Experience with vaginal birth versus cesarean childbirth: integrative review of women's perceptions

Abstracts

Se realizó una revisión integradora para identificar la contribución de las investigaciones, a nivel nacional e internacional, sobre la percepción que experimentan las mujeres en el parto vaginal y la cesárea. La búsqueda de los artículos se hizo en las bases de datos MEDLINE, LILACS, BDENF, CINAHL y INDEXPSI, de 2000 a 2009, con la selección y análisis de 17 estudios, donde se presentan percepciones positivas y negativas de las mujeres sobre los dos tipos de parto: el papel de la mujer y una mejor recuperación en el parto vaginal, la falta de dolor en la cesárea, la insatisfacción con la atención recibida, y recomendaciones para la práctica obstétrica con sugerencias para futuras investigaciones. Los resultados indican aspectos sobre la atención que pueden contribuir a la satisfacción de las mujeres, y la necesidad de realizar otras investigaciones para entender mejor el proceso multidimensional del parto, ya sea por vía vaginal o cesárea.

Parto; Parto normal; Cesárea; Percepción; Enfermería

LITERATURE REVIEWS

Experience with vaginal birth versus cesarean childbirth: integrative review of women's perceptions¹

Vivência do parto normal ou cesáreo: revisão integrativa sobre a percepção de mulheres

La experiencia del parto vaginal y la cesárea: una revisión integrativa sobre la percepción de las mujeres

Manuela Beatriz Velho^I; Evanguelia Kotzias Atherino dos Santos^II; Odaléa Maria Brüggemann^III; Brígido Vizeu Camargo^IV

^IMaster in Nursing. Faculty of the Nursing Department and of PEN/UFSC. Santa Catarina, Brazil. E-mail: [e-mail]

^IIPh.D. in Nursing. Faculty of the Nursing Department and the PEN/UFSC. Santa Catarina, Brazil. E-mail: [e-mail]

^IIIPh.D. in Obstetrics and Gynecology. Faculty of the Nursing Department and the PEN/UFSC.. Researcher with CNPq. Santa Catarina, Brazil. E-mail: [e-mail]

^IVPh.D. in Social Psychology. Faculty of the Psychology Department and the Graduate Program in Psychology at UFSC. Santa Catarina, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

An integrative review was performed aimed at identifying the contribution of the research published in both national and international journals regarding women's perception of vaginal birth versus caesarean section. The search for the articles utilized MEDLINE, LILACS, BDENF, CINAHL and INDEXPSI databases spanning the years 2000 to 2009, and 17 studies were selected and analyzed. The studies present positive and negative perceptions of women regarding the two types of delivery, such as the role of women and easier recovery in vaginal birth, absence of pain in caesarean section and dissatisfaction with the medical care received, as well as recommendations for obstetric practice and suggestions for new investigations. The results indicate aspects of care that may contribute to women's satisfaction and the need for further research in order to better understand the multidimensionality of the delivery process, whether vaginal birth or cesarean section.

Descriptors: Parturition. Natural childbirth. Cesarean section. Perception. Nursing.

RESUMO

Foi realizada uma revisão integrativa com o objetivo de identificar a contribuição das pesquisas desenvolvidas, em âmbito nacional e internacional, sobre a percepção do parto normal e cesáreo pelas mulheres que os vivenciaram. A busca dos artigos ocorreu nas bases de dados MEDLINE, LILACS, BDENF, CINAHL e INDEXPSI, no período de 2000 a 2009, sendo selecionados e analisados 17 estudos. Os estudos apresentam percepções positivas e negativas das mulheres sobre os dois tipos de parto, tais como o protagonismo da mulher e a melhor recuperação no parto normal, a ausência de dor na cesárea, a insatisfação com a assistência recebida; assim como recomendações para a prática obstétrica e sugestão de novas pesquisas. Os resultados apontam aspectos assistenciais que podem contribuir para a satisfação das mulheres e a necessidade de outras investigações para compreender melhor a multidimensionalidade do processo de parto, seja normal ou cesáreo.

Descritores: Parto. Parto normal. Cesárea. Percepção. Enfermagem.

RESUMEN

Se realizó una revisión integrativa para identificar la contribución de las investigaciones, a nivel nacional e internacional, sobre la percepción que experimentan las mujeres en el parto vaginal y cesárea. La búsqueda de los artículos se hizo en las bases de datos MEDLINE, LILACS, BDENF, CINAHL e INDEXPSI, de 2000 a 2009, con la selección y análisis de 17 estudios, donde se presentan percepciones positivas y negativas de las mujeres sobre los dos tipos de parto tales como: el papel de la mujer y una mejor recuperación en el parto vaginal, la falta de dolor en la cesárea, la insatisfacción con la atención recibida, y recomendaciones para la práctica obstétrica con sugerencias para futuras investigaciones. Los resultados indican aspectos sobre la atención que pueden contribuir a la satisfacción de las mujeres, y la necesidad de realizar otras investigaciones para entender mejor el proceso multidimensional del parto, ya sea por vía vaginal o cesárea.

Descriptores: Parto. Parto normal. Cesárea. Percepción. Enfermería.

INTRODUCTION

The childbirth experience has always represented a very important event in women's lives, a unique and special moment, marked by the transformation of the woman in her new role, that of being a mother.¹

Thanks to scientific and technological advances in childbirth care, many improvements have been observed among births characterized as high risk, which have resulted in lower rates of maternal and neonatal morbimortality. However, this assistance is often based on technology developed in a mechanized, fragmented and dehumanized way, with excessive use of interventionist practices. When applied to low-risk childbirth, advanced technology engendered feelings of fear, insecurity and anxiety in women that resulted in difficulties in the evolution of their childbirth processes.^2-3

Studies regarding vaginal birth and caesarean section deliveries have addressed the various problems associated with both types of care, showing some concern involving the quality of obstetric care, the high cesarean section rates found at the present time, and the meaning of childbirth according to the women who experience it.^2-5

In order to support an impression regarding the experience of vaginal delivery and cesarean section from women's perspective, this integrative review of the literature aimed at identifying the contribution of the research developed at national and international levels regarding the perception of vaginal birth versus cesarean section by the women who have experienced them.

METHOD

The integrative review consists of a research method that allows the establishment of a synthesis and general conclusion about a particular study area, performed in a systematic and orderly manner in order to contribute to the knowledge investigated. This type of review must follow the same standards of methodological rigor as an original research study, considering the aspects of clarity, so that the reader can identify the actual characteristics of the selected studies and elucidate knowledge towards the advancement of nursing.^6-9

To develop this integrative review six steps were covered.^6-9 The first step was the identification of the theme and the selection of the research question, which was developed from the themes of vaginal birth and cesarean section. Thus, the following research question was outlined: what scientific knowledge has been produced regarding the perception of vaginal birth versus caesarean section by the women who experienced them?

In the second step, we defined the criteria for inclusion and exclusion of the studies. The following were defined as inclusion criteria: research published as articles in national and international journals in English, Portuguese and Spanish, which investigated the perception of women who experienced vaginal birth and/or cesarean section; published in the period 2000 to 2009, regardless of research method; and that had title and abstracts available and indexed in the databases. We excluded studies that only addressed specific topics such as: assessment of pain in natural labor; pharmacological and non-pharmacological methods for pain relief; comparison of the perception of methods of delivery among ethnic groups, and expectations about vaginal birth or cesarean section.

The search for articles was conducted on the Internet, utilizing the following databases: Medical Literature on Line (MEDLINE), Literature of Latin America and the Caribbean (LILACS), Database of Nursing (BDENF), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Index Psi-Tech Scientific Journals (IndexPsi).

To survey the research in the databases LILACS, BDENF and INDEXPSI, the following Health Science Descriptors (DeCS) were selected from the Virtual Health Library: natural childbirth (parto normal, parto normal), cesarean section (cesárea, cesárea) and perception (percepção, percepción). A complementary search was also performed using the following descriptors: representation AND social (representação AND social, representacion AND social), social AND representations (representações AND sociais, representaciones AND sociales), social AND behavior (comportamento AND social, conducta AND social) and psychology AND social (psicologia AND social, psicologia AND social), which are not included in the DeCS.

For the CINAHL database the following CINAHL headings were selected: labor, cesarean section, perception, psychology, social and social behavior. In the MEDLINE database, we selected the following words from the MeSH Database: labor, obstetrics; cesarean section; perception; psychology; and social and social behavior. We found 614 articles, of which only 17 met the inclusion criteria.

In the third step of this integrative review, the definition of information to be extracted from the selected studies was carried out. This information was cataloged in a bibliographical record and included: the identification of the publication journal, country of origin, the training of the researchers, the language used for publication, keywords, the objectives, theoretical reference, the type of design, location, period of data collection, subjects, delimitation of the sample, instrument used for data collection, method, data analysis and ethical precepts, in addition to identifying the major results, conclusions, recommendations for practice and suggestions of new research and difficulties found.

The fourth step, evaluation of the studies, occurred during the preparation and analysis of the bibliographic records. A critical analysis was performed regarding the selected studies, observing the methodological aspects and subsequent results obtained, which allowed us to elaborate the following categories: positive perceptions related to vaginal birth and cesarean section, negative perceptions related to vaginal birth and cesarean section, and general perceptions regarding vaginal birth and caesarean section.

The discussion and interpretation of the results, the fifth stage of this review, was performed in order to develop recommendations for practice from the findings of the review and submit suggestions for new research, identifying gaps in the studies included.

In the sixth and final step of the integrative review, the summary of the evidence available was prepared, including the production of the results, shown below.

RESULTS AND DISCUSSION

Knowing the studies

In analyzing the research designs used in the sample studies, we identified that eight were developed using a quantitative approach and nine using a qualitative approach, with the use of theoretical references such as phenomenology and social representation being the most frequent approaches. The keywords most frequently used were: childbirth, vaginal delivery, cesarean section and satisfaction. In the data collection process to assess women's perceptions regarding natural birth and/or cesarean section they experienced, eight studies were identified using structured questionnaires, five using semi-structured interviews, three using open interviews and one study using participant observation (Chart 1).

With regard to the objectives of the studies, although using different theoretical and methodological references, in general, they focused on identifying the perceptions of vaginal birth and caesarean section, from the perspective of women who experienced them.

With respect to research subjects, in the quantitative studies there were 4.189 women who participated, 58% of whom experienced vaginal birth ; 27% of the women underwent cesarean section, while only 3% of women had both experiences (vaginal delivery and cesarean section). In the qualitative studies, 124 women participated, of whom 43% had vaginal birth, 28% underwent cesarean section, and 8% had both experiences. Twenty-one percent (21%) of the qualitative participants had no description of the mode of delivery.

Synthesis of the results

The data analyzed show the production of scientific knowledge that presents positive, negative and general aspects regarding the events, as well as recommendations for practice and suggestions for further research.

Positive perceptions related to vaginal birth and cesarean section

In studies with women who had vaginal birth and cesarean sections, the experience of role playing and greater satisfaction with the birth experience were expressed as a preference for natural childbirth.^{11, 22.24} Childbirth is a unique and relevant experience that women expect to experience as a physiological process, something natural and healthy for themselves and their baby.^21,24 Childbirth is a thrilling moment of personal growth towards the construction of a new identity, the status of being a mother,^10-18 surrounded by positive feelings often described as joy, happiness and fulfillment.^15-21

The satisfaction, preference or advantages associated with vaginal birth, regardless of women's previous experience of childbirth, were found in descriptions like: little suffering, faster recovery, requiring less care, experiencing less pain after delivery, the possibility of returning to daily activities sooner and being discharged from the hospital sooner.¹¹, ^15,21,24

Other women said that this type of delivery does not present any disadvantages,¹¹ and they highlighted the quality of the relationship with their baby,²⁴ being together with the child²⁰ and the thrill of first meeting their child.¹⁷

Having information regarding the delivery, having some control over the event and the degree of relaxation are positive perceptions in regards to the childbirth experience.²⁰ Two other important factors associated with satisfaction are: positive opinions about the healthcare team that assisted them in a careful and caring way,^{15,17-18, 21} and the presence of a loved one or birthing attendant.^{15, 20}

Vaginal birth , as an experience beyond the physical, and focusing on their mind, gives women the strength to cope with childbirth, demonstrating confidence in their ability to cope with labor and labor pains.¹⁰ These women perceive the pain as an intrinsic aspect of the childbirth act, almost as an essence of this process; they changed this experience from painful physical sensations into feelings of motherly love and saw the possibility to fully experience female role-playing as provided by motherhood.^18,21,24 They can deal with the pain using non-pharmacological methods and the minimum use of medication.¹⁰

In relation to caesarean section, the reasons to consider it the best form of childbirth are associated with: absence of labor pains,^11,13,23-24 avoiding the fear of childbirth,²³ the speed of the procedure,¹¹ the possibility of having a tubal ligation at the same time,²⁴ safety for the baby,^11,20 having information and control over the event (when the cesarean section is planned), being an overall pleasant experience and enjoying the child with safety.²⁰ In two studies, high levels of satisfaction were reported by mothers who experienced cesarean section.^20,26

Positive factors regarding cesarean delivery were identified by women who have experienced this type of delivery in the past and chose to have it again.²³ They described as positive aspects of this choice that cesarean delivery is easier and faster, the surgical incision is performed on top of the already existing scar, they can set the date, there is greater control and safety for the baby, they avoid the fear of childbirth and induction, they already know what to expect of the procedure, they avoid the trauma of a new emergency cesarean section and recovery is relatively easy. It is important to highlight that the choices are based more on psychosocial aspects than on clinical advice or information about risk.²³

A cross-sectional study showed the existence of a possible association between maternal age and satisfaction with the birth experience, revealing a negative correlation (-0.21) in which the age variable varies in the opposite direction, i.e., the higher the age, the lower the satisfaction and vice versa.¹²

Negative perceptions related to vaginal birth and cesarean section

The experience of institutionalized vaginal birth was associated with fear,^18,21,25 accompanied by the premonition that something bad would happen during the birth, whether due to the possibility of complications with the baby, or through fear of their own death or the baby's death.^14-15,17,19 Women expressed fear of pain,^16,19 a fear which was enhanced by stories heard outside the hospital about labor pains¹⁸ that, for some, could lead to death.¹⁴

Vaginal birth is perceived as a painful process,^11,17 with pain intensity viewed as greater than expected,²⁵ even for a short period of time,²¹ added to by unexpected and painful procedures that contributed to higher levels of pain,^13,18,24-25 such as amniotomy or the administration of oxytocin to accelerate labor.^12,18,21,25 Discomforts associated with epidural analgesia, episiotomy and the type of delivery (with exception of elective cesarean section),^12,25 the transformation of the woman's body into an object of work, not respecting the woman's role in delivery and reproducing the medical model of care ^19,24 also contributed to the negative perception of childbirth. Many women believe that the technical procedures used in hospitals are necessary and important, even though some of them are currently contraindicated, such as Kristeller's Maneuver.¹⁹ Many women are a position of great passivity in relation to the hospital authority.¹⁸

These negative perceptions regarding vaginal birth were described by women: loneliness, grief and abandonment,^14-18 sometimes associated with the absence of a birthing partner as insisted on by the institution.¹⁸ Dissatisfaction with the experience of childbirth is also associated with lack of attention on the part of the team,^{15,17-18,22,25} complications with the baby,^15,22 prolonged ^11,15,17 or difficult delivery,^15,17-18,25 little or no control over labor by the parturient, frequent vaginal examinations, limitations of movement²⁵ and the sharing of rooms with other women experiencing negative vaginal labors, further increasing their anxiety levels.^18,25

The assistance provided by healthcare professionals during labor and birth, mostly in vaginal birth experiences, is characterized by an impersonal relationship in which professionals are distanced from the patient, ^14.16 relations are unequal based on non-verbal communication, and technical terms are used that make it difficult for the women to understand information and instructions.^18-19

These women realize the requirement of predetermined behavior, and do not offer resistance to established knowledge to meet the expectations of the professionals.¹⁶¹⁹ They feel insecure and manipulated, which translates into pain, neglect and abandonment that reflects the physical, psychological or emotional violence to which they were submitted,¹⁹ characterized by a lack of care and even by a lack of professional follow-up.²¹

In regards to the negative perceptions of caesarean section, the women mentioned the pain of the postpartum period, the difficulties in recovery,^11,23-24 the risks of surgery,^21,24 concerns about previous experiences with anesthesia,^17,21,23 higher levels of fear when compared with natural childbirth,^{12-13,20-21,23} and difficulty in resuming sexual activities.²⁴ Women who had a cesarean section by choice or in an emergency were more unhappy when remembering the birth of their children.^12,22

General perceptions about vaginal birth and cesarean section

A common feature in the experience of both vaginal birth and cesarean section was the lack of information about these events in order to experience the childbirth safely and with self-determination.²⁴ Women felt uninformed about the evolution of labor, the performance of exams, medicines received and the health conditions of their babies.¹⁵

The pain experienced is the most memorable part of childbirth. However, when discussing the mode of childbirth, the women described the pain of natural childbirth as present at all times, however tolerable,^11.21 but which allows them to return to natural activities earlier.¹¹ On the other hand, they perceive that, in cesarean section, there is no pain at first, but pain is a consequence of the procedure²¹ and is more persistent and disabling.¹¹

Vaginal birth is most often perceived as an unnatural event in a women's life, which requires medical assistance. Hospitalization becomes an essentially modern life experience, offering specialized technical assistance; the hospital is the safest place to have a child, but it is also the worst place when it comes to the care received by many women and the loss of their autonomy.^19,21

Nevertheless, in a Brazilian study, women identified the doctor as the only professional trained to take care of them during vaginal birth;²¹ however, it is important to note that in two international studies conducted in England and Jordan,^25-26 women reported greater satisfaction with the care received when assisted by obstetrical nurses and midwives.^25-26

Recommendations for obstetric care in vaginal birth and caesarean section

In general, the studies presented recommendations for health professionals and managers, especially as regards the organization of services geared towards customers' needs, aiming at a humane approach to labor and birth. They identified the need for a more human and integrated relationship, considering the uniqueness of the patients, ensuring a suitable place so that they feel welcomed, heard, guided, respected and free to express their feelings. Just like the compliance with the provisions governing the universal rights of man and the principles of the Single Health System, investments towards improving the quality of care in labor and delivery are necessary, as well as the actual implementation of the Program for Humanization of Prenatal Care and Birth in Brazil.^{15-16,19,21,26}

They also indicated that it is essential to plan and implement appropriate strategies that can help women experience childbirth with lower levels of fear and anxiety, using coping mechanisms to reduce the levels of pain and help them regain a sense of control during childbirth.²⁵

The importance of the relationship between health professionals and pregnant women has also been highlighted. In the day-to-day work life of the health care professional, the mother tends to be one more task in the process of giving birth while, for the woman, childbirth is a time of extreme sensitivity, one of the most remarkable episodes in her life.¹⁷ In this regard, reflecting on disrespect and neglect on the part of the professionals towards the women's feelings as parturients is also necessary,²¹ as well as the inclusion of professionals in psychology who might foster better conditions for the parturients and relatives during this experience,¹⁷ including the presence of an escort, especially the mother figure, in caring for parturients, particularly adolescents.¹⁸

Nurses need to understand the factors that influence women in making important decisions regarding childbirth and assist in the ideal choices for both the mothers and their babies,^20.23 as well as develop health education by providing information and guidance about the physiology of childbirth so that the woman is aware of what to expect and develops realistic and positive expectations for the actual childbirth experience, proceeding through this process in a less traumatic way.^20-21,25

The nurses, especially obstetric nurses and midwives, have an important role in childbirth and need to develop interventions such as: providing information on the evolution of labor and involving mothers in decisions about the use of interventions; and fostering positive experiences and promoting coping mechanisms for the pain experienced by the women, guiding them in their labor pain and how to deal with it, especially with non-pharmacological methods, such as breathing and relaxation exercises.^20,25 Nurses should also help and encourage women towards early contact with their babies and reinforce the importance of the role of the labor support person and how they can offer support.²⁰

One must respect the celebration and the socio-cultural context of childlbirth,¹⁰ and strive to regain women's all-important role in childbirth, considering her views on the way that they would like to give birth.^{11, 20}

Suggestions for further research

Some of the studies analyzed suggest further research to investigate the feelings associated with the type of birth,¹⁷ the expectations and satisfaction of women in relation to delivery, how satisfaction can influence the relationship with their children and family over the course of their life,^15.25 the negative experiences, their repercussions,¹² and how these influence the women's choice in opting for cesarean section.²⁰ They highlight the importance of using qualitative research to fully understand their experience.²³

Other factors identified in studies as being of interest for further research were: the relationship between health professionals and the women they care for in childbirth,¹¹ psychological preparation for the emotional adaptation which occurs after childbirth¹² and attention to high-risk pregnant women or women with diagnoses of fetal abnormality or malformation.¹⁷

FINAL CONSIDERATIONS

This integrative review regarding the perception of women who experienced vaginal birth and/or cesarean section reaffirms the importance of the type of delivery in their lives, impacting them deeply with different perceptions and opinions regarding the method of childbirth. Such perceptions include physical, emotional and sociocultural aspects that need to be respected in terms of the individuality and integrity of every human being.

The synthesis of the studies analyzed reveals the production of scientific knowledge that reflects the experience of woman's role-playing, among the positive aspects discovered regarding vaginal birth . This role-playing was associated with emotional and socio-cultural aspects described as a unique and relevant experience beyond the physical experience, which leads to personal growth, to building a new identity, and the status of being a mother. These factors are associated with the emotion of the first meeting with the child, and bring greater satisfaction with a natural birth. Among the positive physical aspects highlighted in the natural birth, we found lower levels of postpartum pain, faster recovery and quicker return to their daily activities.

In cesarean section, the positive perceptions were associated with physical events such as absence of pain, a more rapid procedure and the possibility of setting a date and/or performing a tubal ligation at the same time. The positive perceptions associated with emotional and socio-cultural aspects are described as having greater control over the birth, avoiding fear of labor and induction of labor, being a pleasant experience and enjoying the child with safety.

As for the negative perceptions, among the physical aspects of the cesarean section are the risks of surgery, the pain of the postpartum period, and difficulties with the recovery and return of their sexual activities stand out. Regarding the emotional and socio-cultural aspects, concerns regarding previous experience with anesthesia are described, as well as higher levels of fear and discontent when remembering the birth of their children. As for natural childbirth, the physical aspects described complications with the baby, being a painful process, time consuming or difficult, limitations in mobility and frequency of performing painful procedures. As for the emotional and socio-cultural aspects, the absence of an escort, the little control over their labor, dissatisfaction with the attention provided by the team, and the institutionalization of childbirth translated into fear, feelings of loneliness, suffering and neglect were among the negative perceptions.

The lack of assistance or professional supervision, which characterizes the negative perceptions of the participating women, identified especially by those who experienced vaginal birth, requires immediate consideration by health professionals and managers. These professionals are emotionally distant from the women they assist and cannot identify their real needs. Similarly, public policy managers, despite incentive programs for the humanization of childbirth care and birth in Brazil, need to rethink their action strategies to achieve better results in obstetric practice.

The studies analyzed, regardless of delivery method, list some characteristics of care which may contribute to the achievement of higher levels of satisfaction, namely: the presence of an escort; emotional support and guidance during prenatal care; having quality in the relationship between the professionals and the women; providing information during care; greater participation of women in decision-making; increasing their perception of being in control; and providing greater assistance for the woman and her family aimed at the humanization of childbirth care, which fosters humane and safe conditions for the birth of a child.

The studies also highlight and value the role of the obstetric nurse and midwife in the process of pregnancy, during labor and after labor. Women value professionals who demonstrate greater closeness and attention to the needs of women at birth, as evidenced by higher levels of satisfaction found. Studies also confirm their role in providing information, which may result in greater autonomy for women in the event of the birth of their children.

This synthesis of the knowledge produced regarding women's perceptions of the experience of vaginal birth and cesarean section confirms the importance of using research findings to support clinical practice, just as it points to the need to develop further investigations to better understand the multidimensional aspects involving the experience of childbirth.

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Publication Dates

• Publication in this collection
  26 July 2012
• Date of issue
  June 2012