Cesarean section on maternal request in Norway : A qualitative and normative study of birth counseling and decision-making

Background: Cesarean section (CS) is a common and life-saving intervention. While lack of access is a severe problem in some parts of the world, excessive use has become a growing concern recently. In light of this, a debate has emerged concerning the acceptability of providing CSs in low-risk pregnancies conducted on the request of the mother. The literature shows that attitudes toward the phenomenon vary between healthcare professionals and across countries. Maternally requested CSs challenge such modern ethical concepts as patient autonomy, professional autonomy, shared decision- making, trust, and power. Thus, countries have developed different practices and guidelines on the matter. Objective: The overall objective of this thesis was to develop research that can contribute to good-quality decisions for CSs on maternal request in absence of obstetric indications. This objective was achieved by establishing in-depth knowledge about i) why women request CSs in Norway and ii) how the counseling and decision-making processes were handled, and by conducting iii) a normative analysis of the premises for ethically justified decision-making in the care for women requesting CSs. Methods: Two qualitative studies were conducted, including 17 semi-structured in-depth interviews with women requesting planned CSs at a University Hospital in Norway and six focus-group discussions with 20 healthcare professionals (nine midwives and 11 obstetricians) working in the same hospital. Interviews were taped, transcribed, and analyzed according to systematic-text condensation, which is a method for cross- case analysis of qualitative data. A normative analysis was carried out based on knowledge gained from the qualitative studies and reading of the scientific literature. We drew upon theories about autonomy, power, trust, and risk in the professional-patient relationship in order to explore how to promote ethically justified decisions for planned CSs in absence of obstetric indications. Results: The first study revealed that women had individual and nuanced reasons for wanting a planned CS. Their previous birth and postnatal experiences, self-perceived risks for an emergency CS, or deep-seated fear of giving birth all influenced their decision. Rarely, obstetricians claimed to also experience requests that in their opinion lacked significant fear or well-grounded reasons. This indicates a need for an individually targeted counseling approach. The second study found a prominen