Mode of delivery : does it affect contact with the newborn child, future reproduction and health-related quality of life five years after the birth of the first child?

Abstract

Background: Major changes have occurred in Swedish maternity care since the early 20th century and is now characterized by an increased medicalisation. The incidence of caesarean section and instrumental vaginal births has risen substantially in Sweden the last decades, which means that fewer women give birth spontaneously. Both caesarean section and instrumental vaginal births are associated with adverse physical as well as physiological consequences for both mother and child. The overall aim of this thesis was to explore and describe the impact of mode of delivery and other aspects related to the birth of the first child.

Methods: three of studies were conducted using a prospective cohort design and one using a qualitative approach. A total of 551 healthy first-time mothers where enrolled in the cohort and divided into five different delivery groups; vaginal delivery, instrumental vaginal birth, caesarean section on maternal request, caesarean section on obstetrical indication and emergency caesarean section. A plurality of self-reported questionnaires were administrated at five different time points; in late pregnancy, two days, three and nine months post partum as well as five years after inclusion in the cohort. One of the questionnaires answered by 510 mothers was analyzed in paper I. Follow-up studies were carried out five years after the first birth using questionnaires and were based on answers from 355 (Paper III) respectively 249 (Paper IV) women. Paper II was performed with semi-structured individual interviews with 12 primiparae women requesting a caesarean section in the absence of a medical indication. The women were interviewed between gestational week 26 and 36 weeks.

Results: the contact with the child and the relation to the partner was rated as positive on all occasions and there were no significant differences between the groups. Mothers with a vaginal delivery experienced breastfeeding less stressful than the mothers with a caesarean section. Three and nine months after delivery the mothers with a caesarean delivery on request reported more breastfeeding problems. Women requesting a caesarean section in their first pregnancy described a belief of always knowing that they would not give birth vaginally. A caesarean section was considered as a more controlled and safe way of giving birth. This was described as ‘deeply rooted emotions’ and reflected that this group of women’s emotions towards birth goes beyond fear of childbirth. No differences were observed regarding mode of delivery, factors related to birth and having a second child. Nor was there an association between postnatal depression, fear of childbirth, a negative birth experience and self-estimated contact towards the child and subsequent reproduction. Planning a second child at nine months postpartum was most important in determining to have a second child. The overall health-related quality of life (HRQoL) was perceived to be good five years after the first birth. Suboptimal scores were obtained for the variables sleeping problems, emotional well-being negative effect and sexual functioning. Women having a vaginal birth, an instrumental vaginal delivery or women who underwent caesarean section on maternal request at birth of their first child were more likely to report better perceived HRQoL than women who had undergone an emergency caesarean section or caesarean section due to medical indication.

Conclusions and clinical implications: this thesis provides insights on how mode of delivery and aspects related to birth have different importance to women, depending on the context. Mode of delivery did matter in some respects, and in others it had no meaning. Taking these results into account may assist women and health professionals to better understand how childbirth and mode of delivery may be significant for women from various perspectives.