 Optimising caesarean section (CS) is of global concern. Underuse leads to higher perinatal mortality and morbidity and should remain a global health priority.

There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth.

ObjectiveTo obtain the views of bereaved parents about their interactions with healthcare staff when their baby died just before or during labour.DesignQualitative in-depth interview study, following an earlier national survey. All interviews took place during 2011, either face-to-face or on the telephone. Data analysis was informed by the constant comparative technique from grounded theory.SettingEvery National Health Service (NHS) region in the UK was represented.ParticipantsBereaved parents who had completed an e-questionnaire, via the website of Sands (Stillbirth and Neonatal Death Society). Of the 304 survey respondents who gave provisional consent, 29 families were approached to take part, based on maximum variation sampling and data saturation.Results22 families (n=25) participated. Births took place between 2002 and 2010. Specific practices were identified that were particularly helpful to the parents. Respondents talked about their interactions with hospital staff as having profound effects on their capacity to cope, both during labour and in the longer term. The data generated three key themes: ‘enduring and multiple loss’: ‘making irretrievable moments precious’; and the ‘best care possible to the worst imaginable’. The overall synthesis of findings is encapsulated in the meta-theme ‘One chance to get it right.’ This pertains to the parents and family themselves, clinical and support staff who care for them directly, and the NHS organisations that indirectly provide the resources and governance procedures that may (or may not) foster a caring ethos.ConclusionsPositive memories and outcomes following stillbirth depend as much on genuinely caring staff attitudes and behaviours as on high-quality clinical procedures. All staff who encounter parents in this situation need to see each meeting as their one chance to get it right.

BackgroundChina has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.Methods and findingsWe conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms ‘caesarean section’, ‘preference’, ‘choice’, ‘knowledge’, ‘attitude’, ‘culture’, ‘non-clinical factors’, and ‘health professionals-patient relations’ between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%–17%) and 21% in late pregnancy (95% CI 15%–26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%–20%), 22% in late pregnancy (95% CI 18%–25%), and 30% postpartum (95% CI 19%–40%). Women’s preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%–13%). One longitudinal study reported that the preference for CS among women’s partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women’s perceptions of CS as preferable were based on prioritising the baby’s and woman’s health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals’ preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women’s preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).Concl...

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