Abstract
Objective
The experience of an unplanned cesarean birth may be a risk factor for mood disorders and other challenges in the postpartum period, yet qualitative data on the patient experience are limited. We sought to understand individuals’ experiences of having an unplanned cesarean birth.
Study Design
This was a secondary analysis of a prospective qualitative investigation among low-income postpartum individuals at a single-, tertiary-care center in which the primary aim was to evaluate patients’ postpartum pain experience after a cesarean birth. Participants completed a 60-minute face-to-face interview on postpartum days 2 to 3. Only participants who labored prior to their cesarean birth were included in this analysis. Transcripts were analyzed by two separate authors using the constant comparative method. Themes are illustrated using direct quotes.
Results
A total of 22 individuals were included in this analysis; the majority (n = 16, 72.7%) experienced a primary cesarean birth. Over half (n = 12, 54.5%) identified as Hispanic and one-third (n = 7, 31.8%) identified as non-Hispanic Black race and ethnicity. Four themes regarding the experience of a cesarean birth after labor were identified, including feelings of anguish, belief that vaginal birth is “normal,” poor experiences with care teams, and feelings of self-efficacy. Subthemes were identified and outlined.
Conclusion
In this cohort, individuals who experienced an unplanned cesarean birth after labor expressed feelings of self-blame, failure, and mistrust. Given the association of unplanned cesarean birth with mood disorders in the postpartum period, efforts to enhance communication and support may offer a means of improving individual experiences.
Keywords: cesarean birth, qualitative analysis, unplanned cesarean birth
An unplanned cesarean birth is associated with an increased risk for postpartum depression, posttraumatic stress, challenges with infant feeding, and low birth satisfaction,1–4 yet the evidence for these associations is driven by quantitative data. Qualitative data on individuals’ experiences of an unplanned cesarean birth are limited and provide valuable insight into feelings, perspectives, and needs during this potentially vulnerable time.5 Our objective was to examine individuals’ experiences of having an unplanned cesarean birth.
Materials and Methods
This was a secondary analysis of qualitative data from a prospective investigation of postpartum pain among individuals who underwent a cesarean birth designed to evaluate the postpartum pain experience in women of minority race and ethnicity. This study took place at Northwestern Memorial Hospital, a large, tertiary, academic medical center in Chicago, IL, between December 2020 and June 2021.
Individuals were eligible if they were postpartum after a cesarean birth, were at least 18 years of age, English or Spanish speaking, and were publicly insured. As the aim of the primary analysis focused on the postpartum pain experience, individuals with factors that may alter typical pain management practices were excluded, including those who had contraindications to use of opioids or nonsteroidal anti-inflammatory drugs, were not opioid naïve (defined as ≥3 opioid prescriptions in prior year), had a known substance use disorder, received general anesthesia for birth, or were admitted to the intensive care unit. For this analysis, we included only the subset of individuals who underwent an unplanned cesarean birth after laboring.
Individuals were approached for participation on postpartum day 2 or 3 prior to hospital discharge. Consenting participants completed an in-depth 60-minute in-person, face-to-face interview about their birth, and early postpartum experience. Interviews were conducted immediately following the consent processes. All interviews were conducted by a research staff member trained in qualitative interviewing and fluent in English or Spanish, depending on the participant’s primary language. All interviews were digitally recorded, deidentified, and professionally transcribed. Qualitative data were uploaded to Dedoose, a secure qualitative data analysis software and analyzed using the constant comparative method.6 A preliminary codebook of themes and subthemes was developed after exploration of the first five transcripts by two independent coders (J.D.D. and K.L.). Themes were iteratively modified after constant review of the remaining transcripts by the study team. A final codebook was created and systematically applied to the data by the coders. Disagreements in themes were resolved by adjudication from a third author (N.B.). The sample size was restricted to the sample size available for the primary study. Standards for the Reporting Qualitative Research statement were followed in the reporting of this study.7
All participants provided written, informed consent. This study was approved by the Northwestern University Institutional Review Board and registered with ClinicalTrials.gov (identifier: NCT0460124).
Results
A total of 22 participants met inclusion criteria and were included in this analysis. The majority (n = 16; 72.7%) of participants underwent a primary cesarean birth and 27.3% (n = 6) underwent a repeat cesarean birth. The majority (n = 12; 54.5%) identified as Hispanic or non-Hispanic Black (n = 7; 31.8%) race and ethnicity.
Topics and example questions relevant to this analysis can be found in Table 1. Four main themes were identified through analysis of participant interviews as follows: (1) feelings of anguish, (2) belief that vaginal birth is “normal,” (3) poor experiences with the care team, and (4) feelings of self-efficacy (Table 2). Themes, subthemes, and exemplary quotations are displayed in Table 2. Subthemes related to feelings of anguish included self-doubt, defeat, and self-blame. Several participants felt their cesarean birth experience could have been prevented, had their antenatal or peripartum course been managed differently.
Table 1.
Semistructured interview guide
| Content categories | Selected questions |
|---|---|
| General birth expectations | •How did you expect to deliver your baby? |
| Experience of cesarean birth | •When you found out that you would need a cesarean birth, how did you feel? •How would you describe the actual cesarean birth? •What do you wish you would have known prior to having a cesarean birth? |
Table 2.
Themes and quotations of the patient experience of having an unplanned cesarean birth
| Theme | Subthemes | Exemplary quotation |
|---|---|---|
| Feelings of anguish | Self-doubt | “… well for me it’s like I look at it and I’m like man, what if I woulda came a hour later? What if I woulda came a hour earlier? What if I woulda came a day later? What if I came two weeks later? Like should I still be pregnant now? Would that have been the healthiest outcome for me? And sometimes I ask those questions, but you know, we not that advanced to like go back in time.” |
| Defeat | “I felt defeated kind of. I was really heartbroken in some ways. I tried everything not to be in a C-section.” | |
| Self-blame | “I just wish that, I just feel like if I wouldn’t have missed so many appointments, then I probably could have found out like even sooner about what was going on.” | |
| Belief that vaginal birth is “normal” | Desire to experience vaginal birth | “I wanted my body to go naturally go through that birth. Like I wanted to, like I wanted that. I wanted to, you know, for me it would have been a release, especially after carrying this baby for nine months and having the complications I had.” |
| Cesarean birth as failure | “Like I felt like my body was broken and you know, I also had this hideous scar on my body. And my body just changed from like its natural state because somebody was … I had like a surgery.” | |
| Cesarean birth as unnatural | “But with a C-section you need a little bit more to help control the pain. Just because your body is not supposed to go through that, if that makes any sense. Like it’s something that, it’s for your good, but it’s not what your body intends, how to push a baby out.” | |
| Poor experiences with the care team | Desire for increased anticipatory counseling | “I think that … like in pregnancy, regardless if someone is at risk for something or not, I think discussion should be had throughout about possibilities …. That way, you’re prepared and not to scare, not to scare the woman, but just so they know.” |
| Desire for increased provider support | “But for the future, if I do decide to have another child, I know that I’d want like a midwife or doula, you know, someone to go through the whole process with me. And I do not want another C-section again.” | |
| Mistrust in management | “I was just thinking about, thinking back on the conversations in the whole evening, and going into the night, into the early morning hours to where we were at that moment. Like well did you guys do this? Did you try this? Do you forget to do this? And you know, for me it’s even more detrimental because I’m not a doctor.” | |
| Self-efficacy | Pride | “… if I had the choice I wouldn’t have did it. I would never ever do this, but I’m, like I said, overall I’m proud of myself that I’m healthy and the baby health, and that’s all that really matters.” |
| Courage | “I cried for like two minutes and then I said okay, it’s what I got to do. I’m gonna have my baby.” |
Participants often referred to vaginal birth as “normal” and many expressed views regarding their cesarean birth as a failure or unnatural. Subthemes related to poor experiences with care teams included a lack of anticipatory guidance, lack of provider support, and mistrust in medical management. Individuals expressed a desire to be provided more information about potential birth outcomes, specifically more thorough discussions about a cesarean birth as a possibility before and during their labor. In contrast, some individuals reported feeling proud of the strength they displayed during their birth experience. Positive themes related to feelings of self-efficacy were identified and highlighted participants’ feelings of pride and courage regarding their birth experience.
Discussion
In this cohort of publicly insured postpartum individuals who experienced an unplanned cesarean birth, many participants expressed feelings of anguish about their birth experience. Participants also expressed feelings that a cesarean birth was unnatural and feelings of failure related to not having a vaginal birth. Conversely, positive themes emerged and some participants expressed feelings of empowerment.
Ample quantitative data suggest that an unplanned cesarean birth is associated with adverse psychosocial outcomes in the postpartum period.1–3 A retrospective cohort study by Smithson et al found that an unplanned cesarean birth may be an independent risk factor for postpartum depression.1 Similarly, a systematic literature review by Benton et al found that an emergency cesarean birth was associated with negative psychosocial outcomes, such as posttraumatic stress disorder and low self-esteem.2 Literature has also documented the distress individuals may experience after a cesarean birth; for instance, those who have a cesarean birth are more likely to view their birth experience as traumatic compared to those who have a vaginal birth.3 The results of our study corroborate these findings and add the patient voice. Many participants in this present cohort expressed negative emotions regarding their birth experience which increases their risk for adverse psychosocial outcomes.8
Our study is unique in its application of qualitative analysis on the experience of an unplanned cesarean birth from the individual perspective. The incorporation of patient voices in clinical research is imperative to begin to understand individuals’ perspectives and experiences and, ultimately, to develop impactful interventions addressing the unique needs of individuals in the postpartum period. Nevertheless, this study is not without limitations. This study was conducted at a single, tertiary, academic care center and limited to individuals with public insurance, and, therefore, the results may not be widely generalizable. However, qualitative research is not intended to be widely generalizable but instead to provide in-depth insights regarding the experience of specific populations to guide future ideas and hypotheses.9 Additionally, the experience of an unplanned cesarean birth may differ based on whether the individual underwent a primary or repeat cesarean birth. However, our limited sample size makes it challenging to draw conclusions based on this variable. Further work is warranted to examine differences regarding the experience of an unplanned cesarean birth based on prior cesarean exposure within a larger cohort. Finally, this analysis focuses on individuals’ perspectives in the immediate postpartum period, and therefore individuals’ expressed thoughts and feelings about their birth experience may evolve or change with additional time to process.
Conclusion
Given the association of unplanned cesarean birth with mood disorders, low birth satisfaction, difficulty breastfeeding, and neonatal bonding,1,2 efforts to enhance communication and support may be particularly important for this population. Data in nonobstetric populations have demonstrated that increased support and communication among health care providers are associated with a decrease in negative psychosocial outcomes such as self-blame, failure, and mistrust.10,11 Health care teams may consider debriefing a patient’s birth experience prior to discharge to answer lingering questions and address concerns. Future steps may include how health care teams and health systems can play a greater role in providing information and support for individuals who are most vulnerable in experiencing negative feelings regarding their birth.
Key Points.
In this cohort, many individuals expressed negative feelings after an unplanned cesarean birth.
Conversely, positive themes related to feelings of self-efficacy were identified.
Efforts to enhance communication and support after an unplanned cesarean birth are warranted.
Funding
This study was funded by the U.S. Department of Health and Human Services, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, grant no.: 3R01HD098178-02S1.
Footnotes
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Health.
Conflict of Interest
None declared.
References
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