women’s psychosocial outcomes following an emergency ...post-traumatic stress was one of the most...
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RESEARCH ARTICLE Open Access
Women’s psychosocial outcomes followingan emergency caesarean section: Asystematic literature reviewMadeleine Benton1* , Amy Salter2, Nicole Tape1, Chris Wilkinson3 and Deborah Turnbull1
Abstract
Background: Given the sudden and unexpected nature of an emergency caesarean section (EmCS) coupled withan increased risk of psychological distress, it is particularly important to understand the psychosocial outcomes forwomen. The aim of this systematic literature review was to identify, collate and examine the evidence surroundingwomen’s psychosocial outcomes of EmCS worldwide.
Methods: The electronic databases of EMBASE, PubMed, Scopus, and PsycINFO were searched between November2017 and March 2018. To ensure articles were reflective of original and recently published research, the searchcriteria included peer-reviewed research articles published within the last 20 years (1998 to 2018). All study designswere included if they incorporated an examination of women’s psychosocial outcomes after EmCS. Due to inherentheterogeneity of study data, extraction and synthesis of both qualitative and quantitative data pertaining to keypsychosocial outcomes were organised into coherent themes and analysis was attempted.
Results: In total 17,189 articles were identified. Of these, 208 full text articles were assessed for eligibility. Onehundred forty-nine articles were further excluded, resulting in the inclusion of 66 articles in the current systematicliterature review. While meta-analyses were not possible due to the nature of the heterogeneity, key psychosocialoutcomes identified that were negatively impacted by EmCS included post-traumatic stress, health-related qualityof life, experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the mostcommonly examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptomsand diagnosis.
Conclusions: EmCS was found to negatively impact several psychosocial outcomes for women in particularpost-traumatic stress. While investment in technologies and clinical practice to minimise the number ofEmCSs is crucial, further investigations are needed to develop effective strategies to prepare and supportwomen who experience this type of birth.
Keywords: Systematic literature review, Childbirth, Emergency caesarean section, Psychosocial outcomes,Maternal health, Postpartum
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: [email protected] of Psychology, University of Adelaide, Adelaide, South Australia,AustraliaFull list of author information is available at the end of the article
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 https://doi.org/10.1186/s12884-019-2687-7
IntroductionThere has been a dramatic increase in caesarean section(CS) rates around the world over the past three decades,particularly in middle and high income countries [1]. At apopulation level, the World Health Organization has con-cluded that CS rates higher than 10% are not associatedwith reductions in maternal and newborn mortality rates[2]. Despite this, recent data has reported rates of 40.5% inLatin America and the Caribbean, 32.3% in NorthernAmerica, 31.1% in Oceania, 25% in Europe, 19.2% in Asiaand 7.3% in Africa [3]. Globally, CS rates have almost dou-bled between 2000 and 2015, from 12 to 21% [4].CSs are broadly classified depending on whether they
are an elective or emergency procedure. An elective CSis defined as a planned, non-emergency delivery whichoccurs before initiation of labour [5]. In contrast, emer-gency caesarean section (EmCS) is defined as an un-planned CS delivery performed before or after onset oflabour, which is typically urgent and is most often re-quired due to fetal, maternal or placental conditions (eg.fetal distress, eclampsia, placental/cord accidents, uterinerupture, failed instrumental birth etc) [5, 6].While CS has an important place in potentially protect-
ing both mother and baby from harm, it is associated withshort and long term physical and psychological riskswhich can extend many years beyond the current deliveryand effect the health of the woman, her child, and futurepregnancies [7]. In a review of research on the outcomesof CS, Lobel [8] noted that the procedure is uniquely chal-lenging as it combines surgery and birth, events that elicitvery diverse emotional responses. The circumstances sur-rounding an EmCS add an additional layer of complexityto this experience which has thereby prompted re-searchers to explore the psychosocial impact of this typeof birth. The nature of the event accompanied by a seriesof subsequent rapid psychological adjustments may be dis-tressing, anxiety-provoking and emotionally unsettling forwomen [9, 10].The primary outcome of obstetric care, is of course, to
ensure both mother and infant remain physically healthyhowever, psychosocial aspects and outcomes of mater-nity care and obstetrics are no less important [11, 12].Psychosocial outcomes identified and examined in theliterature as potentially related to CS include: mentalhealth problems such as, postpartum depression, post-traumatic stress and anxiety; decreased maternal satis-faction with childbirth; the mother infant relationship;parents’ sexual functioning; and health behaviours suchas infant feeding.
The current studyGiven the nature of EmCS and the increased risk ofpsychological distress for women, it is imperative togain insight into the diverse psychosocial outcomes
for women experiencing this type of birth. Knowledgeand awareness surrounding the impact of EmCS onwomen’s psychosocial outcomes is likely to enhancethe overall quality of maternity care. The aim of thecurrent systematic literature review is to identify, col-late, and examine the evidence surrounding women’spsychosocial outcomes of EmCS.
MethodA systematic literature review constituting a rigorousmethod of research for summarising evidence from mul-tiple studies on a specific topic was undertaken [13, 14].The present study was conducted in accordance withthe Preferred Reporting Items for Systematic Reviewsand Meta-analyses (PRISMA) recommendations [15]. Ana priori designed study protocol guided the literaturesearch, study selection and data synthesis, with quantita-tive meta-analysis attempted when possible. This sys-tematic review was registered in the internationalprospective register of systematic reviews (PROSPERO)database: CRD42018087677.
Search strategyThe search strategy was designed and developed followingconsultation with a health and medical sciences universitylibrarian in order to ensure a comprehensive search and in-crease the robustness of the study [16]. The medical andpsychological electronic databases of EMBASE, PubMed,Scopus, and PsycINFO were searched between November2017 and March 2018. When conducting searches, key-words were combined representing the two primary con-cepts; psychosocial outcomes and EmCS. In this systematicliterature review, psychosocial outcomes were consideredto be variables that encompass social and psychological as-pects of an individual’s life [17]. The Boolean operators‘OR’ and ‘AND’ were utilised to facilitate maximum inclu-sion of relevant articles [18]. Detailed search algorithmsand indexing language used for each database are outlinedin the Additional File 1.To ensure that included articles were reflective of
original and recently published research, limits wereapplied within the literature search to incorporateinclusion criteria such as: research articles, publica-tion within the last 20 years (1998 to 2018), andpeer-reviewed articles [19]. Further, the search waslimited to English language publications due to un-availability of funding for language translation. Greyliterature or trial registries were not persued forpractical purposes.
Eligibility criteriaInclusion and exclusion criteria (based on the PICOS[population, intervention, comparison, outcome, studydesign] framework) were established in advance and
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 2 of 24
documented in the review protocol to identify all pertin-ent studies.
� Population: Women who have delivered via EmCS� Intervention: EmCS� Comparison: Any mode of delivery (MoD) where
reported, otherwise no comparison� Outcomes: Psychosocial variables (i.e. postnatal
depression, anxiety, post-traumatic stress, infantfeeding, sexual functioning, satisfaction, views andexperiences)
� Study Design: Quantitative (excluding case studies),qualitative or mixed methods
Study selectionPotential papers were screened initially by title and ab-stract by two reviewers who reviewed half of papers each(MB and NT) and full texts were retrieved for those cita-tions considered potentially relevant for inclusion. Bothreviewers completed an initial subset of papers togetherin order to ensure consistency in their approach. Refer-ence lists of retrieved full text papers were examined toidentify potentially relevant studies not captured by elec-tronic searches [20]. Full texts of the remaining articleswere independently appraised against the eligibility cri-teria for final inclusion by two reviewers (MB and NT).In case of disagreement in the selection process, a thirdreviewer was available for consultation.
Data extractionUtilising a data extraction form designed by the authors,MB extracted descriptive data on study aims, study de-sign, study location, sample size, data collection period,measures utilised, and included a text description sum-marising the psychosocial and EmCS related findingsfrom each study. These data were cross-checked by NT.A data synthesis of the findings from each article wasthen performed, involving identification of prominentand recurrent themes in the literature and the synthesisof findings from studies under thematic headings. Thisapproach has been described as flexible, allowing consid-erable latitude to systematic reviewers, and provides ameans of integrating qualitative and quantitative evi-dence [20].
Quality assessmentIn line with standard systematic literature review meth-odology a formal methodological quality appraisal ofeach included study was performed using the MixedMethods Appraisal Tool (MMAT) version 11 [21]. Thistool allows for the critical appraisal of quantitative,qualitative, and mixed methods studies and was devel-oped to address some of the challenges of critical ap-praisal in systematic mixed studies reviews. The MMAT
has been validated and used for quality assessment insimilar mixed method systematic reviews [22]. TheMMAT comprises 19 items for appraising the methodo-logical quality of 5 different types of studies: qualitativestudies (4 items), randomised controlled trials (4 items),non-randomized studies (4 items), quantitative descrip-tive studies (4 items), and mixed methods studies (4items). Based on the number of criteria met for an indi-vidual study, the overall quality assessment rating (QAR)is presented using descriptors *, **, ***, and ****, rangingfrom * (single criterion met) to **** (all criteria met).Each study included in the quality assessment was evalu-ated by two independent reviewers (MB and NT). Athird reviewer was available for consultation if disagree-ment occurred.
ResultsStudy selection and characteristicsA summary of the search process is illustrated in Fig. 1,as recommended by the PRISMA guidelines [15]. Intotal 17,189 articles were initially identified. For the ini-tial screening, all search results were imported into cit-ation management software Endnote × 7 where 1068duplicates were identified and removed, leaving 16,121articles (Pubmed, n = 12,960, EMBASE n = 829, Psy-cINFO n = 56, Scopus n = 2276). Titles and abstractswere then assessed by two reviewers (MB, NT), with thisprocess ending with the inclusion of 208 articles. Fulltexts were then retrieved for those citations consideredpotentially relevant and assessed for eligibility by thetwo reviewers (MB, NT). Of these 208 articles, 149 wereexcluded. The most common reason for exclusion was alack of differentiation between type of CS when report-ing study results (see Fig. 1). Reference lists of includedstudies were hand searched by the first author and a fur-ther 7 articles were subsequently included. A total of 66relevant articles [5, 9, 23–86] were thus included in thecurrent systematic literature review.
Description of included studiesCharacteristics of the 66 included studies are presented inTable 1. Studies were conducted in 22 different countrieswith the majority conducted in Sweden (n = 12), followedby the UK (n = 10), and then Nigeria (n = 5). Most studieswere quantitative in nature (n = 51), followed by qualita-tive (n = 14) and just one study with mixed methods.Cross sectional (n = 19) and prospective designs (n = 31)were most prevalent.
Quality assessmentMixed Methods Appraisal Tool quality assessment rat-ings (MMAT QARs) are included in Table 1. Amongthe 51 quantitative non-randomised studies, 14 met allfive criteria, 31 met four criteria, 4 met three criteria and
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 3 of 24
2 met two criteria. Of the 14 qualitative studies, 12met all five criteria. The one study with mixed methodsmet four of the five criteria. The main reason severalquantitative studies did not meet all criteria was a lackof reporting for the complete set of outcomes (withoutadequate justification), response rate or follow-up rate.
Data extraction and synthesisKey psychosocial outcomes were examined in the final66 studies. Data synthesis was employed to extract andsynthesise data pertaining to key psychosocial outcomesfrom each study into coherent themes. Psychosocialoutcomes potentially associated with EmCS includedpostpartum depression, post-traumatic stress, health re-lated quality of life, mother infant bonding, infant feed-ing, sexual function, experiences, satisfaction, self-esteem, distress, and fear. Due to an excess of meth-odological heterogeneity between studies (even for sub-sets of studies with some common features), a meta-analysis was deemed inappropriate. Table 2 summarizesevidence of associations for identified psychosocial out-comes and EmCS.
Key outcomesPostpartum depressionTwelve studies examined depression as an outcome ofEmCS [33, 36, 38, 43, 45, 51, 60, 62, 71, 80, 85, 87]. Thesestudies used varying measures, with the majority (n= 8) uti-lising the Edinburgh Postnatal Depression Scale (EPDS),three using Beck’s Depression Inventory (BDI) and onestudy not specifying the measure used. Studies identified re-ported mixed findings in terms of postpartum depression(PPD) and the experience of EmCS. The majority of studiesfound no significant association between having an EmCSand PPD relative to other MoDs [33, 38, 43, 45, 62, 80, 85].For example, a prospective cohort study (n = 10, 934) fromthe UK found no significant evidence of increased risk ofPPD between different MoDs including EmCS [62]. In con-trast, a much smaller prospective cohort study reportedEmCS was a predictor of PPD [51]. Additionally, a recentcross-sectional study conducted in Iran [71] reported thatthe prevalence of PPD was 33.4%, of which the highest pro-portion consisted of women who had experienced EmCS at41.3%. Furthermore, a recent large longitudinal study foundthat compared with spontaneous VD, women who delivered
Fig. 1 Search and Selection Flow Diagram
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 4 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Adams,
2012
Toassess
theassociation
betw
eenmod
eof
delivery
(MoD
)andmaternal
postpartum
emotional
distress.
Prospe
ctive
Coh
ort
Norway
55,814
17&30
weeks
gestation
and6
mon
ths
postpartum
1998–2008
Shortform
oftheHop
kins
Symptom
Che
cklist-25
(SCL-8)
Emotional
Distress
MoD
was
notassociated
with
thepresen
ceof
emotionald
istress
postpartum
.
*****
Ade
wuya,
2006
Toestim
atetheprevalen
cePTSD
afterchildbirthandto
exam
ineassociated
factors.
Cross-
sectional
Nigeria
876
6weeks
postpartum
2004
MINIInternatio
nal
Neuropsychiatric
Interview,
Inde
xof
marital
satisfaction,Med
ical
Outcomes
Stud
ySocial
Supp
ortSurvey,Life
even
tsscale,Labo
uragen
tryscale
PTSD
Instrumen
tald
eliveryand
Emerge
ncyCaesarean
Section(EmCS)
were
associated
with
PTSD
,while
electivecaesareansection
(ElCS)
sections
show
edno
sign
ificant
effect.
*****
Ahluw
alia,
2012
Toassess
therelatio
nship
betw
eenMoD
and
breastfeed
ing.
Prospe
ctive
long
itudinal
United
States
3026
Before
birth
and10
times
durin
gthe
year
after
birth.
2005–2006
Stud
yspecific
Breastfeed
ing
Med
ianbreastfeed
ing
duratio
nwas
20.6weeks
for
EmCS.Breastfeed
ing
duratio
nam
ongwom
enwho
initiated
breastfeed
ing
show
that
theprevalen
ceof
breastfeed
ingat
any
timethroug
h60
weeks
afterde
liverywas
lowest
forthosewho
hadindu
ced
VDor
EmCSthan
amon
gthosein
theothe
rtw
ogrou
ps(spo
ntaneo
usVD
orplanne
dCS).
Beck,2008
Toexploretheim
pact
ofbirthtraumaon
mothe
rs’
breastfeed
ingexpe
riences.
Qualitative
New
Zealand,
US,
Australia,
UK,Canada
52Unspe
cified
Unspe
cified
Stud
yspecific
Infant
feed
ing
Wom
enrepe
ated
lyexplaine
dthat
their
decision
tobreastfeed
was
driven
bytheirne
edto
makeam
ends
tothe
infantsforthetraumatic
way
they
hadarrived
into
theworld,for
exam
ple,by
EmCS.
*****
Baas,2017
Toun
derstand
the
relatio
nshipbe
tweenclient-
relatedfactorsandtheex-
perienceof
midwifery
care
durin
gchildbirthto
im-
provecare.
Prospe
ctive
long
itudinal
Nethe
rland
s2377
20and34
weeks
preg
nant
and6weeks
postpartum
2009–2011
Stud
yspecificandLabo
urAge
ncyScale
Expe
rienceof
care
MoD
effected
expe
riences
ofcare.W
omen
who
had
anun
planne
dCSwere
morelikelyto
indicate
that
they
hadreceived
“less
than
good
”midwifery
care
durin
gchildbirth.
****
Baston
,2008
Toexam
inewhatfactors
relate
towom
en’sappraisal
oftheirbirththreeyears
later.
Prospe
ctive
Coh
ort
England
and
Nethe
rland
s
2048
3years
postpartum
2003–2004
Stud
yspecific
Satisfactionof
expe
rience
EmCSwas
afactor
contrib
utingto
ane
gative
appraisalo
fbirthin
Englandandthe
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 5 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Nethe
rland
s.
Bergant,
1998
Tostud
ythesubjective
psycho
logicaland
physical
stressfulexperienceof
childbirthbu
rden
.
Cross-
sectional
Austria
1250
5days
postpartum
1993–1994
EPDS,Trait-Anxiety
Inven-
tory,Burde
nof
childbirth
Burden
ofchildbirth
Wom
enwho
expe
rienced
emerge
ncysurgical
interven
tion(EmCSand
vacuum
extractio
n)de
mon
stratedhigh
erchildbirthbu
rden
scores.
****
Bryanton
,2008
Tode
term
inefactorsthat
pred
ictwom
en’s
percep
tions
ofthe
childbirthexpe
rienceand
toexam
inewhe
ther
these
vary
with
thetype
ofbirth
awom
anexpe
riences.
Prospe
ctive
coho
rtCanada
652
12–47h
postpartum
2004–2005
Questionn
aire
Measurin
gAttitu
desAbo
utLabo
urandDelivery
Percep
tions
ofbirth
Wom
enwho
hada
planne
dCSbirthscored
sign
ificantlylower
onbirth
percep
tionthan
thosewho
hadan
EmCSor
aVD
.
****
Burche
r,2016
Toelicitwom
en’snarratives
oftheirun
planne
dCS
births
toiden
tifypo
tentially
alterablefactorsthat
contrib
uteto
CSregret.
Qualitative
United
States
142–6weeks
postpartum
Unspe
cified
Stud
yspecific
Regret
and
dissatisfaction
Four
keythem
esem
erge
dfro
mpatients’un
planne
dCSnarratives:p
oor
commun
ication,fear
ofthe
operatingroom
,distrustof
themed
icalteam
,and
loss
ofcontrol.
*****
Carqu
illat,
2016
Tocompare
subjective
childbirthexpe
rience
accordingto
different
deliverymetho
ds.
Cross-
sectional
Switzerland
andFrance
291
4–6weeks
postpartum
2014–2015
Questionn
aire
for
Assessing
Childbirth
Expe
rience
Childbirth
Expe
rience
Wom
enwho
hadan
EmCS
wereat
high
estriskof
expe
riencingchildbirthin
ane
gativeway.
****
Che
n,2002
Tocompare
wom
enwho
hadaVD
with
thosewho
hadaCSin
depression
,pe
rceivedstress,social
supp
ort,andself-esteem
.
Cross-
sectional
Taiwan
357
6-weeks
postpartum
1999
TheBeck
Dep
ression
Inventory,ThePerceived
Stress
Scale,The
Interpersonal
Supp
ortEvaluationList
(ISEL)ShortForm
,Coo
persmith
’sSelf-Esteem
Inventory
Dep
ression,
perceivedstress,
socialsupp
ort,
self-esteem
Therewas
noassociation
foun
din
thisstud
ybe
tweenthetype
ofCS
(plann
edor
emerge
ncy)
andpsycho
socialmeasures.
*****
Creed
y,2000
Tode
term
inetheincide
nce
ofacutetraumasymptom
sandPTSD
inwom
enas
aresultof
theirlabo
urand
birthexpe
riences,and
toiden
tifyfactorsthat
contrib
uted
tothe
wom
en’spsycho
logical
distress.
Prospe
ctive
Long
itudinal
Australia
499
4–6weeks
postpartum
1997–1998
PosttraumaticStress
Symptom
sinterview
PTSD
Theexpe
rienceof
anEm
CS
was
correlated
with
the
developm
entof
trauma
symptom
s.
****
Durick,2000
Toexam
ineifun
planne
dCSwou
ldbe
relatedto
less
optim
alou
tcom
esandthat
thisrelatio
nshipwou
ldbe
Long
itudinal
coho
rtUnited
States
570
4and12
mon
ths
postpartum
Unspe
cified
TheEysenckPerson
ality
InventoryForm
,The
Cen
treforEpidem
iologic
Stud
iesDep
ressionScale,
Mothe
r-infant
interactions,
Neuroticism,
Dep
ression,Self-
Thepsycho
logical
expe
riences
associated
with
deliveryby
unplanne
dCS,
byplanne
dCS,or
VDare
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 6 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
med
iatedby
mothe
r’sappraisalo
fthe
delivery
andwou
ldattenu
ateover
time.
Rosenb
erg’s(1965)
self-
esteem
scale
esteem
,ap-
praisalo
fthe
birthexpe
rience.
distinct,and
unplanne
dCS
deliveriesareappraised
mostne
gatively.
Eckerdal,
2017
Toexploretheassociation
betw
eenMoD
and
postpartum
depression
.
Long
itudinal
coho
rtSw
eede
n3888
118th
gestational
week,the
32nd
week
of preg
nancy,
at6weeks,
6mon
ths
postpartum
2009–2014
EPDS
Postpartum
depression
Ahigh
erprevalen
ceof
depressive
symptom
sat
6weeks
postpartum
was
notedam
ongwom
enwho
delivered
byEm
CS,
whe
reas
nosign
ificant
associationwith
MoD
was
foun
dregardingPPDat
six
mon
thspo
stpartum
.
*****
Enabud
oso,
2011
Toassess
theprevalen
ceof
satisfaction,andassociated
factors,am
ongwom
enwho
hadrecentlyde
livered
byCS.
Cross-
sectional
Nigeria
211
2–5days
postpartum
2010
Stud
ysepcific
Satisfaction
Satisfactionwith
CSwas
sign
ificantlyhigh
eram
ong
wom
enwho
hadElCSas
comparedwith
EmCS.
***
Fenaroli,
2016
Toexploretheinfluen
ceof
cogn
itive
andem
otional
variables
onlabo
urand
deliveryou
tcom
esand
exam
ineho
windividu
alcharacteristics,coup
leadjustmen
t,andmed
ical
factorsinfluen
cethe
childbirthexpe
rience.
Long
itudinal
coho
rtItaly
121
Betw
een32
and37
weeks
ofpreg
nancy
and30–40
days
postpartum
2010–2012
Wijm
aDeliveryExpe
ctancy
Questionn
aire,EPD
S,DyadicAdjustm
entScale
Childbirth
expe
ctations,
depression
Therewas
norelatio
nship
foun
dbe
tweenMoD
and
perceivedem
otional
expe
rience.
****
Fenw
ick,
2009
Toexplorewom
en’s
expe
riences
ofCS.
Qualitative
England
21Betw
een7
and32
weeks
postpartum
1999–2000
Expe
riences
Feelings
offailure
were
presen
twhe
ther
orno
tthe
CSwas
planne
dor
anem
erge
ncy,andthese
feelings
hadan
impact
ontheirstatus
passageto
mothe
rhoo
dforseveral
reason
s.Thesurgery
resultedin
theloss
ofwom
en’sfamiliar,normal,
healthybo
dy.From
their
perspe
ctive,theirbo
dyhad
letthem
down,de
nying
them
ano
rmalbirth.
*****
Forti-Buratti,
2017
Tocompare
themothe
r-to-
infant
bond
ofmothe
rswho
gave
birthby
elective
C-sectio
nversus
EmCS.
Prospe
ctive
coho
rtSpain
116
48–72hand
10–12weeks
afterde
livery
Not
specified
Mothe
r-to-In
fant
Bond
ing
Scale,respon
sesto
separatio
n
Mothe
r-infant
bond
ing
Nosign
ificant
differences
betw
eenthetw
oCSin
bond
ing,
newbo
rnrespon
seto
separatio
nor
type
offeed
ingwere
observed
atanytim
e
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 7 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
points.
Furuta,2016
Toiden
tifyfactors
associated
with
birth-
relatedpo
st-traum
aticstress
symptom
sdu
ringtheearly
postnatalp
eriod.
Prospe
ctive
coho
rtEngland
1824
6–8weeks
postpartum
2010
Impact
ofEven
tScale
PTSD
EmCSwas
ahigh
riskfactor
forpo
st-traum
aticstress
symptom
s.
*****
Gam
ble,
2005
Toexam
inetherelatio
nship
betw
eenMoD
and
symptom
sof
psycho
logical
traumaat
4–6weeks
postpartum
Prospe
ctive
coho
rtAustralia
400
72hand4–
6weeks
postpartum
2001–2002
Mini-Internatio
nal
Neuropsychiatric
Interview-
Post-Traum
aticStress
Dis-
orde
r(MINI-PTSD)
PTSD
Wom
enwho
hadan
EmCS
orop
erativeVD
weremore
likelyto
meetthe
diagno
sticcriteria
forPTSD
than
wom
enwho
hadan
ElCSsectionor
spon
tane
ousVD
.
****
Gaillard,
2014
Toiden
tifysocio-
demog
raph
ic,p
sychosocial
andob
stetricalriskfactors
ofpo
stpartum
depression
.
Prospe
ctive
coho
rtFrance
312
32–41weeks
gestation,
and6
–8weeks
postpartum
2007–2009
EPDS(Frenchversion)
Dep
ression
Wom
enwith
PNDdidno
tdifferfro
mtheothe
rsin
MoD
(spo
ntaneo
usvaginal,
assisted
vaginal,Em
CSor
ECS).
****
Gibbins,
2001
Toexplore,de
scrib
eand
unde
rstand
the
expe
ctations
durin
gpreg
nancyandsubseq
uent
expe
riences
ofchildbirthin
wom
en.
Qualitative
England
82weeks
post
birth
Unspe
cified
Stud
yspecific
Expe
riences
Wom
enexpressedpo
sitive
feelings
abou
ttheirlabo
urs,
even
thou
ghallw
omen
felt
that
labo
urwas
different
towhatthey
hadexpe
cted
.
*****
Goker,2012
Tode
term
inetheeffect
ofMoD
ontheriskof
postpartum
depression
.
Cross-
sectional
Turkey
318
6weeks
postpartum
Unspe
cified
EPDS
Dep
ression
Deliveringby
spon
tane
ous
VD,ECS,or
EmCShadno
effect
onEPDSscores.
***
Graham,
1999
Toassess
thede
gree
and
nature
ofwom
en’s
involvem
entin
thede
cision
tode
liver
byCSsection,
andwom
en’ssatisfaction
with
thisinvolvem
ent.
Qualitative
Scotland
166
3–4days
and
6–12
weeks
postpartum
1995–1996
Stud
yspecific
Satisfactionand
decision
making
Wom
enun
dergoing
ElCS
sectionge
nerally
received
adeq
uate
inform
ation;
however,w
ithEm
CS,half
ofthewom
enhadno
treceived
enou
ghinform
ationdu
ring
preg
nancy.Asign
ificant
prop
ortio
nof
wom
enexpe
rienced
negative
feelings,p
articularlywith
EmCS(30%
).
****
Guittier,
2014
Tode
term
ineim
portant
elem
entsassociated
with
firstde
liveryexpe
rience
accordingto
theMoD
.
Qualitative
Switzerland
244–6weeks
postpartum
2012
Stud
yspecific
Expe
riences
TheMoD
directlyim
pacted
onkeyde
liveryexpe
rience
determ
inantsas
perceived
control,em
otions,and
the
firstmom
entswith
the
newbo
rn.
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 8 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Hande
lzalts,
2017
Tocompare
theim
pactson
childbirthexpe
rienceof
`plann
ed’d
elivery(elective
CSandvaginald
elivery)
versus
`unp
lann
ed’d
elivery
(vacuu
mextractio
nor
EmCS).
Cross-
sectional
Israel
469
Upto
72h
postpartum
2014–2015
SubjectiveChildbirth
Expe
rienceQuestionn
aire
andPerson
alInform
ation
Questionn
aire
Expe
rience
Une
xpectedMoD
(EmCS)
results
inamorene
gative
birthexpe
riencethan
aplanne
dMoD
.
*****
Herishanu
-Gilutz,2009
Toexam
inethesign
ificance
ofthesubjective
expe
rienceof
mothe
rswho
gave
birthby
anEm
CS.
Qualitative
Finland
104–6mon
ths
Unspe
cified
Stud
yspecific
Expe
riences
Them
eswereiden
tified
relatedto
thetraumatic
expe
rienceof
the
operation,e.g.senseof
loss
ofcontrolreg
arding
the
decision
toop
erate,feeling
offear
andange
rtoward
thecaretaking
staff.
*****
Hob
bs,2016
Toexam
ineMoD
and
breastfeed
inginitiation,
duratio
n,anddifficulties
repo
rted
bymothe
rsat
4mon
thspo
stpartum
.
Prospe
ctive
Coh
ort
Canada
3021
34–36weeks
gestation
and12–14
mon
ths
postpartum
2008
Unspe
cified
Infant
feed
ing
Wom
enwho
delivered
byEm
CShadahigh
erprop
ortio
nof
breastfeed
ing
difficulties
(41%
),andused
moreresourcesbe
fore
(67%
)and
after(58%
)leavingtheho
spital,whe
ncomparedto
VD(29,40,
and52%,respe
ctively)or
planne
dCS(33,49,and
41%,respe
ctively).
****
Iwata,2015
Toiden
tifyfactorsfor
pred
ictin
gpo
st-partum
de-
pressive
symptom
safter
childbirthin
Japane
sewom
en.
Prospe
ctive
Coh
ort
Japan
479
1daybe
fore
hospital
discharge,1,
2,4,and6
mon
ths
post-partum.
2012–2013
EPDS,ThePo
stnatal
Accum
ulated
Fatig
ueScale,ThePo
stpartum
MaternalC
onfid
ence
Scale,
TheChildcare
ValueScale
Dep
ression
Sixvariables
reliably
pred
ictedtheriskof
postpartum
depression
includ
ingEm
CS.
*****
Jansen
,2007
Toinvestigatefatig
ueand
HRQ
oLin
wom
enafterVD
,ElCS,andEm
Cs.
Prospe
ctive
coho
rtNethe
rland
s141
12–24hafter
VDand24-
48hafterCS
and1,3,
weeks
postpartum
2003–2004
TheMultid
imen
sion
alFatig
ueInventory,EuroQoL
5D,Sho
rt-Form
36
HRQ
oLPatientsafterVD
had
high
ermeanph
ysical
HRQ
oLscores
than
afterCS.
Theaveragepe
riodto
reachfullph
ysicalrecovery
was
3weeks
afterVD
,6weeks
afterelectiveCS,and
6weeks
afterEm
CS.
*****
Karlström
,2017
Tocompare
self-repo
rted
birthou
tcom
esforwom
enun
dergoing
birththroug
hspon
tane
ouson
setof
labo
urbe
tweenthosewho
actuallyhadavaginalb
irth
andthosewho
even
tually
Prospe
ctive
Long
itudinal
Swed
en870
Mid
preg
nancy
(18–19
weeks),late
preg
nancy
(32–34
weeks),2
Unspe
cified
Stud
yspecific
Birthfear
and
expe
rience
Birthexpe
rienceweremore
amon
gwom
enhaving
anEm
CS.
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 9 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
hadan
EmCS.
mon
thsand
1year
postpartum
/
Karlstrom
,2007
Toinvestigatewom
en’s
expe
rienceof
postop
erative
pain
andpain
reliefafterCS
andfactorsassociated
with
pain
assessmen
tandthe
birthexpe
rience.
Cross-
sectional
Swed
en60
2–9days
postpartum
2004
and
2005
TheVisualAnalogScale,
andstud
yspecific
Expe
riences
Theriskof
ane
gativebirth
expe
riencewas
80%
high
erforwom
enun
dergoing
anEm
CScomparedwith
electiveCS.
***
Loto,2010
Toexam
inetheassociation
betw
eentheMoD
,self-
esteem
,and
parentingself-
efficacybo
that
delivery
andat
6weeks
postpartum
.
Prospe
ctive
coho
rtNigeria
115
Priorto
hospital
discharge
and6weeks
postpartum
2007–2008
Rosenb
ergself-esteem
scaleandparent–child
re-
latio
nshipqu
estio
nnaire
Self-esteem
Factorsthat
were
sign
ificantlyassociated
with
low
self-esteem
includ
ebe
-ingsing
leandhaving
EmCS.
***
Loto,2009
Toassess
thelevelo
fself-
esteem
ofne
wlyde
livered
mothe
rswho
hadCSande
-valuatethesociod
emo-
graphicandob
stetrics
correlates
oflow
self-
esteem
inthem
.
Cross-
sectional
Nigeria
109
2007–2008
Rosenb
ergself-esteem
scale
Self-esteem
EmCScloselycorrelated
with
low
self-esteem
inwom
enwho
hadCS.
****
Lurie,2013
Toevaluate
sexual
behaviou
rlong
itudinally
inthepo
stpartum
perio
dby
MoD
.
Prospe
ctive
coho
rtIsrael
826,12,and
24weeks
postpartum
2010–2011
FemaleSexualFunctio
nInde
xSexualFunctio
nSexualfunctio
ndidno
tdiffersign
ificantlyby
MoD
at6,12,or24
weeks
postpartum
.
****
Maclean,
2000
Toexam
inewom
en’s
distress
inrespon
seto
one
offour
obstetric
proced
ures:spo
ntaneo
usVD
;ind
uced
VD;
instrumen
talV
D;or,Em
CS.
Cross-
sectional
England
406weeks
postpartum
1996–1997
Impact
ofEven
tScale,
HospitalA
nxiety
and
Dep
ressionScale
Expe
rience,
wellbeing
,distress
Wom
enwho
gave
birth
assisted
byinstrumen
tal
deliveryrepo
rted
the
childbirtheven
tas
distinctlymoredistressing
than
thewom
enin
the
othe
rthreeob
stetric
grou
ps(VD;ind
uced
VD;
EmCS).
****
Mod
arres,
2012
Toestim
atetheprevalen
ceof
childbirth-relatedpo
st-
traumaticstress
symptom
sandits
obstetric
andpe
ri-natalriskfactors.
Cross-
sectional
Iran
400
6–8weeks
afterbirth
2009
Post-traum
aticSymptom
Scale-Interview
PTSD
EmCSwas
asign
ificant
contrib
utingfactor
toPTSD
afterchildbirth.
****
Noyman-
Veksler,
2015
Toinvestigatethe
protectiveroleof
senseof
cohe
rence(SOC)a
ndpe
rceivedsocialsupp
ortin
theeffect
ofEm
CS/ELCSon
postnatalp
sycholog
ical
symptom
sandim
pairm
ent
Prospe
ctive
Long
itudinal
Israel
142
6and12
weeks
postpartum
Unspe
cified
Post-partum
bond
ing
questio
nnaire,Post-
traumaticdiagno
sticscale,
Edinbu
rghpo
st-natalde
-pression
questio
nnaire,
Senseof
cohe
rence,Social
supp
ortqu
estio
nnaire
Dep
ression,
bond
ing,
PTSD
,socialsupp
ort
Noeffect
was
foun
dof
the
MoD
onbo
ndingwith
the
infant.A
nEm
CSpred
icted
anincrease
inPTSD
symptom
sin
Time2,bu
ton
lyam
ongwom
enwith
low
levelsof
Time-1social
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 10 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
inmothe
r–infant
bond
ing.
supp
ort.
O’Reilly,
2014
Toestablishagreater
unde
rstand
ingof
the
emotionaland
cogn
itive
mechanism
sassociated
with
CS.
Cross-
sectional
France
201
Atleast6–8
weeks
postpartum
2011–2012
Labo
urAge
ntry
Scale,
MaternalSelfR
eport
Inventory,Uncon
ditio
nal
Self-
Accep
tanceQ
uestionn
aire
Senseof
control
durin
gthe
delivery,
maternalself-
esteem
self-
acceptance
Senseof
controld
uring
labo
urandde
liverywas
sign
ificantlyhigh
erfor
wom
enwho
hada
spon
tane
ousVD
whe
ncomparedto
thosewho
hadun
dergon
ean
instrumen
talV
D,a
planne
d,or
anEm
CS.
*****
Patel,2005
Toassess
theassociation
betw
eenelectiveCS
sectionandPD
compared
with
planne
dVD
and
whe
ther
EmCSor
assisted
VDisassociated
with
PDcomparedwith
spon
tane
ousvaginal
delivery.
Prospe
ctive
coho
rtUK
10,934
8weeks
postpartum
1991–1992
EPDS
Dep
ression
Noincreasedriskof
PDwas
foun
dbe
tweenMoD
.*****
Porter,2007
Toexplorethefactorsthat
wom
eniden
tifiedas
distressingso
asto
unde
rstand
theirrespon
ses
tostandard
questio
nson
satisfaction.
Mixed
metho
dsScotland
1661
Upto
22years
postpartum
2002
Stud
yspecific
Distress
Manywom
enhadne
ver
hadan
operationbe
fore
andthefact
that
theirCS
was
classifiedas
an“emerge
ncy”
frigh
tene
dthem
.
****
Redshaw,
2010
Togain
abe
tter
unde
rstand
ingof
CSby
investigatingwom
en’s
recent
expe
riences
and
reflections
ontheircare.
Qualitative
England
2960
3mon
ths
postpartum
2006
Stud
yspecific
Expe
riences
with
care
Fear
andconfrontation
with
theun
expe
cted
were
them
esiden
tifiedfro
mwom
enwho
hadan
EmCS.
*****
Rowland
s,2012
Toexam
inetheph
ysical
andpsycho
logical
outcom
esof
wom
enin
the
firstthreemon
thsafter
birth,andwhe
ther
these
variedby
MoD
.
Cross-
sectional
England
5332
3mon
ths
postpartum
2010
Stud
yspecific
PTSD
and
gene
ral
psycho
logical
outcom
es
Wom
enhaving
unplanne
dCSsectionbirths
were
marginally
morelikelyto
repo
rtPTSD
-typesymp-
toms,ho
wever,the
rewas
noassociationbe
tween
PTSD
type
symptom
sand
planne
dCSsectionbirths.
****
Ryding
,1998
Tode
scrib
ewom
en’s
thou
ghtsandfeelings
durin
gtheprocessof
ade
liverythat
ende
din
anEm
CS,to
ascertainifan
EmCSmight
fulfilthe
stressor
criterio
nPTSD
accordingto
DMSIV.
Qualitative
Swed
en53
2days
after
birth
Unspe
cified
Stud
yspecific
PTSD
and
Expe
riences
55%
ofwom
enexpe
rienced
intensefear
for
theirow
nlifeor
that
oftheirbaby.8%
feltvery
badlytreatedby
thestaff.
Alm
ostallw
omen
had
adeq
uate
know
ledg
eof
the
reason
sfortheEm
CS.
*****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 11 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Ryding
,Wijm
a1998
Tocompare
the
psycho
logicalreactions
ofwom
enafterEm
CS,ElC,
instrumen
talV
D,and
norm
alVD
.
Prospe
ctive
coho
rtSw
eden
326
2days
and1
mon
thpo
stpartum
1992–1993
Wijm
aDeliveryExpe
ctancy
Expe
rienceQuestionn
aire
theIm
pact
ofEven
tSelf-
Ratin
gScaleI,35-item
ver-
sion
oftheSymptom
sChe
ckList
Expe
riences
and
trauma
TheEm
CSgrou
prepo
rted
themostne
gativede
livery
expe
rienceat
both
times,
followed
bythelVDgrou
p.Atafew
days
postpartum
theEm
CSgrou
pexpe
rienced
morege
neral
men
tald
istressthan
theVD
grou
p,bu
tno
twhe
ncomparedwith
theElCSor
theinstrumen
talV
Dgrou
ps.A
t1mon
thpo
stpartum
theEm
CS
grou
pshow
edmore
symptom
sof
post-
traumaticstress
than
the
ECSandinstrumen
talV
Dgrou
ps,b
utno
twhe
ncom-
paredto
theVD
grou
p.
****
Ryding
,2000
Toinvestigatethe
possibility
tocatego
rize
wom
en’sexpe
riences
ofEm
CSbasedon
the
patterns
displayedin
their
narrationof
theeven
t,and
tode
scrib
etypicalfeatures
ofthosecatego
ries.
Qualitative
Swed
en25
Afew
days
and1–2
mon
ths
postpartum
.
Unspe
cified
Stud
yspecific
Expe
riences
Thenarratives
ofthe25
wom
enwerecatego
rized
asfollows:Pattern1-
confiden
cewhatever
happ
ens(n
5);Pattern
2-
positiveexpe
ctations
turninginto
disapp
ointmen
t(n
7);
Pattern3-fearsthat
come
true
(n9);and
Pattern4-
confusionandam
nesia(n
4).
*
Safarin
ejad,
2009
Toqu
antifytherelatio
nship
betw
eenMoD
and
subseq
uent
incide
nceof
sexualdysfun
ctionand
impairm
entof
quality
oflife
(QOL)
both
inwom
enand
theirhu
sbands.
Prospe
ctive
coho
rtIran
912
Everymon
thpo
stde
liveryupto
12mon
ths.
2006–2007
FemaleSexualFunctio
nInde
x(FSFI),and
InternationalInd
exof
ErectileFunctio
n(IIEF),
SexualFunctio
n,QoL
Wom
enwith
VDandEm
CS
hadstatisticallysign
ificant
lower
FemaleSexual
Functio
nInde
x(FSFI)scores
ascomparedwith
planne
dCSSectionwom
en
*****
Saisto,2001
Toexam
inetheextent
towhich
person
ality
characteristics,de
pression
,fear
andanxiety
abou
tpreg
nancyandde
livery,
andsocio-econ
omicback-
grou
nd,p
redict
disapp
oint-
men
twith
deliveryandthe
riskof
puerpe
rald
epression.
Prospe
ctive
Long
itudinal
Finland
211
Onceafter
the
30thweekof
preg
nancy,
and2–3
mon
thsafter
delivery
Unspe
cified
Beck’sDep
ression
Inventory,theNEO
-PIScale
forne
uroticism,a
partne
r-ship
satisfactionscale,a
Preg
nancyAnxiety
Scale,a
revisedversionof
afear-of-
childbirthqu
estio
nnaire
Disappo
intm
ent
with
delivery
andsatisfaction
Strong
estpred
ictorsof
disapp
ointmen
twith
deliverywerelabo
urpain
andEm
CS.
*****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 12 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Sarah,2017
Toinvestigatethe
relatio
nshipbe
tweentype
ofde
liveryandpo
stpartum
depression
.
Cross-
sectional
Iran
Unspe
cifed
Unspe
cified
2013
Beck
depression
inventory
Dep
ression
Theprevalen
ceof
postpartum
depression
is33.4%,respe
ctively,of
which
13.8%
relatedto
EmCS,7.2%
ofvaginal
deliveries,and8%
ofelectiveCS.
**
Shorten,
2014
Toexplorewom
en’svalues
andexpe
ctations
durin
gtheirprocessof
decision
makingabou
tthene
xtbirth.
Qualitative
Australia
187
36–38weeks
preg
nant
and6–8
weeks
postpartum
Unspe
cified
Stud
yspecific
Decisions
after
priorCS
Wom
ende
scrib
edlong
labo
ursen
ding
inCSdid
notwantto
gothroug
hit
again,andespe
ciallydid
notwantto
repe
atthe
“emerge
ncy”
scen
ario.
Manyde
scrib
edasenseof
loss
aftertheprevious
CS
expe
rienceandexpresseda
person
alne
edto
remed
ythisfeelingthroug
ha
better
expe
riencein
the
next
birth.“After
anem
erge
ncyCSIfeltIh
adfailed,
Ifeltcheatedof
the
childbirthexpe
rienceIh
adwanted”.
*****
Sode
rquist,
2002
Tostud
ywhe
ther
orno
ta
morestressfuld
eliverywas
positivelyrelatedto
traumaticstress
after
childbirth.
Cross-
sectional
Swed
en1550
Unspe
cified
1994–1995
Traumaticeven
tscale
Traumaticstress
Traumaticstress
symptom
sandhaving
aPTSD
symptom
profile
werebo
thsign
ificantlyrelatedto
the
expe
rienceof
anEm
CSor
aninstrumen
talV
D.
****
Somera,
2010
Toexplorewom
en’s
expe
rienceof
anEm
CS
birthto
gain
abe
tter
unde
rstand
ingof
their
thou
ghts,and
feelings
throug
hout
thebirth
process.
Qualitative
Canadian
91–5days
afterbirth
and11–27
days
after
birth
Not
specified
Ope
n-en
dedqu
estio
nsExpe
rience
Seventhem
eswere
iden
tifiedde
scrib
ingthe
wom
en’sexpe
rience:(1)It
was
forthebe
st,(2)
Idid
nothave
control,(3)
Everything
was
goingto
beokay,(4)
Iwas
sodisapp
ointed
,(5)
Iwas
soscared
,(6)
Icou
ldno
tbe
lieve
itand(7)Iw
asexcited.
*****
Spaich,2013
Toinvestigatetheextent
towhich
satisfactionwith
childbirthde
pend
son
the
MoD
,and
evaluatedfactors
determ
iningpo
stpartum
satisfaction.
Prospe
ctive
coho
rtGermany
335
Unspe
cified
2010–2011
Salm
on’sItem
List
Expe
rience
Therewereno
wom
enin
thesubg
roup
with
EmCS
who
scoreindicatin
gan
overalln
egativebirth
expe
rience.Thesubjective
expe
rienceof
birthwas
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 13 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
describ
edas
‘goo
d/very
good
’in89%
ofthe
wom
enwho
unde
rwen
tEm
CS.
Storksen
,2013
Toassess
therelatio
nbe
tweenfear
ofchildbirth
andprevious
birth
expe
riences.
Prospe
ctive
coho
rtNorway
1657
Weeks
17and32
preg
nant
2009–2011
Wijm
aDeliveryExpe
ctancy
Questionn
aire
Fear
EmCSandvacuum
extractio
nwereassociated
with
fear
ofchildbirthin
subseq
uent
preg
nancies.
*****
Tham
,2007
Toexam
inethe
associations
betw
eenne
wmothe
r’ssenseof
cohe
rence(SOC)a
ndob
stetric
andde
mog
raph
icvariables
afew
days
postpartum
,and
post-
traumaticstress
symptom
s3mon
ths’po
stpartum
inre-
latio
nto
wom
enwho
had
unde
rgon
ean
emerge
ncy
CSsection.
Prospe
ctive
coho
rtSw
eden
122
2days
and3
mon
thpo
stpartum
Not
specified
Senseof
Coh
eren
ceScale
(SOC-13),Impact
ofEven
tScale(IES-15).
PTSD
25%
ofthewom
enrepo
rted
symptom
sof
post-traum
aticstress
toa
mod
eratede
gree
(indicat-
ingane
edforfollow-up),
and9%
hadahigh
degree
ofsymptom
s(indicatin
gpo
ssiblePTSD
).
****
Tham
,2010
Tode
scrib
ewom
enwith
andwith
outsymptom
sof
post-traum
aticstress
follow-
ingEm
CS,andho
wthey
perceivedthesupp
ortre-
ceived
inconn
ectio
nwith
thebirthof
theirchild.
Qualitative
Swed
en84
6–7mon
ths
postpartum
Not
specified
Questions
seekingthe
wom
en’se
xperienced
social
andem
otionalsup
port
from
thestaffand
from
theirfamilies
Expe
rienceand
supp
ort
Themidwives’action,the
conten
tandorganisatio
nof
care,the
wom
en’s
emotions,and
theroleof
thefamily
weremain
catego
riesthat
seem
edto
influen
cetheinterviewees’
percep
tions
ofsupp
ortin
conn
ectio
nwith
childbirth.
Wom
enwith
PTSS
furthe
rmen
tione
dne
rvou
sor
non-
interested
midwives,in-
tensefear
andfeelings
ofsham
edu
ringde
livery,lack
ofpo
stnatalfollow-up,
long
-term
postpartum
fati-
gueandinadeq
uate
help
from
husbands
asinfluen
-cing
factors.Wom
enwith
-ou
tsymptom
srepo
rted
involvem
entin
theEm
CS
decision
andafeelingof
relief.
****
Trivino-
Juarez,2017
Tocond
uctalong
itudinal
stud
yto
analysedifferences
inHRQ
oLat
thesixthweek
andsixthmon
th
Prospe
ctive
Long
itudinal
Spain
547
6weeks
and
6mon
ths
postpartum
2013–2014
EPDS,SF-36
HRQ
oLWom
enwho
hadvaginal,
forcep
sor
vacuum
-extractio
nbirths
atthesixth
weekpo
stpartum
repo
rted
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 14 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
postpartum
,with
mod
eof
birthas
themain
inde
pend
entvariable.
better
physicalfunctio
ning
than
wom
enwho
had
electiveor
EmCS.Atthe
sixthmon
thpo
stpartum
,asign
ificantlyhigh
erprop
or-
tionof
wom
enin
thefor-
ceps
grou
p(34%
)thanin
theEm
CSgrou
p(15%
)re-
ported
beingless
satisfied
with
theirsexualrelatio
nsthan
before
preg
nancy.
Tully,2013
Toexam
inewom
en’s
expe
riences
ofand
explanations
for
unde
rgoing
cesarean
delivery.
Qualitative
England
115
Not
specified
2006–2009
Stud
yspecific
Expe
riences
Allmothe
rsde
scrib
edlabo
urpriorto
their
unsche
duledcaesareans
aswastedeffort.
*****
Ukpon
g,2006
Toinvestigatepo
stpartum
emotionald
istress
includ
ingde
pression
wom
enwho
hadaCSby
comparin
gthem
at6–8
weeks
followingchildbirth
with
47matched
controls
who
hadno
rmalvaginal
delivery.
Cross-
sectional
Nigeria
946–8weeks
postpartum
Unspe
cified
Gen
eralHealth
Questionn
aire
(GHQ-30),
Beck
Dep
ressioninventory
Dep
ression,
gene
ralh
ealth
Therewas
norelatio
nship
betw
eenthede
pression
scores
andbe
ing
sche
duledforeither
ElCSor
EmCS.
****
Vossbe
ck-
Elsebu
sch,
2014
Toreplicateearlier
finding
sregardingthepred
ictio
nof
PTSD
levelsfollowing
childbirthby
know
npren
atal,p
erinataland
postnatalp
redictors.
Prospe
ctive
coho
rtGermany
224
1–6mon
ths
Unspe
cified
Posttraumatic
Diagn
osticScale(PDS),
University
ofCalifornia,Los
Ang
eles
Social
Supp
ortIn
ventory(UCLA
-SSI-d
),Peritraum
atic
DissociativeExperience
Questionn
aire
(PDEQ
),Po
sttraumaticCog
nitio
nsInventory(PTC
I),Respon
sestoIntrusions
Questionn
aire
(RIQ),
German
versionof
the
PerseverativeThinking
Questionn
aire
(PTQ
)
PTSD
ThemeanPD
S(Posttraum
aticDiagn
ostic
Scale)
scoreforwom
enwho
hadan
EmCSwere
sign
ificantlyhigh
erthan
thePD
Sscoreforwom
enwho
hadano
rmalVD
.
*****
Wijm
a,2002
Toexam
inewhe
ther
the
wom
en’spsycho
logical
cond
ition
durin
gpreg
nancycorrelates
with
theirpsycho
logicalw
ell-
beingafterEm
CS.
Prospe
ctive
coho
rtSw
eden
1981
Gestatio
nweek32,a
few
days,
andon
emon
th
Unspe
cified
Wijm
aDelivery
Expe
ctancy/Expe
rience
Questionn
aire,Spielbe
rger
TraitAnxiety
Inventory,
Stress
Cop
ingInventory,
Impact
ofEven
tScale,
Symptom
Che
cklist
Fear
Surgicalcomplications
includ
ingEm
Cscorrelated
with
postpartum
fear
ofchildbirthne
gativelyafew
days
aftertheop
eration,
butpo
sitivelyon
emon
thlater.
****
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 15 of 24
Table
1Summarycharacteristicsof
includ
edstud
ies(Con
tinued)
Autho
r/Year
Aim
Stud
yDesign
Stud
yLocatio
nParticipants
Timeframe
Stud
yPerio
dMeasure
Psycho
social
Outcomes
Relevant
KeyFind
ings
MMAT
QARa
Wiklund
,2009
Toexam
inechange
sin
person
ality
from
late
preg
nancyto
early
mothe
rhoo
din
prim
iparas
having
vaginalo
rCS.
Prospe
ctive
coho
rtSw
eden
314
37–39
gestational
weeks
inpreg
nancy
and9
mon
thsafter
delivery.
2003–2006
KarolinskaPerson
ality
Scales
Person
ality
Wom
enwho
hadan
EmCS
scored
high
eron
the
subscalemeasurin
gPsychasthe
nia(low
degree
ofmen
talene
rgyandstress
suscep
tible)9mon
thsafter
birthcomparedto
those
who
hadaspon
tane
ous
VD.
****
Wiklund
,2007
Toexam
inethe
expe
ctations
and
expe
riences
inwom
enun
dergoing
aCSon
maternalreq
uestand
compare
thesewith
wom
enun
dergoing
CS
with
breech
presen
tatio
nas
theindicatio
nandwom
enwho
intend
edto
have
VDactin
gas
acontrolg
roup
andto
stud
ywhe
ther
assisted
deliveryandEm
CS
inthecontrolg
roup
affected
thebirth
expe
rience.
Prospe
ctive
coho
rtSw
eden
496
Priorto
deliveryand
3mon
ths
postpartum
2003–2005
Wijm
aDelivery
Expe
ctancy/Experience
Questionn
aire
Expe
riences
Wom
enplanning
aVD
but
expe
riencingan
EmCSor
anassisted
VDhadmore
negativebirthexpe
riences
than
theothergrou
ps.
****
Xie,2011
Toexam
inewhe
ther
orno
tCSde
liveryisassociated
with
increasedriskof
postpartum
depression
.
Cross-
sectional
China
534
2weeks
postpartum
2007
Chine
seversionof
the
EPDS(EPD
S),Social
Supp
ortRatin
gScale,
Dep
ression
PPDrate
was
high
erin
the
grou
pwho
hadelectiveCS
deliverythan
inthegrou
pwho
hadEm
CS.
****
Yang
,2011
Toexam
inewhe
ther
MoD
areassociated
with
postnatald
epression.
Prospe
ctive
coho
rtTaiwan
10,535
Unspe
cified
2003–2006
Datacollected
from
the
NationalH
ealth
Insurance
Research
Database
Dep
ression
Risk
ofacqu
iring
PPDwas
lower
inmothe
rswith
ano
rmalVD
oran
instrumen
talV
Dcompared
tomothe
rswith
anEm
CS.
Thewom
enwho
electedto
have
aCSsectionwas
high
erriskthan
anEm
CS.
****
Zanardo,
2016
Toassess
feelings
towards
newbo
rninfantsin
mothe
rsw
hode
livered
byelective
(ElCD)or
emerge
ncyEm
CS.
Cross-
sectional
Italy
573
Not
specified
2014–2015
Mothe
r-to-In
fant
Bond
ing
Scale(M
IBS)
Mothe
r-infant
bond
ing
EmCSne
gativelyaffected
mothe
rbo
ndingand
open
ingem
otions,and
originated
inmothe
rfeeling
sadn
essand
disapp
ointmen
tforthe
unplanne
dde
livery.
**
a Mixed
Metho
dsApp
raisal
Tool
Qua
lityAssessm
entRa
ting
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 16 of 24
Table 2 Associations of identified psychosocial outcomes and EmCS
Keypsychosocialoutcomes
Numberofstudies
Association betweenEmCS and psychosocialoutcomes
Inconclusive associationsbetween EmCS andpsychosocial outcomes
Qualitative summary
Postpartumdepression(PPD)
12 + Studies reported inconsistent findings. The majority of studiesreported no significant association (n = 7) between EmCS and PPDwhereas the remaining studies reported a relationship betweenEmCS and increased symptoms of PPD (n = 5).
Post-traumaticstress disorder(PTSD)
11 + All studies (n = 11) reported consistent findings that EmCS was acontributing factor to increasing post-traumatic stress symptomsand PTSD after childbirth.
Health relatedquality of life
2 – Consistent findings were found across studies (n = 2) that womenwho had an EmCS had poorer physical functioning compared toother MoDs.
Mother infantbonding
3 – Studies reported inconsistent findings. In n = 1 study EmCSappeared to have a negative association with mothers bondingand opening emotions with their baby. In contrast, no significantaffect was found in terms of MoD on mother-infant bonding in theremaining studies (n = 2).
Infant feeding 3 – Consistent findings were found across studies in that EmCSimpacted negatively in varying ways on infant feeding (n = 3).Women who have an EmCS were more likely to have had anunsuccessful first breastfeeding attempt, were less likely tobreastfed their baby within the first 24 h and upon leaving thehospital, and to breastfeed for a shorter duration of time comparedto other MoDs.
Sexual function 3 +/− Studies were inconsistent in their findings (n = 3) in terms ofsatisfaction with sexual relations after birth and sexual functionpostpartum.
Experiences 21 +/− In terms of quantitative research (n = 9), the majority of studiesfound that EmCS was more likely to result in a negative birthexperience (n = 6), n = 1 study reported MoD had no influence onmother experiences and n = 2 studies reported that EmCS wasrelated to positive experiences in comparison to other MoDs. Interms of the qualitative studies (n = 12) women described a widevariety of emotions as salient aspects to their EmCS experiencehowever, a number of dominating negative experiences wereconsistent across all studies
Satisfaction 4 – Consistent findings were reported across all studies (n = 4) withwomen who had an EmCS more likely to appraise their deliveriesless favourably than those who delivered via other MoDs.
Self-esteem 3 – Consistent findings were reported across all studies (n = 3). Womenwho had an EmCS were more likely to report feelings of emotionalvulnerability after delivery including feelings of failure, regret, andlower self-esteem.
Distress 3 – Findings were inconsistent in terms of distress after EmCS. Nosignificant association between MoD and distress were reported ina study (n = 1), another study reported other MoD causing moredistress than EmCS (n = 1), the final study reported a relationshipbetween EmCS and distress.
Fear 2 – Inconsistent findings were reported. With n = 1 study reportingEmCS was associated with increased fear of childbirth insubsequent pregnancies and n = 1 study reporting a correlationwith fear of childbirth a few days after the operation, however thisdecreased one month later.
Other
ChildbirthBurden
1 + Women who experienced emergency surgical intervention (i.eEmCS) were more likely to demonstrate higher childbirth burdenscores than any other MoD (n = 1).
Feelings ofcontrol
1 – Women who had a spontaneous VD reflected having a significantlyhigher sense of control during their labour and childbirth relativeto with an instrumental VD, a planned CS, or an EmCS (n = 1).
+ indicates that some (or all) evidence supports a positive association- indicates that some (or all) evidence supports a negative association
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 17 of 24
by EmCS had significantly higher odds of PPD 6weeks afterdelivery (OR= 1.45) [36]. Additionally, a cohort study(n = 10, 535) reported that the odds of PPD was significantlylower for women who had a normal VD (OR= 0.67) or aninstrumental VD (OR= 0.56) compared to women who hadEmCS [87]. However, women who had an elective CS hadhigher odds of PPD than women who had EmCS (OR=1.48, p= 0.0168) [87]. Heterogeneity in the tools, their useand findings can be seen in Table 3 and makes the compari-son of these figures problematic.
Traumatic stressEleven included studies examined trauma as an outcomeof an EmCS [24, 34, 41, 42, 59, 60, 65, 66, 73, 76, 81].These studies were conducted across a diverse range ofcountries including Australia, Nigeria, UK, Iran, Israel,Sweden and Germany. Study designs included, six cross-sectional, four prospective and one qualitative. All stud-ies consistently reported that EmCS was a contributingfactor for post-traumatic stress symptoms and PostTraumatic Stress Disorder (PTSD) after childbirth. Sev-eral of the studies stated that any unplanned interven-tions during childbirth including EmCS were predictorsof PTSD [42, 88]. For example, a prospective cohortstudy (n = 1824) identified EmCS as a risk factor forpost-traumatic stress symptoms [41]. Findings from asmaller cross-sectional study in Australia reported agreater than expected frequency of PTSD in women whohad EmCS, specifically, 73% reporting trauma symptoms
4–6 weeks postpartum [42]. Further, a qualitative re-search study conducted in Sweden concluded that expe-riences of women who delivered via EmCS weretraumatic enough to fulfil the stressor criterion of PTSDin the DSM IV [66]. This study stated that 55% ofwomen interviewed a few days after an EmCS reportedfeelings of intense fear of death or injury to themselvesor to their baby during the delivery process [66].
Health related quality of lifeTwo studies specifically examined Health Related Qual-ity of Life (HRQoL) [52, 78]. One study utilised theShort-Form 36 (SF-36) to measure HRQoL [78] and theother utilised the SF-36 and the EuroQoL 5D [52]. Bothstudies reported consistent findings that women with anEmCS had poorer physical functioning, relative to otherMoDs. A prospective study in the Netherlands reportedthat the average period to reach full physical recoverywas 3 weeks after VD, 6 weeks after elective CS andEmCS [52]. Similarly, a larger more recent study re-ported that women who had a vaginal, forceps orvacuum-extraction delivery, had better physical func-tioning at 6 weeks postpartum relative to those withelective CS or EmCS [78]. In a cohort study in Sweden,women who had EmCS scored higher on the subscalemeasuring Psychasthenia (low degree of mental energyand stress susceptible) 9 months after birth relative tothose with spontaneous VD [84].
Table 3 Heterogeneity across studies examining depression
Study Cut score Timepostpartum
Samplesize
Participantswithdepression
EmCSsubgroup
EmCS subgroupwith depression
Evidence of associationbetween EmCS and PPD
Edinburgh Postnatal Depression Scale
Eckerdal,2017
EDPS> 12 6 weeks 3888 505 (13%) 346 50 (16.7%) No
Gaillard,2014
EDPS> 12 6–8weeks
264 44 (16.7%) 44 6 (13.6%) No
Goker,2012
EDPS> 13 6 weeks 318 100(31.4%)
106 37 (34.9%) No
Iwata,2015
EDPS> 9 6months 479 21.5% 60 24 (40%) Yes
Patel,2005
EDPS> 13 8 weeks 10,934 N/A 572 56 (9.8%) No
Xie, 2011 EDPS> 13 2 weeks 534 103(19.3%)
149 24 (16.1%) Yes: PPD higher in ElCSthan EmCS
Beck Depression Inventory
Chen,2002
BDI 9–10 6 weeks 357 N/A N/A N/A No
Sarah,2017
N/A N/A N/A 33.4%, N/A 13.8% of 33.4% No mention
Ukpong,2006
BDI > 9 significant, 10–18 mild/moderate,19–29 moderate/severe, 30–63 extreme
6–8weeks
47 29.8% 40 N/A No
Benton et al. BMC Pregnancy and Childbirth (2019) 19:535 Page 18 of 24
Mother-infant bondingThree studies examined the relationship between EmCSand mother-infant bonding [5, 35, 40] with conflictingresults. Two studies utilised the Mother-to-Infant Bond-ing Scale [5, 40] and the third utilised the Parent-ChildEarly Relational Assessment Tool [35]. A recent, largescale cross-sectional study found EmCS appeared tohave a negative association with mothers bonding andopening emotions with their baby. In contrast, a similarsized study reported no significant differences inmother-infant interactions at 4 or 12 months postpartumbetween MoD [35]. Similarly, a smaller scale cohortstudy found that type of CS did not appear to signifi-cantly affect mother-infant bonding in the first 72 h fol-lowing delivery or at 12 weeks postpartum [40].
Infant feedingThree studies examined the relationship between infantfeeding and EmCS [25, 26, 50]. Study designs were pro-spective cohort, cross-sectional, and qualitative. Thelarge scale prospective cohort study reported thatwomen with EmCS were more likely to have an unsuc-cessful first breastfeeding attempt and were less likely tobreastfed their baby within the first 24 h and upon leav-ing the hospital [50]. Furthermore, the study reportedthat women with EmCS had more breastfeeding difficul-ties (41%), and used more hospital resources before andafter leaving the hospital (67, 58%), in comparison tothose with a VD (29, 40, and 52%, respectively) or aplanned CS (33, 49, and 41%, respectively). Additionally,a similar sized cross-sectional study reported that breast-feeding duration varied substantially with MoD [25]. Inthe same study, median breastfeeding duration was 45.2weeks among women who had a spontaneous VD, 38.7weeks among planned CS, 25.8 weeks among inducedVD and 21.5 weeks among women with EmCS [25]. Inthe qualitative study women frequently stated that theirdecision to breastfeed was driven by their desire to makeup for the traumatic way their baby was delivered, in-cluding, by EmCS [26]. In this study a women withEmCS stated, “breastfeeding became almost an act ofvindication. I had to make up for failing to provide mydaughter with a normal birth, so I sure wasn’t going tofail again” [26].
Sexual functionThree studies, conducted in Israel, Iran and Spain, ex-amined the relationship between EmCS and sexualfunction postpartum [57, 69, 78], with inconsistentfindings. A prospective cohort study reported a signifi-cantly higher proportion of women at 6 monthspostpartum being less satisfied with their sexual rela-tions after birth in the forceps group (34%) relative tothe EmCS group (15%) [78]. In contrast, a larger
prospective cohort study reported that women whohad a VD or EmCS had statistically significantly lowerFemale Sexual Function Index (FSFI) scores on aver-age relative to those with a planned CS [69]. Thesefindings were contrary to that of a small scale cohortstudy that found no significant difference betweenaverage sexual function scores and various MoD post-partum [57], potentially due to a lack of power.
ExperiencesA large number (n = 21) of identified studies examinedwomen’s experiences with EmCS. A variety of measureswere used across studies including: Impact of EventScale, Wijma Delivery Expectancy/Experience Question-naire, and Questionnaire for Assessing Childbirth Ex-perience (QACE). Studies examined varying aspects ofwomen’s experiences of EmCS including women’s over-all birth experiences, emotional experiences and experi-ences with care and staff.The majority of quantitative research studies found that
EmCS was more likely to result in a negative birth experi-ence. For example, a recent large prospective cohort studyin Sweden reported that birth experience was more likelyto be negative among women with EmCS relative to VD[53]. Similar findings were reported in another recent butsmaller cross-sectional study, where unexpected MoD in-cluding EmCS resulted in a higher likelihood of negativebirth experiences [48] with this finding supported in nu-merous other studies [32, 54, 83, 89]. Contrary to this find-ing, two prospective cohort studies reported that MoD hadno direct influence on women’s experience of childbirth[38, 74]. Interestingly, in one of these studies no women inthe EmCS subgroup attained a score which indicated anegative birth experience; rather 89% of these women de-scribed the birth experience as ‘good/very good’ [74]. Fur-thermore, the majority of women in this study with EmCSalso evaluated their feelings of control during labour andthe opportunities they had to make informed choices/deci-sions as ‘good/very good’ [74]. Interestingly, a large pro-spective study found that women who had a planned CSscored significantly lower in terms of negative birth percep-tion than those who had an EmCS or a VD [30].Twelve studies utilised a qualitative design to examine
women’s experiences of an EmCS [9, 31, 39, 44, 47, 49,64, 66, 68, 72, 77, 79]. In all of these studies, women de-scribed a wide variety of emotions as salient to theirEmCS experience however, a number of dominatingnegative experiences were consistent across all studiesincluding: loss of perceived control and feelings of help-lessness [9, 31, 39, 47, 49]; fear (own or/and for baby) [9,31, 64, 66, 68, 77]; and disappointment [9, 66, 77]. In astudy conducted by Shorten [72] one participant re-ported “after an emergency caesarean I felt I had failed, Ifelt cheated of the childbirth experience I had wanted”.
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Experiences with maternity care and staffA large prospective cohort study reported that womenwho had an unplanned CS were more likely to indicatethat they had received “less than good” midwifery careduring childbirth [90]. It was suggested that as womenwho have an EmCS often have their care transferred toother care providers during childbirth, it is possible thatthe discontinuity of care between the providers may in-fluence women’s experiences with staff [90].
SatisfactionFour studies examined women’s satisfaction after EmCS[28, 37, 46, 70] with all reporting that women withEmCS were more likely to appraise their deliveries lessfavourably than those with other MoDs. In a large pro-spective cohort study conducted in both the Netherlandsand England, EmCS appeared to be a contributing factorto a negative appraisal of birth [28].
Self esteemThree studies examined women’s self-esteem and EmCS[32, 55, 56] with all studies reporting consistent findings.A cross sectional study reported that MoD influencedwomen’s mood at one-month postpartum, with an itemreading ‘I am proud of myself’, representing self-esteem,being more likely to have negative results for womenwith EmCS [32]. In two smaller Nigerian studies, womenwere more likely to report feelings of emotional vulner-ability after delivery including feelings of failure, regret,and lower self-esteem [55, 56].
DistressThree studies in Norway, Scotland and England exam-ined distress in relation to EmCS [23, 58, 63]. In a verylarge prospective cohort study (n = 55,814) conductedover a 10 year period, no significant association betweenMoD and emotional distress postpartum was reported[23]. Further, a small cross-sectional study reported thatwomen who gave birth assisted by instrumental deliverywere more likely to report that their birth was distinctlymore distressing than women in three other obstetricgroups (VD, induced VD, EmCS) [58]. A mixed methodsstudy reported that the fact that a CS was classified asan “emergency” frightened women, resulting in feelingsof distress [63].
FearTwo studies examined fear as an outcome of EmCS [75, 82].A large prospective cohort study reported that EmCS wasassociated with increased fear of childbirth in subsequentpregnancies [75]. A similarly designed and sized study foundthat EmCS correlated with increased postpartum fear ofchildbirth a few days after the operation, however this de-creased 1 month later [82].
Other outcomesChildbirth burden and feelings of control were examinedin two studies. A large cross-sectional study reportedthat women who experienced emergency surgical inter-vention (EmCS and vacuum extraction) were more likelyto demonstrate higher childbirth burden scores thanthose with any other MoD [29]. A small cross-sectionalstudy reported that women who had a spontaneous VDhad a significantly higher sense of control during theirlabour and childbirth relative to those with an instru-mental VD, a planned CS, or an EmCS [61].
DiscussionSummary of findingsA number of psychosocial outcomes were consistentlyand negatively reported to be associated by EmCS in-cluding post-traumatic stress, HRQoL, infant feeding,experiences, satisfaction and self-esteem. All studiesexamining post-traumatic stress consistently foundthat EmCS was a contributing factor for symptomsand PTSD after childbirth. Two studies exploringHRQoL reported consistent findings that women withEmCS had poorer physical functioning relative toother MoDs. Three studies examining infant-feedingreported that women with EmCS were more likely tohave an unsuccessful first breastfeeding attempt, lesslikely to breastfed within the first 24 h and upon leav-ing the hospital, and to breastfeed for a shorter dur-ation of time in comparison to other MoDs. Theseresults are consistent with those reported by Ahluwa-lia [25] who noted that women with EmCS often ex-perience; a difficult labour, stress, and delays inmother-infant interactions, each of which may reducethe likelihood or duration of breastfeeding.Consistent findings were reported for satisfaction in that
women with EmCS were more likely to appraise their de-liveries less favourably than those with other MoDs. Stud-ies examining self-esteem found women who had anEmCS were more likely to report feelings of emotionalvulnerability after delivery including feelings of failure, re-gret, and lower self-esteem. Twenty one articles examinedvarying aspects of women’s experiences of EmCS, whichconstituted the most commonly examined psychosocialoutcome among included studies. In both quantitative andqualitative studies it was reported that women with EmCSwere often at the highest risk of assessing their childbirthexperience in a negative way and described a wide varietyof negative emotions including: loss of perceived controland feelings of helplessness, fear (own or/and for baby),and disappointment.Psychosocial outcomes including depression, mother-
infant bonding, sexual function, fear, and distress werealso identified and examined within in the literature.However, studies either reported mixed findings or no
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sufficient evidence of an association between these out-comes and EmCS.
LimitationsWe recognise that potentially relevant articles couldhave been missed, written in languages other thanEnglish, or indexed in other databases other thanthose chosen and therefore may not have been iden-tified. Studies identified in the review were con-ducted in 22 diverse countries and as such it mustbe acknowledged that cross-cultural differences arecommon and can greatly influence women’s psycho-social outcomes of childbirth [91]. Postnatal accessto healthcare; procedural differences; quality of avail-able care; levels of social support; religious beliefs;poverty; societal attitudes regarding pregnancy, birthand motherhood; gender roles and attitudes regard-ing mental health problems are just a few of theknown socio-cultural and environmental factors thatmay influence findings in the identified studies [92].Of the included articles the strengths and mean-
ingfulness of the findings differ substantially due tovariations in study design, sampling procedures, andsample size. It has been previously identified that re-search examining the psychosocial outcomes of CShave generally suffered from numerous methodo-logical limitations including; reliance on small sam-ple sizes, use of measures of unknown reliability andvalidity and the lack of a comparison group or vary-ing comparison groups [93]. Several of these limita-tions were present in the included studies. Forexample, as noted previously, one of the primaryreasons for excluding articles was the failure to spe-cify or differentiate between type of CS for womenin a study. Furthermore, there was often no discus-sion within included studies about reasons andcauses for EmCS and it is possible that some causesare more strongly associated with the psychosocialoutcomes examined. Studies identified in the reviewreported on wide varying time frames for postpartumdata collection, with collection ranging from hoursafter birth to years after birth as well ultilising dif-ferent cut-points on the same measures for diagno-sis. The timing of data collection is an importantmethodological consideration as there is considerableevidence that the impact of a women’s birth experi-ence changes over time [94]. As time passes, thepositive affect from one’s baby and satisfaction withbeing a mother has been shown in some cases tofavourably influence a women’s feeling about herlabour experience [94].As a result of the heterogeneous nature of these fac-
tors (exemplified in Table 3 for depression), meaningfulpooled quantitative measures of study findings were
unable to take place, even for subsets of studies. Overall,there appears a paucity of published evidence with con-sistent measures and adherence to guidelines for report-ing (e.g. for cut-scores) which is crucial to rectify infuture studies so that (gold standard) systematic litera-ture reviews can meaningfully pool data in a quantitativemanner.
Strengths and implicationsTo our knowledge, this study is the first to systemat-ically review the available literature on women’s psy-chosocial outcomes of EmCS. The review presentsthe findings of quantitative, qualitative and mixedmethods studies from a vast array of countries andas a result identifies and examines a wide variety ofpsychosocial outcomes.The review has highlighted the need for the further
development of technologies and clinical practices toreduce the number of unnecessary EmCSs. Critically, itunderscores the requirement for evidence based strat-egies to provide psychosocial support and informationabout EmCS in the context of routine antenatal andpostnatal care. While high-level research currently ex-ists in this area, for example in the form of routinedebriefing to prevent psychological trauma after child-birth (103), it fails to show benefit. More broadly, whileprograms for postnatal psychosocial support have beenpromoted in many countries to improve maternalknowledge related to parenting, mental health, qualityof life, and physical health, it has been concluded in asystematic review that the most effective strategies re-main unclear [95].
ConclusionThe review has highlighted the diverse impact thatEmCS can have on women. Numerous psychosocialoutcomes that are negatively impacted by this MoDwere identified including post-traumatic stress, health-related quality of life, experiences, infant-feeding, satis-faction, and self-esteem. In particular, there was strongconsensus that EmCS contributes to symptoms anddiagnosis of post-traumatic stress. This review has alsohighlighted the need for further investigation on thistopic using robust methodology including the use ofconsistent, valid and reliable measures with consistentuse of guidelines for appropriate cut scores, consistentcomparison groups, adequately powered studies anddifferentiation between types of CS. Overall, enhancedknowledge and understanding in this area will providean imperative step towards implementing effectivestrategies to improve women’s health and well-beingfollowing EmCS.
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Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12884-019-2687-7.
Additional file 1. Logic Grids.
AbbreviationsBDI: Beck’s Depression Inventory; CS: Caesarean Section; EmCS: EmergencyCaesarean Section; EPDS: Edinburgh Postnatal Depression Scale;HRQoL: Health Related Quality of Life; MMAT: Mixed Methods Appraisal Tool;MoD: Mode of Delivery; PPD: Postnatal depression; PROSPERO: Prospectiveregister of systematic reviews; PRSIMA: Preferred Reporting Items forSystematic Reviews and Meta-analyses; PTSD: Post Traumatic Stress Disorder;QAR: Quality Assessment Rating; SF-36: Short-Form 36; VD: Vaginal delivery
AcknowledgementsWe thank librarian Vikki Langton at the University of Adelaide library whoprovided support and knowledge in relation to performing the literaturesearch. We would also like to thank all the authors and publishers of theoriginal studies and the women who took part in all original research.
Authors’ contributionsMB, DT, AS have made substantial contributions to conception and design ofthe review. MB and NT conducted the literature search, initial screening ofpapers, full text assessment, and quality assessment of included studies. MBextracted data and characteristics of included studies. MB wrote initialmanuscript and DT, AS, and CW provided intellectual content and extensivereview of final manuscript. All authors read and approved the finalmanuscript.
FundingThe current study is funded by the NHMRC project grant 1129648. Thefunding body played no role in the collection, analysis, interpretation of dataor in writing the manuscript.
Availability of data and materialsNot applicable.
Ethics approval and consent to participateEthics approval was not needed for this systematic literature review.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Author details1School of Psychology, University of Adelaide, Adelaide, South Australia,Australia. 2School of Public Health, University of Adelaide, Adelaide, SouthAustralia, Australia. 3Maternal Fetal Medicine, Women’s and Children’sHospital, Adelaide, South Australia, Australia.
Received: 19 May 2019 Accepted: 17 December 2019
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