child. She stressed: It is so wonderful when I have a positive pregnancy test. I have been waiting for this moment for 5 years already. All my dreams have come true. Therefore, I must do everything that can ensure the safety of my daughter because I may not be pregnant again. I cannot afford any risk. Although my doctor claims that both my baby and me are in good condition, I select caesarean section for I think that it is the safest method for delivery and I am confident that the safety of my baby will be ensured.
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Three women emphasised that caesarean section was a better choice to give birth because they strongly believed that asphyxia was due to severe birth trauma and could be prevented by caesarean section. Mrs H declared: I understand that there are some risks of undergoing caesarean section because it is a kind of operation and the mother should be put under general anaesthesia. However, it is more dangerous if the mother can’t expel the baby out during labour. The baby will suffocate.
Avoiding personal risk – Mrs M’s doctor had told her that she could try for a vaginal birth because her pelvic size was normal and the baby’s head was corresponding to her pelvis. However, she insisted on choosing a caesarean section. She said: I can try vaginal birth myself. However, it carries certain risks. My major concern is to consider the safety of my baby. Nowadays, caesarean birth is so common. Most of my friends select caesarean section even though everything is normal. I think that it is not necessary for me to take any risk.
Avoiding painful labour – Some of the women regarded labour pain as the most severe pain in the human experience. It was thought that experiencing such pain was unnecessary. Selecting a caesarean section to deliver the baby was a way to avoid labour pain. Initially, Mrs Y was scheduled to have an elective caesarean section. However, the onset of labour necessitated her having an emergency caesarean section. Therefore, she had experienced both the labour pain and caesarean section. She claimed: I was determined to have a caesarean section during my early pregnancy just because I do know that I cannot endure the labour pain. I think that caesarean sections are better than vaginal deliveries. Everybody knows that I am timid and fear pain and blood. It is why I cannot do the job as a nurse. At last, I proved that I have made the right choice. I felt pain suddenly in the midnight of last Saturday. The pain was so terrible that I hadn’t experienced before. I could not tolerate any more and therefore I strongly requested the operation to be done immediately after I was admitted into the hospital. Mrs H used a special term ‘Grade-Ten Pain’ to describe the labour pain. She argued: I have suffered from low back pain since I am pregnant. I still can’t tolerate it. Someone told me that they experienced a prolonged and
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painful labour. I think I cannot stand that ‘Grade-ten Pain’. I prefer to fall into sleep (means under general anaesthesia), and to have a cut (means receiving caesarean operation) on my abdomen. Mrs C said: My mom and some of my friends suggest me to try labour. They said that nobody would know whether they can have vaginal delivery or not if they do not try. Of course, I can’t know the outcome. However, if the labour is prolonged and ultimately I fail to have natural birth, I have to undergo caesarean section. Then I have to suffer two times. I think it is not necessary to suffer twice, thus I select caesarean section.
Avoiding damage to the body and loss of figure – Some women argued that a vaginal delivery would lead to some adverse effects on the pelvic floor muscle. Mrs S disclosed her concern as follows: Different people will set different priorities. However, my first priority is to prevent the problem of loosening the pelvic floor muscle after vaginal delivery. I think it will affect my future sex relationship. Well, I just get married for ten months only. Sex relationship with my husband is my top concern. My aunt who has a vaginal birth before tells me that her vagina becomes loose during sexual intercourse. She says that once the pelvic floor muscle has been stretched and the perineum has been cut for baby’s delivery, it would not recover as tight as before. Mrs C declared that she feared any vaginal examination and explained: I feel embarrassed when the doctor performs a vaginal examination for me. Therefore, I would select a caesarean section in order to avoid such examinations. Moreover, many people tell me that a women’s pelvis will become larger after vaginal delivery. The perineum muscle will be loosened and many bad effects such as stress incontinence and an ugly figure will result. I don’t want to be like that.
Exercising autonomy in childbirth decisionmaking Some of the women realised that their mothers did not have the opportunity to make independent choices for childbirth. They declared that it was a new era and they had the right to make decisions regarding the childbirth issue. They could make the choice for mode of delivery, and even the baby’s date of the birth. Mrs S had her
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own view about autonomous decision-making. She said: I have the right to make choices for myself. I have decided to have a caesarean section at the very beginning, nobody can change my decision. Although my husband disagrees with me, he still expresses that I have the right to make the final decision. Mrs C described herself as a dependent person who often followed others’ opinions. However, she had strong views concerning the matter of childbirth, she said: It is a great event in my life. I think that I should make the choice myself this time. My husband also agrees with me.
Chinese belief systems Selecting a ‘lucky day’ as the date of birth – Five of the women purposely selected the Chinese so-called ‘lucky day’ for their operations. Mrs C said: My husband is a businessman. He usually selects a lucky day for a great event such as commencement of the transaction. My husband says that if I choose caesarean section, we can select a ‘lucky day’ as the date of the baby’s birth. We can also invite a feng-shui master to give the baby a good name. We are sure that this baby will be healthy and can bring fortune to us. Mrs M further reported that a popular perception of Chinese childbirth beliefs had influenced her decision-making: While I made the decision to do the caesarean operation, I decided to ask someone to choose a ‘lucky day’ for my baby and give my baby a good name. It is a common practice nowadays in Hong Kong. Many of my friends and even the film stars are choosing caesarean section to be done in a particular day hoping for good fortune, best wishes, and healthy of course. Therefore, my parents told an old master about my husband’s and my ‘eight characters’ (date and time of birth). With reference to our ‘eight characters’, the old master selected a ‘lucky day’ for my baby’s birth date and gave her a good name. We hope that she can grow up healthy and will not bring harm to us. Mrs S said that although she did not believe in the Chinese traditional beliefs, her mother-in-law did. She said: Initially, I purposely arranged the operation to be done when I went into labour because it
meant that the baby was mature enough to be born. However, my mother-in-law strongly suggested I to choose a ‘lucky day’ for the baby’s birthday. All of the family members were very delighted because they thought that the little boy could bring good fortune to us. Indeed it was a great event to them as the baby boy was their first grandson! But I still don’t believe it.
Rejoicing and regretting Satisfaction with the choice of caesarean sections – All these women expressed their joy at having been able to make autonomous decisions. Mrs C reported her feeling about pleasing her husband through having selected a lucky date for the caesarean section: I think the operation is worth doing. Despite the wound pain, I feel satisfied with my decision since I can please my husband. My happiness is built on him. He is so delighted because our baby is born on a ‘lucky day’ that may bring good fortune to our family. Indeed the baby boy is healthy too. We now have a stronger feeling as a real family. Mrs L was delighted about the good condition of the baby, which she thought was attributable to having had a caesarean section: I really don’t mind about the cut on my abdomen when I see that my daughter is so lovely and healthy. If you ask me what is my choice of childbirth for next pregnancy, the answer must be caesarean section. It is because it can assure the safety of my baby. Despite the unexpected severity of wound pain, Mrs H had no regret at having had a caesarean section since she thought that the situation might be even worse with a vaginal delivery. She said: I wonder why my sister-in-law did not feel any pain after a caesarean operation. I think it may be due to individual difference. The wound is quite unendurable. Today is much better. . .. Well! I have no regret in undergoing caesarean section because I think that the labour pain is much more severe than this wound pain. Furthermore, the pain has gone when I hold my baby in my arm and feed him.
A sense of loss – Apart from the positive feeling associated with a caesarean birth, some women reported that they had missed something yet were unable to verbalise what they had missed. This sense of loss incorporated not being the first one to see the baby after birth. Mrs Y confessed
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a sense of regret because she was not the first one to see the baby after he was born. She said: Some people said that it will be very exciting to see your baby being born. I don’t know whether it’s true or not because I didn’t have this experience. Actually, I am very happy every time when I see my baby. However, I might be very excited if I were the first one to see the baby being born. It seems to me that I have missed something but I cannot tell what it is. Mrs S also shared similar feeling and she expressed: The feeling was not so touching. My friends who had natural deliveries said that it was a strong feeling of warmth and touching when they had the first sight of their babies. It was a sense of bonding. But my feeling was not as strong as they described.
DISCUSSION In the past Chinese women had little control over their birth experiences. Having choice in healthcare is relatively unheard of in Chinese traditional medicines (Chalmers et al. 1998). The findings of this study demonstrated that a certain cohort of women in Hong Kong had exercised independent decision-making on their own childbirth issue. These findings must be interpreted in light of the fact that these women were of the middle socio-economic class, had a steady family income and a minimum of secondary education. The women further admitted that they were independent and decisive. With no past childbirth experience, the women had to face various uncertainties concerning how, when and where the delivery would take place. In obstetrics, an elective caesarean section in the absence of clinical indications has traditionally been considered inappropriate. Moreover, the ‘jury is still out’ on the benefits and disadvantages of caesarean section and vaginal delivery (Paterson-Brown & Amu 1998). Given that all the women in this study were well educated, they understood that vaginal birth was the most natural mode of delivery and that women’s postnatal recovery would be smoother and quicker. However, delayed childbirth and cultural beliefs associated with an auspicious birth date were putting more pressure on Chinese women to ensure a perfect birth outcome and posed consideration in the choice of caesarean section. In addition, in a rapidly modernising society such as Hong Kong, a high level of medical intervention is equated with wealth, promoting this group of middle socio-economic class Chinese women to choose a caesarean
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section for the baby’s birth. Women in Hong Kong generally believe that caesarean section is very safe. Nevertheless, Hong Kong has no formal statistics to measure the mortality and morbidity of caesarean section. In the private hospital where participants were selected for this study, records show that the mortality rate for caesarean section for the past 30 years is zero and the morbidity rate is minimal.
Economic in£uences on Chinese women’s decision-making International research on the family has repeatedly addressed the notion that parents trade quantity and quality of children over the course of industrial development (Goode 1963, Caldwell 1982, Giddens 1992, Hirschman 1994, Thornton & Lin 1994). During the period of rapid industrial development that has characterised Hong Kong for the past few decades, increasing numbers of wives and mothers are employed. Therefore, the time that can be set aside for childcare has diminished greatly. During the past three decades, the Hong Kong Family Association has been promoting the slogan ‘Two is enough’, while at the same time there is an increasing community concern for quality childhood. As a result, women tend to have fewer children and put a high expectation on their children. The women in this study stated that they would only have one or two children. Thus the need to produce a ‘perfect baby’ was obvious. Women did not want to expose their unborn babies to the risk of uncontrollable consequences during labour and vaginal birth. Therefore, they sought what they saw as a safer mode of delivery. A Canadian study, however, refutes these beliefs and finds that there is no relationship between high caesarean section rates and improved perinatal outcome (Menticoglu 1997).
Social in£uences on Chinese women’s decision-making Freund and McGuire (1995) contend that how a woman perceives and experiences the process of giving birth is shaped by the social context of childbirth. Most of the women in this study had mentioned that having caesarean sections for childbirth was a common practice among the younger generation of women in Hong Kong, as many of their friends and even film stars did so. Instead of complying with the biomedical approach that is espoused by healthcare professionals, these women chose social prestige, safety and auspicious dates as factors informing their choice for caesarean deliveries. Fear of labour pain was another major element that led these women to select caesarean
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sections. The women viewed general anaesthesia as a welcome relief from labour pain. In addition, they also believed that there was no reason for them to experience such severe pain as other delivery alternatives were financially accessible to them. Reluctance to experience labour pain in higher socio-economic women has been documented in previous studies as a common reason for requesting caesarean section (Simkin 1996, Jackson & Irvine 1998).
Cultural in£uences on Chinese women’s decision to have a caesarean section Li (1995) contends that most Chinese people attempt to calculate how to best match his or her ‘eight characters’ (date and time of birth) with specific points occuring in the flow of cosmic time. The appropriate matching of the individual’s eight characters with the cosmic time will bring good fortune to the person, but a bad matching will bring calamities. Therefore most of the women in this study insisted on selecting a ‘lucky day’ and time for the baby’s birth in order to pursue good fortune and avoid calamity to the baby and family. Even though the women had the confidence to grasp or manipulate events, such as selecting the date and mode of delivery, they still had a firm belief in the influence of fate in predicting birth outcomes. Such a belief in the magico-religious powers has been shown to provide comfort in times of uncertainty, such as childbirth (Scarborough 1998). These women were pleased to have the autonomy to pursue a caesarean section and in general were satisfied with their birth outcome. Whether the operation would lead to subsequent long-term complications, and whether a baby born on a lucky day would bring good fortune to the family, posed unknown factors. Disregarding these benefits, all these women had to face the risks of general anaesthesia and surgery. In recent years, literature has reported similar incidences with many Chinese couples desiring auspicious delivery dates, despite the dangers of induced labour and caesarean section (Yeung 1999). Five women followed suggestions from husband, mother-in-law and other family members, and chose a ‘lucky day’ as the date of operation. These actions could be explained by the Chinese view of respecting authority. Chinese Confucian philosophy demands that the individual act according to his or her social status (Cheng 1990). Within a Chinese family, the father-inlaw, mother-in-law and husband have high status and authority, while the wife and children are expected to respect and obey them. The authority figures in the family, such as the father and mother-in-law, have considerable influence on decision-making, particularly with regard to the
life processes of childbirth and death. Individuals learn to follow the prevailing opinion rather than disagree (Gudykunst et al. 1985, Anderson 1986). A Confucian belief system emphasises that it is important for the Chinese to remain in harmony with nature, people and social institutions in order to be well and functioning. Therefore, a person is expected to accommodate rather than confront. Personal desires must be controlled to avoid conflict. Behaviours such as to show filial piety, loyalty, sincerity and benevolence to others are therefore highly valued in Chinese people (Giger & Davidhizar 1999). Thus it is not surprising that the women chose caesarean section to be performed on a lucky day in order to please their husbands and mothers-inlaw.
Towards an explanation for regret The sense of loss experienced by two women demonstrated that the operation might lead to a certain degree of negative emotional sequelae. Early international studies have indicated that women undergoing a caesarean delivery were demonstrating low satisfaction with the birth experience (Norr et al. 1977, Bradley et al. 1983, Padawer et al. 1988). Other studies have shown that women view emergency caesarean sections as a serious deviation from normal birth, and this leads to negative consequences including feelings of guilt, failure, disappointment and anger (Marut & Mercer 1979, Cranley et al. 1983). However, the current study did not support such phenomenon as the caesarean sections were planned well in advance (Fawcett & Weiss 1993). In addition, the Hong Kong healthcare culture of a high level of technological intervention has contributed to a shift towards prizing expensive intervention, further contributing to this phenomenon. As existing literature shows that women who have undergone caesarean section may not experience negative emotional consequences, inconsistent findings in this study and the literature require further investigation.
Implications for midwives Chinese women would benefit from the provision of a ‘named’ midwife who provides continuity of care to the woman throughout her pregnancy and confinement. Such a midwife could provide the woman with comprehensive information on the pros and cons of caesarean section. It is essential to keep women fully informed and educated about the different modes of delivery and potential problems. With such a close relationship and knowledge base, midwives can empower woman to make an individual choice which is most suitable to her.
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Owing to the fact that some women express negative feelings after a caesarean section, strategies such as establishing peer support groups, need to be implemented to enhance women’s feelings about themselves and to reduce the feeling of disappointment. Women should be provided with adequate information about the possibility of negative feelings after a caesarean birth well before the operation. Early detection of emotional distress needs encouragement, and counselling can be provided to the women when necessary. Given that the Chinese belief system of favouring auspicious years, days and times was clearly influential in these women’s decisionmaking, midwifery education needs to accommodate a knowledge of these factors to provide cultural congruence. In addition, the influence of family members in Chinese women’s decisionmaking needs to be taken into account. The limitations of this study include its small interview sample of middle class women only. Thus generalisation cannot be made to all Chinese women. The experience of women from different social classes and cultural backgrounds can be explored so that more comprehensive international comparisons can be made. In addition, further investigations are needed in the concurrent process of decision-making regarding elective caesarian sections for women from Mainland China. A large-scale study needs to be conducted in Hong Kong’s public and private hospitals to examine the determining eligibility for caesarean section. Finally, the emotional aspects of undergoing a caesarean section, such as a sense of loss or struggling during the decision-making process, need further exploration. REFERENCES Al-Mufti R, McCarthy A, Fisk NM 1996 Obstetricians’ personal choice and mode of delivery. Lancet 347: 544 Anderson JM 1986 Ethnicity and illness experience: ideological structures and the health care delivery system. Social Sciences Medicine 22(11): 1277–1283 Bradley CF, Ross SE, Warnyca J 1983 A prospective study of mothers’ attitudes and feelings following caesarean and vaginal births. Birth 10: 79–83 Caldwell J C 1982 Theory of fertility decline. Academic Press, New York Chalmers B, Samarskaya M, Tkatchenko E et al. 1998 Women’s experiences of birth in St. Petersburg, Russian Federation. Journal of Reproductive & Infant Psychology 16(4): 243–259 Cheng SKK 1990 Understanding the culture and behaviour of East Asians: a Confucian perspective. Australian and New Zealand Journal of Psychiatry 24: 510–515 Cranley MS, Hedahl KJ, Pegg SH 1983 Women’s perceptions of vaginal and caesarean births. Nursing Research 32(1): 10–15 Fawcett J, Weiss ME 1993 Cross-cultural adaptation to caesarean birth. Western Journal of Nursing Research 15(3): 282–297 Flint C 1987 Retracing out cultural roots. Nursing Times 83(11): 22–36
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Fox B 1999 Revisiting the critique of medical childbirth. Gender &Society 13(3): 326–347 Freund PES, McGuire MB 1995 Health, illness, and the social body — a critical sociology (2nd ed). Prentice Hall, New Jersey Giddens A 1992 The transformation of intimacy: sexuality, love and eroticism in modern societies. Standard University Press, Standard Giger JN, Davidhizar RE 1999 Transcultural nursing; assessment and intervention. Mosby, St. Louis Goode W 1963 World revolution and family patterns. The Free Press, New York Goodkind D 1996 Chinese lunar birth timing in Singapore: new concerns for child quality amidst multicultural modernity. Journal of Marriage and the Family 58(3): 784–795 Green J, Kitzinger J, Coupland V 1994 Midwives’ responsibilities, medical staffing structures and women’s choice in childbirth. In: Robinson S, Thomson AM (eds) Midwives, research and childbirth. Chapman & Hall, St. Louis Gudykunst WB, Stewart LP, Toomey ST 1985 Communication, culture, and organizational process. Sage, Newbury Park Hickling R 1999 Alternatives in maternity care. Obstetric & Gynecology 1(2): 131–134 Hirschman C 1994 Why fertility changes? Annual Review of Sociology 20: 203–233 Hong Kong Department of Health 1999 Annual Departmental Report for the Financial Year 1997 – 1998. Hong Kong Department of Health, Hong Kong Jackson NV, Irvine LM 1998 The influence of maternal request on the elective caesarean section rate. Journal of Obstetrics and Gynecology 18(2): 115–120 Ko KL 1999 Reasons for choosing caesarean section (in Chinese). Shing Tao Jih Pao August 2nd: 10 Leninger M 1991 Cultural care diversity and university: a theory of nursing. National League for Nursing Press, New York Li YY 1995 Notions of time, space and harmony in Chinese popular culture. In: Huang CC, Zurchir E (eds). Time and space in Chinese culture. EJ Brill, Leiden Marut JS, Mercer RT 1979 Comparison of primiparas’ perceptions of vaginal and caesarean deliveries. Nursing Research 28(5): 260–266 Menticoglu SM 1997 Differences among obstetricians in caesarean section rates. Australian New Zealand Journal of Obstetrics and Gynaecology 37(4): 387 Ng WM 1998 The yin-yang-wu-hsing doctrine in the textual tradition of the Tokugawa Japanese agriculture. Asian Philosophy 8(2): 119–129 Norr KL, Block CR, Charles A et al. 1977 Explaining pain and enjoyment in childbirth. Journal of Health and Social Behaviour 18: 260–275 Padawer JA, Fagan C, Janoff-Bulman R et al. 1988 Women’s psychological adjustment following emergency caesarean versus vaginal delivery. Psychology of Women Quarterly 12: 25–34 Paterson-Brown S, Amu O 1998 Should doctors perform an elective caesarean section on request? British Medical Journal 317(7156): 462–469 Scarborough J 1998 Comparing Chinese and Western cultural roots: why ‘East is East and. . .’. Business Horizon 41(6): 15–25 Schimmel LM, Schimmel LD, Dejoseph J 1997 Towards lower caesarean section birth rates and effective care: five years’ outcomes of joint private obstetric practice. Birth 24(3): 181–187 Simkin P 1996 The experience of maternity in a woman’s life. Journal of Obstetric, Gynecologic and Neonatal Nursing 25(3): 247–252
322 Midwifery Sultan AH 1997 Anal incontinence after childbirth. Current Opinion in Obstetrics and Gynaecology 9: 320–324 Thornton A, Lin H S 1994 Social change and the family in Taiwan. University of Chicago Press, Chicago
VandeVusse L 1999 Decision making in analyses of women’s birth stories. Birth 26: 43–58 Yeung L 1999 The lucky baby boom. South China Morning Post 26.12.1999: 4
LindaY|n King Lee RN, RM, BN (Hons), MNurs Lecturer (Nursing), The Open University of Hong Kong, 30 Good Shepherd Street, Ho ManT|n, Kowloon, Hong Kong, E-mail: [email protected] Eleanor Holroyd RN, RM, BN, M Mid, PhD (Medical Anthropology) Associate Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong ChunYuen Ng RN, RM, BN (Hons) Nursing O⁄cer, Maternity Unit, Hong Kong Baptist Hospital, 222 Waterloo Road, KowloonTong, Kowloon, Hong Kong (Correspondence to LYKL) Received: 6 July 2000 Revised: 20 December 2000; 27 March 2001 Accepted: 28 March 2001
INTRODUCTION Requesting an elective caesarean section for an uncomplicated pregnancy has been an increasing trend in the Asian region, particularly in Hong Kong and China. This trend has been fuelled by the diminishing birth rate in Hong Kong. From the statistical data, Hong Kong’s birth rate in 1998 dropped to 4.9/10 000 compared with 5.1/ 10 000 in 1989 (Hong Kong Department of Health 1999). Other factors such as the desire to ensure a perfect birth outcome, the cultural valuing of medicalisation as a sign of affluence, concern over neonatal morbidity and a belief system based on fortune attributable to correct birth and birth data have also contributed to this trend. In addition, Asian women are increasingly aware of their rights for choice and involvement in the childbirth decision, and choose to exercise these rights. Elective caesarean sections are perceived to be associated with safety in Asian societies in which childbirth has historically been linked to danger and disfigurement (Simkin 1996, Sultan 1997, Paterson-Brown & Amu Midwifery (2001) 17, 314 ^322 & 2001 Harcourt Publishers Ltd doi:10.1054/midw.2001.0274, available online at http://www.idealibrary.com on
1998, VandeVusse 1999). It has recently been suggested by Yeung (1999) that requests for elective caesarean section on auspicious dates or for social reasons are not uncommon among Chinese families. Such practice leads to a high rate of elective caesarean section in the private sector. Recently, a growing body of literature has pointed to the high elective caesarean section rate in Western countries (Simkin 1996, Schimmel et al. 1997, Jackson & Irvine 1998, Paterson-Brown & Amu 1998). Yet relatively little is known about the factors which go into making this decision. In particular, there is little empirical work on how this phenomenon can be contextualised in Chinese society.
Choice of a Caesarean section With the popularity of pre-pregnancy counselling, antenatal screening and prenatal diagnosis, the desire to promote a ‘designer baby’ has become increasingly apparent in Asian societies (Paterson-Brown & Amu 1998). In the past,
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vaginal delivery was the legitimate choice for giving birth (Flint 1987). Nowadays, fear of perineal damage, delayed onset of childbearing among professional women and spouses’ influence have been major factors associated with an increased demand for caesarean section (Al-Mufti et al. 1996). International studies have indicated that some women regard the experience of labour pain as unnecessary (Simkin 1996, Jackson & Irvine 1998), and were therefore reluctant to undergo it. In addition, women undergoing vaginal deliveries have reported concerns regarding damage to the pelvic floor, stress incontinence, and birth trauma such as fractured bones and cerebral palsy to the baby. Neonatal morbidity or mortality associated with previous vaginal delivery were also factors that informed the decision to request elective caesarean sections (Jackson & Irvine 1998). An opinion survey conducted with female obstetricians showed that 31% would choose an elective caesarean section for themselves despite the absence of clinical complications (Al-Mufti et al. 1996).
Maternal choice and the opportunity for decision-making Traditionally, maternity services have been dominated by the bio-medical model. Women have little or no chance to be involved in decision-making (Hickling 1999). VandeVusse (1999) has argued that women prefer an open flow of communication with health professionals. They are dissatisfied with lack of autonomy and being controlled by doctors. Educated, middle-class women have been shown to express a strong desire to control their childbirth (Fox 1999). The importance of sharing information and sharing control over childbirth decisions on the delivery mode has been repeatedly emphasised in a number of recent studies (Green et al. 1994, Paterson-Brown & Amu 1998, Hickling 1999, VandeVusse 1999). Such a situation parallels Hong Kong, where an increase in awareness of patients’ rights is advocated in response to the recent publication of the ‘Patient Charter’ (Ko 1999).
The in£uence of Chinese traditional folk beliefs on childbirth practice Pregnancy and childbirth are significant life events that are accorded with special rituals and customs in all cultures (Flint 1987). The doctrine of yin-yang-wu-hsing and the calendrical cycles inform Chinese cultural beliefs, and serve as a major theoretical framework of living (Ng 1998). It is well recognised that individual health behaviour is embedded in cultural patterns of exchange (Leninger 1991). Goodkind
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(1996) reported that lunar birth fluctuations have been documented among a variety of Asian societies with Confucian belief origins. Many Chinese societies throughout the world exhibit birth fluctuations during significant lunar zodiac years. ‘Baby booms’ in an auspicious year, such as that of the ‘Dragon’, has resulted from the Chinese cultural belief that babies born in such years will have health, dynastic nobility, and longevity. Such a baby-boom was exhibited in Hong Kong in 1988 (Year of the Dragon). According to the Hong Kong Department of Health (1999), the total number of registered live births was 75 412 in 1988, whereas the number was 69 958 in 1987 and 69 621 in 1989. An additional 5000 babies were born in 1988, when compared with the years of 1987 and 1989. Within auspicious years, such as the Chinese lunar Year of the Dragon, particular days are considered to be ‘lucky days’. It is common to find that more elective caesarean sections are scheduled on these ‘lucky days’ (Goodkind 1996). In recent years, lunar birth timing is manifested more clearly as recent family size has declined and the parents have more concerns for promoting the health of the fewer and more highly prized children.
METHODS An exploratory cross-sectional study using a qualitative approach was used, with the study objectives being: 1. to identify the factors that specifically influence Hong Kong Chinese nulliparous women when choosing an elective caesarean section; 2. to explore Chinese women’s perceptions of their autonomous involvement in childbirth decision making.
Sampling A purposive sample of six Chinese women was selected from the maternity unit of a 500-bed private hospital in Hong Kong. A private setting was chosen because women in the public hospitals are not allowed to request caesarean births without clinical indications. Due to the difference in hospital policy, women who purposely seek to undergo caesarean section for personal reasons and can afford to do so usually have their operations done in the private hospitals. The selection criteria for the study were Chinese nulliparous women with a single fetus who had requested a caesarean section, without maternal and/or fetal complications, and were able to speak Cantonese.
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Ethical considerations Ethical approval was obtained from the Open University of Hong Kong Research Ethics Committee. Permission from the Deputy Medical Superintendent of the study hospital was sought for access to undertake the study. In order to gain access to the sample, the names of all women who had delivered two days prior were made available from the hospital record. Women who fulfilled the sample selection criteria were invited to participate. The purpose and nature of the study was explained to each woman, and they were assured of confidentiality and anonymity. Written consent was then obtained from each participant. The interview process was piloted with one woman, and modifications in interviewing skills were made as a result of the feedback obtained.
of the other three women were high diploma, bachelor and masters degree respectively. The women’s total family incomes ranged between HK$240,000 to HK$1 200 000 per year. Five women had full-time work (secretary, beautician, clerk, university lecturer, and assistant manager) and one woman was a housewife. Five of the women had undergone an elective caesarean section on a self-selected date, and one woman, because of the sudden onset of labor, had received an emergency caesarean section before her original scheduled date. All the caesarean sections were performed under general anaesthesia. There was no significant obstetric birth or postnatal complication among these women. Neonatal morbidity was not detected in any of the babies.
Categories Data collection procedures Semi-structured interviews were conducted to obtain information regarding why women requested caesarean sections, and their perceptions. Such methods also enabled the researcher to gain a description of the phenomenon and to elicit detail. On average, the interviews lasted about 45 minutes. The interviews took place in hospital, two days after the women’s caesarean sections. Interviews were so arranged in order to allow women some time to adjust to the demands of motherhood, and prior to discharge. An interview guide was derived from the literature, and it served to enhance the reliability of the interview. In addressing threats to the validity of the study, all interviews were tape-recorded and field notes of observations were recorded. The interview tapes were transcribed verbatim and translated from Chinese into English and back translated to check for accuracy in the interpretation. Interpretations of the findings were given to the women as a means of cross-checking the data.
Data analysis The transcribed and translated data were coded and then analysed using content analysis, constant comparative techniques, and a code-mapping category. Categories and themes were generated.
FINDINGS Sample characteristics The six women ranged in age from 26 to 35 years, with a mean age of 29.5 years. All of the women were married. Three women had attained secondary education level. The education levels
After content analysis on the interview data, four major categories were identified. These categories were: avoiding fetal and maternal risks, exercising autonomy to make a choice, Chinese belief systems, rejoicing and regretting. The following quotations are reported as direct translation to convey the expression, hence may not always present as grammatically adequate.
Promoting a quick recovery of mother and baby While all the women felt that a vaginal birth was more desirable from the women’s perspective, there were some common elements that led these women to select caesarean section as a preferred mode of delivery. All these women thought that caesarean section could help to ensure the baby’s safety, to avoid personal risk, to avoid painful labour, and to avoid damage to the body and loss of figure. Ensuring the baby’s safety – Five of the six women mentioned that their main concern was to guarantee the baby’s safety. Mrs Y had experienced infertility for some years before she became pregnant. She treasured this baby very much and claimed that most probably it would be her only child. She stressed: It is so wonderful when I have a positive pregnancy test. I have been waiting for this moment for 5 years already. All my dreams have come true. Therefore, I must do everything that can ensure the safety of my daughter because I may not be pregnant again. I cannot afford any risk. Although my doctor claims that both my baby and me are in good condition, I select caesarean section for I think that it is the safest method for delivery and I am confident that the safety of my baby will be ensured.
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Three women emphasised that caesarean section was a better choice to give birth because they strongly believed that asphyxia was due to severe birth trauma and could be prevented by caesarean section. Mrs H declared: I understand that there are some risks of undergoing caesarean section because it is a kind of operation and the mother should be put under general anaesthesia. However, it is more dangerous if the mother can’t expel the baby out during labour. The baby will suffocate.
Avoiding personal risk – Mrs M’s doctor had told her that she could try for a vaginal birth because her pelvic size was normal and the baby’s head was corresponding to her pelvis. However, she insisted on choosing a caesarean section. She said: I can try vaginal birth myself. However, it carries certain risks. My major concern is to consider the safety of my baby. Nowadays, caesarean birth is so common. Most of my friends select caesarean section even though everything is normal. I think that it is not necessary for me to take any risk.
Avoiding painful labour – Some of the women regarded labour pain as the most severe pain in the human experience. It was thought that experiencing such pain was unnecessary. Selecting a caesarean section to deliver the baby was a way to avoid labour pain. Initially, Mrs Y was scheduled to have an elective caesarean section. However, the onset of labour necessitated her having an emergency caesarean section. Therefore, she had experienced both the labour pain and caesarean section. She claimed: I was determined to have a caesarean section during my early pregnancy just because I do know that I cannot endure the labour pain. I think that caesarean sections are better than vaginal deliveries. Everybody knows that I am timid and fear pain and blood. It is why I cannot do the job as a nurse. At last, I proved that I have made the right choice. I felt pain suddenly in the midnight of last Saturday. The pain was so terrible that I hadn’t experienced before. I could not tolerate any more and therefore I strongly requested the operation to be done immediately after I was admitted into the hospital. Mrs H used a special term ‘Grade-Ten Pain’ to describe the labour pain. She argued: I have suffered from low back pain since I am pregnant. I still can’t tolerate it. Someone told me that they experienced a prolonged and
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painful labour. I think I cannot stand that ‘Grade-ten Pain’. I prefer to fall into sleep (means under general anaesthesia), and to have a cut (means receiving caesarean operation) on my abdomen. Mrs C said: My mom and some of my friends suggest me to try labour. They said that nobody would know whether they can have vaginal delivery or not if they do not try. Of course, I can’t know the outcome. However, if the labour is prolonged and ultimately I fail to have natural birth, I have to undergo caesarean section. Then I have to suffer two times. I think it is not necessary to suffer twice, thus I select caesarean section.
Avoiding damage to the body and loss of figure – Some women argued that a vaginal delivery would lead to some adverse effects on the pelvic floor muscle. Mrs S disclosed her concern as follows: Different people will set different priorities. However, my first priority is to prevent the problem of loosening the pelvic floor muscle after vaginal delivery. I think it will affect my future sex relationship. Well, I just get married for ten months only. Sex relationship with my husband is my top concern. My aunt who has a vaginal birth before tells me that her vagina becomes loose during sexual intercourse. She says that once the pelvic floor muscle has been stretched and the perineum has been cut for baby’s delivery, it would not recover as tight as before. Mrs C declared that she feared any vaginal examination and explained: I feel embarrassed when the doctor performs a vaginal examination for me. Therefore, I would select a caesarean section in order to avoid such examinations. Moreover, many people tell me that a women’s pelvis will become larger after vaginal delivery. The perineum muscle will be loosened and many bad effects such as stress incontinence and an ugly figure will result. I don’t want to be like that.
Exercising autonomy in childbirth decisionmaking Some of the women realised that their mothers did not have the opportunity to make independent choices for childbirth. They declared that it was a new era and they had the right to make decisions regarding the childbirth issue. They could make the choice for mode of delivery, and even the baby’s date of the birth. Mrs S had her
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own view about autonomous decision-making. She said: I have the right to make choices for myself. I have decided to have a caesarean section at the very beginning, nobody can change my decision. Although my husband disagrees with me, he still expresses that I have the right to make the final decision. Mrs C described herself as a dependent person who often followed others’ opinions. However, she had strong views concerning the matter of childbirth, she said: It is a great event in my life. I think that I should make the choice myself this time. My husband also agrees with me.
Chinese belief systems Selecting a ‘lucky day’ as the date of birth – Five of the women purposely selected the Chinese so-called ‘lucky day’ for their operations. Mrs C said: My husband is a businessman. He usually selects a lucky day for a great event such as commencement of the transaction. My husband says that if I choose caesarean section, we can select a ‘lucky day’ as the date of the baby’s birth. We can also invite a feng-shui master to give the baby a good name. We are sure that this baby will be healthy and can bring fortune to us. Mrs M further reported that a popular perception of Chinese childbirth beliefs had influenced her decision-making: While I made the decision to do the caesarean operation, I decided to ask someone to choose a ‘lucky day’ for my baby and give my baby a good name. It is a common practice nowadays in Hong Kong. Many of my friends and even the film stars are choosing caesarean section to be done in a particular day hoping for good fortune, best wishes, and healthy of course. Therefore, my parents told an old master about my husband’s and my ‘eight characters’ (date and time of birth). With reference to our ‘eight characters’, the old master selected a ‘lucky day’ for my baby’s birth date and gave her a good name. We hope that she can grow up healthy and will not bring harm to us. Mrs S said that although she did not believe in the Chinese traditional beliefs, her mother-in-law did. She said: Initially, I purposely arranged the operation to be done when I went into labour because it
meant that the baby was mature enough to be born. However, my mother-in-law strongly suggested I to choose a ‘lucky day’ for the baby’s birthday. All of the family members were very delighted because they thought that the little boy could bring good fortune to us. Indeed it was a great event to them as the baby boy was their first grandson! But I still don’t believe it.
Rejoicing and regretting Satisfaction with the choice of caesarean sections – All these women expressed their joy at having been able to make autonomous decisions. Mrs C reported her feeling about pleasing her husband through having selected a lucky date for the caesarean section: I think the operation is worth doing. Despite the wound pain, I feel satisfied with my decision since I can please my husband. My happiness is built on him. He is so delighted because our baby is born on a ‘lucky day’ that may bring good fortune to our family. Indeed the baby boy is healthy too. We now have a stronger feeling as a real family. Mrs L was delighted about the good condition of the baby, which she thought was attributable to having had a caesarean section: I really don’t mind about the cut on my abdomen when I see that my daughter is so lovely and healthy. If you ask me what is my choice of childbirth for next pregnancy, the answer must be caesarean section. It is because it can assure the safety of my baby. Despite the unexpected severity of wound pain, Mrs H had no regret at having had a caesarean section since she thought that the situation might be even worse with a vaginal delivery. She said: I wonder why my sister-in-law did not feel any pain after a caesarean operation. I think it may be due to individual difference. The wound is quite unendurable. Today is much better. . .. Well! I have no regret in undergoing caesarean section because I think that the labour pain is much more severe than this wound pain. Furthermore, the pain has gone when I hold my baby in my arm and feed him.
A sense of loss – Apart from the positive feeling associated with a caesarean birth, some women reported that they had missed something yet were unable to verbalise what they had missed. This sense of loss incorporated not being the first one to see the baby after birth. Mrs Y confessed
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a sense of regret because she was not the first one to see the baby after he was born. She said: Some people said that it will be very exciting to see your baby being born. I don’t know whether it’s true or not because I didn’t have this experience. Actually, I am very happy every time when I see my baby. However, I might be very excited if I were the first one to see the baby being born. It seems to me that I have missed something but I cannot tell what it is. Mrs S also shared similar feeling and she expressed: The feeling was not so touching. My friends who had natural deliveries said that it was a strong feeling of warmth and touching when they had the first sight of their babies. It was a sense of bonding. But my feeling was not as strong as they described.
DISCUSSION In the past Chinese women had little control over their birth experiences. Having choice in healthcare is relatively unheard of in Chinese traditional medicines (Chalmers et al. 1998). The findings of this study demonstrated that a certain cohort of women in Hong Kong had exercised independent decision-making on their own childbirth issue. These findings must be interpreted in light of the fact that these women were of the middle socio-economic class, had a steady family income and a minimum of secondary education. The women further admitted that they were independent and decisive. With no past childbirth experience, the women had to face various uncertainties concerning how, when and where the delivery would take place. In obstetrics, an elective caesarean section in the absence of clinical indications has traditionally been considered inappropriate. Moreover, the ‘jury is still out’ on the benefits and disadvantages of caesarean section and vaginal delivery (Paterson-Brown & Amu 1998). Given that all the women in this study were well educated, they understood that vaginal birth was the most natural mode of delivery and that women’s postnatal recovery would be smoother and quicker. However, delayed childbirth and cultural beliefs associated with an auspicious birth date were putting more pressure on Chinese women to ensure a perfect birth outcome and posed consideration in the choice of caesarean section. In addition, in a rapidly modernising society such as Hong Kong, a high level of medical intervention is equated with wealth, promoting this group of middle socio-economic class Chinese women to choose a caesarean
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section for the baby’s birth. Women in Hong Kong generally believe that caesarean section is very safe. Nevertheless, Hong Kong has no formal statistics to measure the mortality and morbidity of caesarean section. In the private hospital where participants were selected for this study, records show that the mortality rate for caesarean section for the past 30 years is zero and the morbidity rate is minimal.
Economic in£uences on Chinese women’s decision-making International research on the family has repeatedly addressed the notion that parents trade quantity and quality of children over the course of industrial development (Goode 1963, Caldwell 1982, Giddens 1992, Hirschman 1994, Thornton & Lin 1994). During the period of rapid industrial development that has characterised Hong Kong for the past few decades, increasing numbers of wives and mothers are employed. Therefore, the time that can be set aside for childcare has diminished greatly. During the past three decades, the Hong Kong Family Association has been promoting the slogan ‘Two is enough’, while at the same time there is an increasing community concern for quality childhood. As a result, women tend to have fewer children and put a high expectation on their children. The women in this study stated that they would only have one or two children. Thus the need to produce a ‘perfect baby’ was obvious. Women did not want to expose their unborn babies to the risk of uncontrollable consequences during labour and vaginal birth. Therefore, they sought what they saw as a safer mode of delivery. A Canadian study, however, refutes these beliefs and finds that there is no relationship between high caesarean section rates and improved perinatal outcome (Menticoglu 1997).
Social in£uences on Chinese women’s decision-making Freund and McGuire (1995) contend that how a woman perceives and experiences the process of giving birth is shaped by the social context of childbirth. Most of the women in this study had mentioned that having caesarean sections for childbirth was a common practice among the younger generation of women in Hong Kong, as many of their friends and even film stars did so. Instead of complying with the biomedical approach that is espoused by healthcare professionals, these women chose social prestige, safety and auspicious dates as factors informing their choice for caesarean deliveries. Fear of labour pain was another major element that led these women to select caesarean
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sections. The women viewed general anaesthesia as a welcome relief from labour pain. In addition, they also believed that there was no reason for them to experience such severe pain as other delivery alternatives were financially accessible to them. Reluctance to experience labour pain in higher socio-economic women has been documented in previous studies as a common reason for requesting caesarean section (Simkin 1996, Jackson & Irvine 1998).
Cultural in£uences on Chinese women’s decision to have a caesarean section Li (1995) contends that most Chinese people attempt to calculate how to best match his or her ‘eight characters’ (date and time of birth) with specific points occuring in the flow of cosmic time. The appropriate matching of the individual’s eight characters with the cosmic time will bring good fortune to the person, but a bad matching will bring calamities. Therefore most of the women in this study insisted on selecting a ‘lucky day’ and time for the baby’s birth in order to pursue good fortune and avoid calamity to the baby and family. Even though the women had the confidence to grasp or manipulate events, such as selecting the date and mode of delivery, they still had a firm belief in the influence of fate in predicting birth outcomes. Such a belief in the magico-religious powers has been shown to provide comfort in times of uncertainty, such as childbirth (Scarborough 1998). These women were pleased to have the autonomy to pursue a caesarean section and in general were satisfied with their birth outcome. Whether the operation would lead to subsequent long-term complications, and whether a baby born on a lucky day would bring good fortune to the family, posed unknown factors. Disregarding these benefits, all these women had to face the risks of general anaesthesia and surgery. In recent years, literature has reported similar incidences with many Chinese couples desiring auspicious delivery dates, despite the dangers of induced labour and caesarean section (Yeung 1999). Five women followed suggestions from husband, mother-in-law and other family members, and chose a ‘lucky day’ as the date of operation. These actions could be explained by the Chinese view of respecting authority. Chinese Confucian philosophy demands that the individual act according to his or her social status (Cheng 1990). Within a Chinese family, the father-inlaw, mother-in-law and husband have high status and authority, while the wife and children are expected to respect and obey them. The authority figures in the family, such as the father and mother-in-law, have considerable influence on decision-making, particularly with regard to the
life processes of childbirth and death. Individuals learn to follow the prevailing opinion rather than disagree (Gudykunst et al. 1985, Anderson 1986). A Confucian belief system emphasises that it is important for the Chinese to remain in harmony with nature, people and social institutions in order to be well and functioning. Therefore, a person is expected to accommodate rather than confront. Personal desires must be controlled to avoid conflict. Behaviours such as to show filial piety, loyalty, sincerity and benevolence to others are therefore highly valued in Chinese people (Giger & Davidhizar 1999). Thus it is not surprising that the women chose caesarean section to be performed on a lucky day in order to please their husbands and mothers-inlaw.
Towards an explanation for regret The sense of loss experienced by two women demonstrated that the operation might lead to a certain degree of negative emotional sequelae. Early international studies have indicated that women undergoing a caesarean delivery were demonstrating low satisfaction with the birth experience (Norr et al. 1977, Bradley et al. 1983, Padawer et al. 1988). Other studies have shown that women view emergency caesarean sections as a serious deviation from normal birth, and this leads to negative consequences including feelings of guilt, failure, disappointment and anger (Marut & Mercer 1979, Cranley et al. 1983). However, the current study did not support such phenomenon as the caesarean sections were planned well in advance (Fawcett & Weiss 1993). In addition, the Hong Kong healthcare culture of a high level of technological intervention has contributed to a shift towards prizing expensive intervention, further contributing to this phenomenon. As existing literature shows that women who have undergone caesarean section may not experience negative emotional consequences, inconsistent findings in this study and the literature require further investigation.
Implications for midwives Chinese women would benefit from the provision of a ‘named’ midwife who provides continuity of care to the woman throughout her pregnancy and confinement. Such a midwife could provide the woman with comprehensive information on the pros and cons of caesarean section. It is essential to keep women fully informed and educated about the different modes of delivery and potential problems. With such a close relationship and knowledge base, midwives can empower woman to make an individual choice which is most suitable to her.
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Owing to the fact that some women express negative feelings after a caesarean section, strategies such as establishing peer support groups, need to be implemented to enhance women’s feelings about themselves and to reduce the feeling of disappointment. Women should be provided with adequate information about the possibility of negative feelings after a caesarean birth well before the operation. Early detection of emotional distress needs encouragement, and counselling can be provided to the women when necessary. Given that the Chinese belief system of favouring auspicious years, days and times was clearly influential in these women’s decisionmaking, midwifery education needs to accommodate a knowledge of these factors to provide cultural congruence. In addition, the influence of family members in Chinese women’s decisionmaking needs to be taken into account. The limitations of this study include its small interview sample of middle class women only. Thus generalisation cannot be made to all Chinese women. The experience of women from different social classes and cultural backgrounds can be explored so that more comprehensive international comparisons can be made. In addition, further investigations are needed in the concurrent process of decision-making regarding elective caesarian sections for women from Mainland China. A large-scale study needs to be conducted in Hong Kong’s public and private hospitals to examine the determining eligibility for caesarean section. Finally, the emotional aspects of undergoing a caesarean section, such as a sense of loss or struggling during the decision-making process, need further exploration. REFERENCES Al-Mufti R, McCarthy A, Fisk NM 1996 Obstetricians’ personal choice and mode of delivery. Lancet 347: 544 Anderson JM 1986 Ethnicity and illness experience: ideological structures and the health care delivery system. Social Sciences Medicine 22(11): 1277–1283 Bradley CF, Ross SE, Warnyca J 1983 A prospective study of mothers’ attitudes and feelings following caesarean and vaginal births. Birth 10: 79–83 Caldwell J C 1982 Theory of fertility decline. Academic Press, New York Chalmers B, Samarskaya M, Tkatchenko E et al. 1998 Women’s experiences of birth in St. Petersburg, Russian Federation. Journal of Reproductive & Infant Psychology 16(4): 243–259 Cheng SKK 1990 Understanding the culture and behaviour of East Asians: a Confucian perspective. Australian and New Zealand Journal of Psychiatry 24: 510–515 Cranley MS, Hedahl KJ, Pegg SH 1983 Women’s perceptions of vaginal and caesarean births. Nursing Research 32(1): 10–15 Fawcett J, Weiss ME 1993 Cross-cultural adaptation to caesarean birth. Western Journal of Nursing Research 15(3): 282–297 Flint C 1987 Retracing out cultural roots. Nursing Times 83(11): 22–36
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