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How Are Women Making the Decision to Have an Elective Cesarean Section When There is No Medical Indication?… Randhawa, Prabhjot 2021-03

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  1 HOW ARE WOMEN MAKING THE DECISION TO HAVE AN ELECTIVE CESAREAN SECTION WHEN THERE IS NO MEDICAL INDICATION? A SCOPING REVIEW by:  PRABHJOT RANDHAWA  Bachelor of Science in Nursing, Langara College, 2011   A SCHOLARLY PRACTICE ADVANCED RESEARCH (SPAR) PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING  In  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (School of Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)    March 2021    © Prabhjot Randhawa, 2021      2 The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a scholarly practice advanced research project entitled:  How Are Women Making the Decision to Have an Elective Cesarean Section When There is No Medical Indication? A Scoping Review           submitted by Prabhjot Randhawa             in partial fulfillment of the requirements for the degree of Master of Science in Nursing        , in  The Faculty of Graduate and Postdoctoral Studies     ,  Examining Committee: Dr. Manon Ranger , Supervisor  Dr. Maura MacPhee , Supervisory Committee Member   3 Acknowledgements  I could not have completed this step in my academic journey alone. My sincerest thank you to my supervisor, Dr. Manon Ranger. For our numerous conversations and your encouragement in molding and helping to create this project, I am forever grateful. Your open communication and supporting me in thinking my ideas ‘out loud’ are so very appreciated. I would also like to thank my committee member, Dr. Maura MacPhee for her expertise, insight, and help in finishing this project. I feel lucky to have had our paths cross and look forward to working with both of you in the future. A special thank you to Katherine Miller from the UBC library team, whose help in conducting research is immensely appreciated.   A big thanks to my nursing colleagues and peers, who assisted me as I completed my graduate degree. Whether it was offering an ear to listen or providing guidance as I chose courses and completed projects, I am so fortunate to have such a strong network of amazing nurses to connect with.   To my family, thank you for always encouraging and supporting me to achieve my goals. From dropping off meals, providing welcome distractions, or understanding when I had to sit out on occasions, your endless consideration made this journey easier. Thank you for celebrating when I began this endeavor and I look forward to the celebrations as I finally am done!  To my husband Neil, I cannot begin to put into words how much your unwavering support on my countless adventures means to me. Thank you for the endless encouragement when I take on what often seems like another intimidating mission. You truly keep me calm and focused. Your positive affirmations that I am capable of accomplishing my goals are always what I need to hear.       4 Dedication To my mom and dad- my cheerleaders from day one, without whom I could not have completed my undergraduate degree and thus my MSN. Thank you for always believing that I can achieve anything!      5 Abstract Background: Globally, elective cesarean sections without medical indication have recently seen a rise and British Columbia holds one of the highest rates of cesarean delivery in Canada. The decision-making process behind a woman’s choice to have an elective surgical delivery when there is no medical indication is important to gain knowledge about, as this procedure is not without maternal and neonatal risks, is costly, and adds further strain to nursing workload.  Methods: A scoping review was conducted and 12 published articles were examined using the 2005 Arksey and O’Malley methodological framework and the Matrix Method Garrard (2011).  Findings: Various approaches were noted globally, in terms of who was the provider of counseling (the primary care provider, team members, or pregnant women themselves) and how counseling was provided (during regular prenatal appointments, dedicated counseling sessions, or independent research by the woman). Themes were identified amongst the type of information women receive during counseling, including discussion of the risks and benefits of both cesarean and vaginal delivery, the woman’s fears/concerns, and future reproductive family planning. Conclusion: The comprehensive review of the literature suggested that a team-based and multi-sessional counseling approach when discussing mode of delivery may decrease the number of women opting for a cesarean section without medical indication. This is a type of counseling that Canadian nurses may be able to provide for pregnant women as they are respected members of the health care team and it is within their scope to educate and support women during the perinatal period. Finally, knowledge gaps were identified which require further research, including gaining knowledge on Canadian approaches to decision-making for women regarding mode of delivery and determining adequacy of counseling methods.     6 Table of Contents List of Figures & Tables........................................................................................................... 8 Chapter 1: Introduction............................................................................................................. 9 1.1 Background............................................................................................................. 9 1.2 Personal Significance of Issue…............................................................................ 9 1.3 Purpose of Project and Significance for Nursing Practice...................................... 11 1.4 Research Question.................................................................................................. 11 1.5 Chapter Summary................................................................................................... 12 Chapter 2: Methodology........................................................................................................... 13 2.1 Scoping Review Methodology................................................................................ 13 2.2 Systematic Search Process...................................................................................... 114 2.2.1 Main Concepts of Research Question........................................................... 14 2.2.2 Information Sources...................................................................................... 15 2.2.3 Search Strategies........................................................................................... 15 2.3 Literature Selection Process.................................................................................... 18 2.3.1 Inclusion and Exclusion Criteria................................................................... 18 2.3.2 Study Selection, Categorization, and Data Extraction.................................. 19 2.4 Chapter Summary................................................................................................... 21 Chapter 3: Findings................................................................................................................... 22 3.1 Table of Analysis of Findings Included in Scoping Review.................................. 22 3.2 Findings................................................................................................................... 29 3.2.1 Aspects of the Decision-Making/Counseling Process.................................. 30 3.2.2 Those involved in the Decision-Making/Counseling Process......................    34   7 3.2.3 Decisions Made as an Outcome of Counseling............................................ 37 3.3 Summary of Findings.............................................................................................. 38 Chapter 4: Discussion............................................................................................................... 40 4.1 Key Findings........................................................................................................... 40 4.1.1 Rates of Cesarean Section and the Decision-Making/Counseling Process... 40 4.1.2 A Woman’s Right to Choose Her Mode of Delivery.................................... 44 4.1.3 Lack of Nursing Representation in the Decision-Making/Counseling Process...................................................................................................................  46 4.2 Gaps in the Literature and Suggestions for Future Research.................................. 47 4.3 Implications for Nursing Practice in British Columbia.......................................... 49 4.4 Limitations.............................................................................................................. 50 4.5 Conclusions............................................................................................................. 51 References ................................................................................................................................ 53        8 List of Figures & Tables Figure 1 CINAHL Search........................................................................................................ 16 Figure 2 MEDLINE (Ovid) Search.......................................................................................... 17 Figure 3 Flow Chart of Article Selection................................................................................. 20 Figure 4 Articles by Country of Origin.................................................................................... 30 Figure 5 Approaches to the Decision-Making/Counseling Process......................................... 31 Figure 6 Information Shared with Pregnant Women during the Decision-Making Process.... 31 Figure 7 Those Involved in the Decision-Making/Counseling Process................................... 35 Table 1 Analysis of Findings Included in Scoping Review..................................................... 22      9 Chapter 1: Introduction 1.1 Background  Childbirth is a significant experience for the families who go through it. The anticipation of the many unknowns that are part of the labour and delivery process can have an effect on women and their choices regarding parturition (Huang et al., 2013). Globally, in recent years, there has been a steady increase in the incidence of cesarean sections (Olieman et al., 2017). Of particular concern is the increased number of women who electively choose cesarean section without medical indications (Olieman et al., 2017). According to the Canadian Institute for Health Information (CIHI), in 2017-2018 British Columbia had the highest rate of primary cesarean section amongst women aged <35 years and 35+ years, compared to the rest of Canada, at 24.8 % and 30.3%, respectively (2019). The various reasons why women are opting to have cesarean sections per maternal request (CSMR) are well documented in the literature and include fear of vaginal childbirth, unorganized maternity care, and concerns about the well-being of themselves and their unborn baby (Huang et al., 2013; Kelly et al., 2013; Olieman et al., 2017).  It is important to further our understanding of the underlying decision-making process, which leads pregnant women to opt for a CSMR, as these types of deliveries are not necessarily simple surgical procedures or ‘easy’ ways to birth a child. Cesarean sections come with a possibility of unintended complications compared to vaginal births, including higher risk of maternal death and respiratory distress for newborns (Mylonas & Friese, 2015). They also add strain on British Columbia’s public health system as surgical deliveries are not only costly, but resource heavy (British Columbia Perinatal Health Program [BCPHP], 2008).  1.2 Personal Significance of Issue   10 As a perinatal nurse at BC Women’s Hospital and Health Center (BCW) I have observed an increase in the rates of CSMR over the past few years. According to Perinatal Services BC’s surveillance reports, in the 2016/2017 fiscal year ‘maternal request and/or vaginal birth after cesarean section (VBAC) declined’ was the most common indication for cesarean delivery, higher than that of any medical reason (Perinatal Services British Columbia [PSBC], 2018b). This indication accounted for 21.4% of all cesarean sections occurring within the Provincial Health Services Authority (PHSA), of which BCW is the only child-birthing facility (PSBC, 2018b). Amongst all other health authorities in British Columbia in 2016/2017, PHSA lead in the rates of cesarean deliveries due to maternal request and/or VBAC declined (PSBC, 2018b).  In my role as a bedside nurse in the perinatal program at BCW, I have first-hand experience of caring for women as they experience labour, delivery, and postpartum. Nurses are the healthcare providers delivering the majority of direct care to women and families during their birthing experience (Levine & Lowe, 2014). An increase of post-operative patients and related complications may intensify nurses’ workload while limiting the amount of time they can spend caring for and educating families (Ball et al., 2018). I myself have struggled with this balancing act as post-operative patients and potential/actual complications increase. I have found, when looking through patients’ histories, an increased trend of no clear outlined indications other than ‘maternal choice’ to support the selection of cesarean section over vaginal delivery. Furthermore, details are not available in patients’ charts in regard to their decision-making process (e.g. consultations with healthcare professionals). By carefully reviewing the literature regarding this decision-making process, I will focus on reported reasons to determine if women’s’ choices are based on informed practice involving adequate knowledge sharing, as this may have an effect on the upwards trend of CSMR.   11 1.3 Purpose of Project and Significance for Nursing Practice  It is important that new research is undertaken, disseminated, and utilized to influence change in clinical practice settings (Polit & Beck, 2017). The purpose of this Scholarly Practice Advance Research (SPAR) project was to outline the state of the current evidence in relation to women’s decision-making when electing to have a cesarean delivery without medical indication. By reviewing the current state of evidence, this project may help inform healthcare providers’ counseling practices and influence women’s delivery choices. Ultimately, this SPAR project may influence nursing practice with respect to workloads (e.g. less post-operative patients and related complications), and may result in enhanced roles for nurses and other healthcare providers (e.g., antenatal counseling). As trusted professionals, nurses are ideally suited to counsel women during the antenatal period, leading to more informed maternal decisions during the birthing experience (Levine & Lowe, 2014).  This SPAR project is in the form of a scoping review describing what kind of counseling families are receiving prior to making this important choice. Scoping reviews can aid in developing policies and practices informed by evidence (O’Brien et al., 2016) and consequently, this would affect nursing practice.  1.4 Research Question  In line with the purpose of this project, the research question that guided this scoping review was: What kinds of information and counseling do pregnant women receive prior to making a delivery decision of cesarean section with no medical indication?     12 1.5 Chapter Summary Elective cesarean sections without medical indication have seen a rise globally in the last decade (Olieman et al., 2017). British Columbia holds one of the highest rates of cesarean delivery in the nation (CIHI, 2019) and PHSA, thus BCW, has been leading amongst other provincial health authorities for cesarean section upon maternal request (PSBC, 2018b). The decision-making process behind a woman’s choice to have an elective surgical delivery when there is no medical indication is important to gain knowledge about, as these types of deliveries do not come free of maternal and neonatal risks, are costly, and add further strain to nursing workload and public health sectors (Ball et al., 2018; BCPHP, 2008; Mylonas & Friese, 2015).     13 Chapter 2: Methodology This chapter describes the methodology utilized to conduct the systematic literature search and selection. Within it, I will explain the rationale for procedures used, main concepts of my research question, as well as the search process. Figures are included in this chapter to illustrate search strategies and the article selection method.  2.1 Scoping Review Methodology This SPAR project was completed through conducting a scoping review of the current literature, identifying what the decision-making process entails for women and families when choosing to have a CSMR. A scoping review aims to investigate and clarify the variety of the evidence-base about a topic, addressing broad questions (Polit & Beck, 2017). The scope and range of ideas included in this review are comprised of diverse literature, including both qualitative and quantitative approaches as well as literature reviews, in order to distinguish practices and methods utilized when women are making the choice of CSMR.    One of the advantages of scoping reviews is that they are a means of mapping information about extensive topics in order to inform future work (O’Brien et al., 2016). As O’Brien et al. (2016) discuss, by using a less rigid approach compared to that of systematic reviews, scoping reviews focus more on the state of the current research, allowing policy makers the ability to make decisions that are informed by evidence. According to Davis et al. (2009), a scoping review gives an intellectual summary of what is known about a topic and brings attention to areas where there are significant gaps in knowledge. For these reasons, conducting a scoping review was very applicable in the context of this SPAR project, in that it allowed the broad identification of knowledge and practices regarding the topic of interest, i.e. expecting mothers’ decision-making related to CSMR.     14 This scoping review followed the 2005 Arksey and O’Malley methodological framework, as discussed by O’Brien et al. (2016), involving six stages: “…identifying the research question, searching for relevant studies, selecting studies, charting the data, collating, summarizing and reporting the results, and consulting with stakeholders to inform or validate study findings” (p. 2). The final stage involving consultation with stakeholders is optional and was not undertaken for the purposes of this SPAR project.  In conjunction with this framework, I utilized the Matrix Method Garrard (2011) to organize the findings. Using both a structure and process, creating a matrix allows for systematic review of the literature (Garrard, 2011). The Matrix Method Garrard (2011) assisted in concisely summarizing the information I extracted from the articles included in this scoping review. It facilitated the literature to be efficiently organized in table form (see Chapter 3) and thus, utilized proficiently for the purpose of conducting this scoping review (Garrard, 2011).  2.2 Systematic Search Process 2.2.1 Main Concepts of Research Question Population Pregnant women Concept 1 Elective cesarean section when there is no medical indication Concept 2 Decision-making Concept 3 Counseling    In the context of this SPAR project, the population of “pregnant women” considered women in any stage of pregnancy, however, not preconception. The concept of  “elective cesarean section when there is no medical indication” was outlined as a cesarean section surgery that was scheduled and completed prior to the commencement of labour. This concept   15 considered elective surgical deliveries without any medical requirement for maternal or newborn health. Elective repeat cesarean surgeries were not included in this concept, as they can be seen as medically indicated in numerous instances. The concepts of “decision-making” and “counseling” were considered the processes undertaken by women, with or without inclusion of their family members and/or healthcare providers, in making the choice to have an elective surgical birth rather than trialing labour.  2.2.2 Information Sources  In order to find relevant articles addressing my research question, I searched several databases. Throughout the research process, I consulted with a University of British Columbia (UBC) librarian specialized in nursing literature support. Under her guidance, in order to obtain the maximum amount of relevant articles with minimum overlapping content, my main searches were conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE (Ovid) databases. Initially, searches were also conducted using the Google Scholar database, however, they did not provide relevant results and therefore were not included in this SPAR project. Searches on all databases were conducted between September and October 2020.  2.2.3 Search Strategies      In both the CINAHL and MEDLINE databases, the same search terms were used, in form of MeSH headings (MH) and keywords, to be found in the titles (TI/ti), abstracts (AB/ab), or bodies of relevant articles. Search terms included: “cesarean section, elective”, “cesarean section”, “cesarean delivery”, “c-section”, “elective”. All searches with “cesearean” were also done using “caesarean”, acknowledging the alternative spelling of this term in the literature. Also included in the search was the term “decision making” and truncated “decision*” and “decid*” to   16 capture literature with variations of this keyword. “Counseling” and the truncated variation “counsel*” were also search terms used in order to cover main aspects of the research question. Boolean operators (ie. AND, OR, and NOT) were utilized in order to combine keywords and MeSH headings. Figures 1 and 2 detail the exact combination of search terms and the number of relevant articles each search strategy yielded in CINAHL and MEDLINE.  Figure 1 CINAHL Search Search # Search term(s) Number of articles found Number of relevant articles 12 S11 NOT S7 75 7 11 S6 AND S10 112  10 S8 OR S9 79,769  9 TI counsel* OR AB counsel* 58, 371  8 (MH "Counseling+") 39, 267  7 S3 AND S6 283 28 6 S4 OR S5 2,768  5 TI ( ("c-section" or "cesarean section" or "caesarean section" or "cesarean delivery" or "caesarean" or "cesarean") and elective ) OR AB ( ("c-section" or "cesarean section" or "caesarean section" or "cesarean delivery" or "caesarean" or "cesarean") and elective ) 2,669  4 (MH "Cesarean Section, Elective") 261    17 3 S1 OR S2 214,730  2 TI ( decision* or decid* ) OR AB ( decision* or decid* ) 172,104  1 (MH "Decision Making, Patient") OR (MH "Decision Making") OR (MH "Decision Making, Shared") OR (MH "Decision Support Techniques+") 78,090   Figure 2 MEDLINE (Ovid) Search Search # Search term(s) Number of articles found Number of relevant articles 14  S8 AND S12 235 4 13  S9 AND S12 59 4 12 S10 OR S11 133,646  11 Counsel*.ti,ab. 111,915  10 exp Counseling/ 44,669  9 S3 AND S8 720  8 S6 OR S7 8,382  7  (("c-section" or "cesarean section" or "caesarean section" or "cesarean delivery" or "caesarean" or "cesarean") and elective ).ti,ab. 7,980  6 S4 AND S5 1,254  5 Elective Surgical Procedures/ 14,645    18 4 Cesarean Section/ 45,445  3 S1 OR S2 610,340  2 (decision* or decid*).ti,ab.  471,722  1 exp Decision Making 206,242   2.3 Literature Selection Process 2.3.1 Inclusion and Exclusion Criteria  Literature for this scoping review was included if it specifically referred to elective cesarean section without medical indication. Articles were included if they were available in English and could be quantitative, qualitative, or mixed-method studies as well as systematic or literature reviews. Although the focus of this SPAR project was on research in regard to the decision-making process involved with CSMR, in order to identify the maximum amount of information, some studies included in this scoping review investigated the incidence and reason for this type of procedure. Literature was included if it described a level of detail to the decision-making process prior to CSMR. For relevancy about decision-making processes globally, recognizing that the trend for CSMR has increased around the world over the last decade (Olieman et al., 2017), articles were included if they were published in the year 2010 or thereafter and could be based out of any country. Literature was excluded if it solely focused on cesarean section for medical reasons, whether elective or emergent. If the article provided minimal detail on the decision-making process prior to CSMR it was not included in this scoping review. Literature that could not be accessed online or via print, was published prior to 2010, or not available in English was also excluded.   19 2.3.2 Study Selection, Categorization, and Data Extraction  When selecting studies to be included in this scoping review, the process recommended by the Joanna Briggs Institute (JBI) (Peters et al., 2020) was undertaken. First, combinations of search terms in the form of keywords and MeSH headings were applied to identify the literature that was most relevant, as seen in Figures 1 and 2. Next, those articles were screened based upon their title and abstracts; articles were excluded if they did not discuss CSMR and if they were duplicates from other searches (Peters et al., 2020). The remaining articles were independently read and reviewed in their full-text, and the literature included in this scoping review was determined by which articles met inclusion and exclusion criteria as described in previous section. As recommended by the JBI (Peters et al., 2020), a flow chart of the review process was generated (Figure 3 below) outlining the number of relevant selections from each database, screening and elimination of duplicates, and finally, the 12 articles which met eligibility criteria and were included for this SPAR project. The flow chart was created based on The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies (Moher et al., 2009).  Categorization of the selected studies and data extraction from the full-text articles was conducted with considerations of both the JBI (Peters et al., 2020) and the Matrix Method Garrard (2011) recommendations. In order to outline the information relevant for this SPAR project, a table was created including the following information: author(s), year of publication, country of origin, study/article design, details of the decision-making process for CSMR, and who is involved in the process (see Table 1, found in Chapter 3).      20 Figure 3 Flow Chart of Article Selection                                              Articles identified from searches in 2 databases (n=652)  Exclusions based on titles, abstracts, and duplicates (n=609)  Final literature included in scoping review (n=12)  Full-text assessed according to inclusion/exclusion criteria (n=43)  Full-text articles excluded (n=31)  Reasons:  Minimal detail on CSMR counseling process (n=18)  Older than 2010 (n=5)  Not available online or in print (n=6)  Not available in English (n=2)  Identification Screening Eligibility Included   21 2.4 Chapter Summary In this chapter I have described the methodology used to conduct the literature search and article selection for this SPAR project. Various procedures involved in conducting this scoping review, as well as main concepts of the population and concepts being searched, were explained. The literature selection process was detailed, including figures to outline the search strategies and flow of article elimination and selection, resulting in the final 12 articles retained and reviewed for this scoping review. The following chapter provides a comprehensive review of the information collected from these selected articles, as they pertain to the purpose of this SPAR project.      22 Chapter 3: Findings  In this chapter, I describe and discuss the findings in regard to the 12 articles included in this scoping review. The data collected and considered relevant to the purpose of this SPAR project have been outlined in a table and are also comprehensively examined throughout the chapter.  3.1 Table of Analysis of Findings Included in Scoping Review  As aforementioned, the following table took into consideration the JBI (Peters et al., 2020) and the Matrix Method Garrard (2011) recommendations for organization and data extraction. It is organized by article number, author(s), year of publication, country of origin, study/article design (including number of participants if applicable), those involved in the decision-making/counseling approach for CSMR, and details of the process. The literature is ordered from oldest to most recent by year of publication, as per the Matrix Method Garrard (2011) suggestion. Those who are involved in the decision-making are important to outline, as this may be a process that nurses could be involved with locally, hence it being a finding retrieved from the articles. The decision-making process for CMSR column extracts relevant information from the articles as they pertain to the research question, displaying the type of counseling and information given to pregnant women seeking a CSMR. Table 1 Analysis of Findings Included in Scoping Review Article # Author(s) Year of Publication Country of Origin Study/Article Design Those Involved in the Decision-Making Decision-Making Process for CSMR 1 Wiklund et al. 2010 Sweden •  Literature review  • Pregnant women • Midwives • Obstetricians • Appropriate provider   23 of counseling • Early in the pregnancy and antenatal care, midwives ask the woman how she feels about giving birth, in order to identify if the patient needs to be referred to counseling and appropriate consultation/treatment • The woman’s healthcare, medical history, and reason for requesting a CSMR are evaluated • A probability risk assessment is performed, in which the likelihood of future pregnancies and any increased risks related to mode of delivery are weighed • This assessment determines the intensity of the interventions, which vary based on how strong of a reason she has for the request and how many resources to invest in a patient requesting CSMR; the greatest amounts of resources are allocated to women who have the most to gain from reconsidering their desire for a CSMR • When women are requesting CSMR, they must state their reason and receive adequate counseling • If the woman is considered to have acceptable reasoning for her request, the decision must be informed and her understanding of the short- and long-term maternal and neonatal risks and benefits for CSMR, vaginal delivery, and emergency cesarean section is ensured by an obstetrician • If she chooses to continue with her request after receiving counseling and having a sufficiently serious reason, it is considered justified to accommodate her wish 2 Hildingsson et al. 2011 Sweden • Longitudinal regional survey • Participants: 697 women •  Pregnant women • Prenatal midwives • Aurora team midwives Obstetricians  • Psychologists Social workers •  When women request a CSMR to their prenatal midwife, they are then referred to ‘Aurora teams’ • Aurora teams are groups of specially educated midwives who collaborate with obstetricians, psychologists, and social workers  • The team’s purpose is to counsel women and help create a birth plan, not necessarily to persuade women into considering a vaginal delivery  • Counseling/birth plan can include discussing: induction of labour, pain relief early in labour, and possibility of conversion of vaginal delivery to cesarean delivery at any time during labour • Main goal for the counseling programs: to increase the likelihood of a positive birth experience, regardless of which mode of delivery is chosen  • Women are required to see the Aurora team/receive counseling prior to meeting the obstetrician; women cannot choose a CSMR by themselves • An obstetrician must approve the final decision for mode of delivery 3 Alnaif & Beydoun 2012 United States of America (USA) • Cross-sectional study, including quantitative •  Pregnant women • Obstetricians   24 and qualitative data collection via survey  • Participants: Nurse managers/ labour and delivery charge nurses of all 55 hospitals in Virginia that provide obstetric services • The American College of Obstetricians and Gynecologists (AOGC) supports women’s autonomy to choose their mode of delivery, which may be a CSMR • AOGC also wants to protect women, therefore they ask obstetricians to have a good understanding of the scientific evidence in favor or against these requests • When women request a CSMR, the obstetrician explores the woman’s fears, addresses her concerns, and understands her plans for future family size  • Together, they discuss options, risks, benefits, and alternatives in detail • Decisions regarding CSMR should be guided by ethics, respect for patient autonomy, beneficence, nonmaleficence, justice, and veracity • If the obstetrician believes that a CSMR would be unfavorable to the overall health of the woman or fetus, they are ethically obligated to decline the request; the woman may choose to seek care with another physician • When an obstetrician and woman mutually agree with the decision of a CSMR, the obstetrician must obtain informed consent for a CSMR and ensure that the woman’s consent is truly informed 4 Kaimal & Kuppermann 2012 USA •  Literature review •  Pregnant women • Physicians •  The shared decision making model is utilized when care providers are counseling women about their request for a CSMR • The woman’s preference plays a primary role • Ideally there is an assessment of risks and benefits conducted between the patient and care provider  • These discussions are opportunities to educate and build a consensus in regard to the care provider’s recommendation specific to the mode of delivery, based on the medical scenario • The physician offers education and guidance to assist in the woman’s understanding for their recommendation for mode of delivery • In the shared decision making model, educational tools can be helpful to allow both women and their care providers describe their priorities and help manage inevitable uncertainty that comes along with a first labour • Decision support tools may be used to help women consider their preferences and engage in   25 informed shared decision making when CSMR and planned vaginal delivery are both rational options • Informed consent between the woman and her care provider must occur 5 Sydsjö et al 2012 Sweden • Descriptive, retrospective case-control study • Participants: 353 women referred for psychosocial obstetrics; 579 without fear of childbirth for a reference group • Pregnant women • Obstetricians • Midwives Psychotherapists/ • psychologists • Women have one or two consultations with a care provider (most often an obstetrician) • Some women have consultations with specially trained midwives, psychotherapists, or psychologists • These women receive individual psychological support when identifying they want a CSMR • This includes psychoeducation, receiving information about pain relief, the risks and benefits of a vaginal delivery versus having a CSMR • If after receiving this support and education, a woman wanted to still undergo a CSMR, the decision is supported 6 Ecker 2013 USA • Evidence review of reports and published literature • Pregnant women • Obstetricians • If appropriate: partners, family and/or support members • Women are required to be offered the information needed to make informed and autonomous decisions regarding having a CSMR • This information includes the limitations of the data to support any specific delivery mode, potential effects of CSMR on future general and reproductive health • An essential part of the discussion is for the obstetrician to explain absolute risk and relative risks related to CSMR (ie. a ‘higher’ risk of an outcome does not equate to a ‘high’ risk of that outcome) • An ethical approach is taken to informed counseling, which recognizes alternate mode of delivery options as well as other options for management of the issues/concerns that are leading to the CSMR request; other options may include pain management or use of epidural anesthesia • Professionally and ethically, obstetricians are required to provide a balanced discussion when a woman requests a CSMR; these discussions are best completed over the course of several clinic visits • The discussions emphasize the woman’s values, fear, or concerns as a basis of their request   26 for CSMR • Those involved in the dialogue and decision-making should be the physician, woman, and/or partner, family/support members if appropriate • If the obstetrician and patient cannot agree on an intended mode of delivery, the obstetrician may decline and the woman can be referred to another care provider 7 Huang et al. 2013 Taiwan • Qualitative exploratory study • Participants: 20 primiparous women • Pregnant women • The decision-making process is divided into three phases • In the first phase of pre-decision, which occurs in early pregnancy, women start to consider the risks of childbirth; their views of normal vaginal delivery as a threat sprout from health education, television, books, media, and the internet • The Chinese culture’s perception of childbirth causing risk and exertion to mothers can add to the negative connotation associated with vaginal deliveries • Health education can also add to the stress and fear pregnant women feel in regard to vaginal delivery during the pre-decision phase; in this phase, women also begin to see CSMR as a viable alternative, as it is interpreted as more “elegant” compared to vaginal delivery • In the second phase of decision-making, the in-decision phase, women begin to collect information about vaginal and cesarean delivery on their own and weigh their perceived personal risk between both modes of delivery • They consider their own personal situations and risks related to safety, health, comfort, efficiency, feminine charms, time, and economy • Women ‘seesaw’ during this phase, but ultimately lean more towards CSMR as the risks related to vaginal delivery subjectively increase for them • In the final phase, post-decision, women are fearlessly dedicated to their choice of a CSMR and subsequently feel a sense of relief in regard to childbirth • Once the decision is made by the woman to have a CSMR, it is hard to change • They defend their decision to partners and care providers and seek/persuade obstetricians who will follow their preference for mode of delivery 8 Steel & Jomeen 2015 United Kingdom (UK) • Narrative overview • Pregnant women • Obstetricians • Team members as appropriate (ie. psychologist, midwife) • The National Institute for Health and Care Excellence (NICE) guidelines require informed choice be presented when women are requesting a CSMR • To support informed consent, care providers must discuss the risks and benefits of both CSMR and vaginal birth with the woman, and ensure that all of the information is given • Different team members should be involved based on the patient’s needs (ie. appropriate referral to an experienced care provider if the patient has anxiety about vaginal birth) • After discussion and support has been presented and the woman feels that vaginal birth is not   27 an acceptable option for herself, a CSMR can be planned • If the obstetrician involved in the consultation and discussion does not agree with performing the CSMR, a referral is made to another care provider who will do it 9 Galvao et al. 2018 Brazil • Qualitative study • Participants: 8 obstetricians and 19 women who recently gave birth  • Pregnant women • Obstetricians • The Brazilian government requires physicians to document clinical justification for each cesarean section and to utilize prenatal cards and consent forms for CSMR • Although not required: recommended version of the prenatal card contains records of the woman’s prenatal visits, tests, and contains an informational letter that describes the risks of CSMR and the benefits of vaginal delivery • The government’s policy aims to hold physicians responsible for ensuring that CSMR are made by a medically informed decision and encourages women to consider the medical risks of CSMR • In reality: the decision-making process more often does not involve these aspects; conversations about birth occur during prenatal visits between women and obstetricians, and are found to play more of a role in the decision of mode of delivery versus written information included in the prenatal card • If the woman wants a CSMR, often physicians will agree • In most cases no consent form is reviewed or signed between the woman and physician • Despite the government’s policy, often no clinical justification is documented 10 Hatamleh et al. 2019 Jordan • Descriptive qualitative content analysis study  • Participants: 35 first-time mothers  • Pregnant women • Husbands • Family & friends • Most women undertake the decision-making process based on their own social contexts • Their decisions often depend on the lived experiences of their family and friends • The choice to have a CSMR is discussed with and supported by their husband, who is found to be the most influential person when making the decision for mode of delivery • Other influences during the decision-making process include lack of information about childbirth and its environment, the role and responsibility of the healthcare provider, and the role of friends and family • There is a lack of ongoing and open-minded conversation between obstetricians and women requesting CSMR during the prenatal period 11 Eide et al. 2020 Norway • Qualitative study • Participants: 17 women • Pregnant women • Midwives • Obstetricians   28 requesting CSMR, 9 midwives, 11 obstetricians  • When a woman requests a CSMR to her primary care midwife or physician, she is referred for birth counseling at the hospital where she plans to deliver • Obstetricians or midwives provide the counseling, with the final decision about CSMR made by an obstetrician • During counseling, the care provider spends time exploring women’s fear and regenerating safety and trust, in order for the patients to find the best solution in regard to mode of delivery for themselves • Midwives working in counseling invest time and effort in order to establish a strong rapport with women; respecting women and taking them seriously helps to rebuild trust that has been lost in earlier birth experience • During counseling, the care providers spent time creating a birth plan, which is a physical document that allows women to feel safe with their decisions • The goal of counseling is to follow-up with women requesting CSMR and to guide them through the thought process, helping them to feel as confident as they can for their chosen mode of delivery, regardless of which they decide 12 Sun et al. 2020 China • Cross-sectional study  • Participants: 526 obstetricians • Pregnant women • Obstetricians • The Society of Gynecology and Obstetrics in China states that when a woman is requesting a CSMR, the obstetrician should inform her on the risks and benefits of this mode of delivery in comparison to vaginal delivery • Information should be presented in order to change the woman’s preference • 35% of obstetricians feel that it is the woman’s right to choose a CSMR • More than 33% of obstetricians in this study reported that there were no measures being taken to reduce CSMRs occurring at their hospital; there was no face-to-face health education, discussion about pain control during childbirth, or conversation about indications or guidelines for cesarean section      29 3.2 Findings  The purpose of this scoping review was to describe how pregnant women are being counseled and what information they are being presented when requesting to have an elective cesarean section when there is no medical indication. The studies reviewed were published between 2010 and 2020. As the incidence of CSMR is increasing globally (Olieman et al., 2017), articles included in this review originated from different countries (see Figure 4). The highest number of studies came from Sweden (n=3) (Hildingsson et al., 2011; Sydsjö et al., 2012; Wiklund et al., 2010) and the USA (n=3) (Alnaif & Beydoun, 2012; Ecker, 2013; Kaimal & Kuppermann, 2012). One article each from Brazil (Galvao et al., 2018), China (Sun et al., 2020), Jordan (Hatamleh et al. 2019), Norway (Eide et al., 2020), Taiwan (Huang et al., 2013), and the UK (Steel & Jomeen, 2015) made up the remaining literature reviewed. No literature based out of Canada met the inclusion criteria to be reviewed. The articles selected were examined to determine different aspects of the decision-making and counseling approaches, as well as who is involved in the process. A few studies (n=2) also described how the counseling process affected the woman’s final decision of choosing a CSMR.     30 Figure 4 Articles by Country of Origin   3.2.1 Aspects of the Decision-Making/Counseling Process  Amongst the literature selected for this scoping review, there were different approaches noted for the process that women endeavored in making the choice of having a CSMR. Figure 5, below, depicts the number of articles/studies out of the 12 reviewed per each type of decision-making/counseling approach. It is important to note that one of the studies described the decision-making process as sometimes involving women being referred to a counseling team/care providers specifically to discuss mode of delivery, while other times the decision was counseled solely during appointments with the primary care provider during pregnancy (Sydsjö et al., 2012). Therefore, this study was included in both of these decision-making approaches. Another aspect of the decision-making/counseling process outlined is the common themes of information shared during the decision-making process and how many articles referred to each one, as seen in Figure 6. Regardless of differences amongst their counseling approach, many of 0	1	2	3	4	Brazil	 China	 Jordan	 Norway	 Sweden	 Taiwan	 UK	 USA	Number	of	Articles		Country	of	Origin	  31 the studies had similarities in the type of information expected to be shared between care providers and pregnant women requesting CSMR. The themes of information shared are discussed further within this section.   Figure 5 Approaches to the Decision-Making/Counseling Process   Figure 6 Information Shared with Pregnant Women during the Decision-Making Process 0	1	2	3	4	5	6	7	Prenatal	Appointments	with	Primary	Care	Provider	 Sessions	with	Counselling	Care	Providers/Team	 Independently	Researched/Decided	Upon	Number	of	Articles		Approaches	to	Decision-Making/Counseling	with	Pregnant	Women	  32 In six of the studies, the decision-making approach and any counseling regarding having a CSMR occurred during consultations or regular prenatal appointments between pregnant women and their primary care provider, most often being an obstetrician (Alnaif & Beydoun, 2012; Ecker, 2013; Galvao et al., 2018; Kaimal & Kuppermann, 2012; Sun et al., 2020; Sydsjö et al., 2012). This is important to consider, as these appointments were not described as being solely dedicated to counseling on mode of delivery. Regular prenatal appointments have limits in length and frequency, as well as include assessing maternal and fetal well-being and other pregnancy concerns (PSBC, 2018a). Therefore, conversations about having a CSMR using this approach may not include thorough information sharing (Galvao et al., 2018). These six articles shared similarities in the information that was presented to the pregnant women by their primary care providers, in that they were expected to explore the risks and benefits of CSMR and vaginal delivery, their patients’ concerns and fears, future family planning, as well as discussion of alternatives (ie. early pain relief in labour) (Alnaif & Beydoun, 2012; Ecker, 2013; Galvao et al., 2018; Kaimal & Kuppermann, 2012; Sun et al., 2020; Sydsjö et al., 2012). Several of these studies specified that informed consent for the CSMR was to be obtained by the obstetrician over the course of the counseling process (Alnaif & Beydoun, 2012; Ecker, 2013; Galvao et al., 2018; Kaimal & Kuppermann, 2012). Galvao et al.’s  (2018) qualitative study found that in Brazil, despite the government requirements for signed consents to be obtained prior to CSMR, many obstetricians were not doing so and no clinical justification for the CSMR was being documented; if women wanted a CSMR, physicians would often simply agree to it. This was also reported by some care providers in China, where 35% of the obstetricians interviewed in the study felt that it was the woman’s right to choose a CSMR if she saw fit (Sun et al., 2020).    33  Referrals to a specialized care provider(s) or counseling team, specifically for detailed discussions regarding women’s wishes on mode of delivery when they indicated that they wanted a CSMR, was another approach reported by nearly half of the studies reviewed. Five out of the twelve articles included in this scoping review described this as part of the decision-making process (Eide et al., 2020; Hildingsson et al., 2011; Steel & Jomeen, 2015; Sydsjö et al., 2012; Wiklund et al., 2010). The information shared in this type of counseling occurred during multiple conversations, often over the course of several sessions, that were specifically focused on risks related to modes of delivery, fears related to childbirth, and birth plans (Eide et al., 2020; Hildingsson et al., 2011; Steel & Jomeen, 2015; Sydsjö et al., 2012; Wiklund et al., 2010). The common theme in these articles mentioning this counseling approach was that specially trained care providers would see women, not necessarily to convince them out of having a CSMR, but to discuss, in detail, aspects of child birth such as induction of labour, early pain relief, and future reproductive health considerations (Eide et al., 2020; Hildingsson et al., 2011; Steel & Jomeen, 2015; Sydsjö et al., 2012; Wiklund et al., 2010). During this process, care providers often gained the woman’s trust and found the best solution of mode of delivery for her and her future child (Eide et al., 2020). In Sweden, if after undertaking thorough counseling sessions, the woman felt that she had a sufficient reason to continue her request of a CSMR, the obstetrician would support her wish (Sydsjö et al., 2012; Wiklund et al., 2010). However, in Norway and the UK, despite the team approach to counseling, the final decision to carry out a CSMR was made by an obstetrician and if the physician did not agree with the reasoning, a referral was made to another care provider who would do so (Eide et al., 2020; Steel & Jomeen, 2015).    34  In two of the studies reviewed, the decision-making process did not involve any formal or informal type of counseling or information sharing (Hatamleh et al, 2019; Huang et al., 2013). Pregnant women were making the choice to have a CSMR after conducting independent research and considering their own wishes and social influences (Hatamleh et al, 2019; Huang et al., 2013). This included women getting advice from sources such as media, television, family, and friends. In Taiwan, cultural perceptions that vaginal childbirth increases the risk and exertion to mothers affected the decision-making for pregnant women (Huang et al., 2013). Huang et al.’s (2013) qualitative exploratory study found that if sought, health education actually added to the stress and fear that pregnant women felt in regard to having a vaginal delivery. More recently, the study based out of Jordan found that there was a lack of ongoing and open-minded conversations between women requesting a CSMR and obstetricians during the prenatal period, contributing to women making their decision regarding mode of delivery without any formal medical counseling (Hatamleh et al, 2019).  3.2.2 Those involved in the Decision-Making/Counseling Process  Different care providers and people involved in the decision-making process and/or offering counseling were identified in the literature reviewed. Figure 7 outlines those who were involved in the decision-making and counseling process for CSMR as described in each article. As mentioned in the previous section, one article may be included in more than one category, such as was the case for the Sydsjö et al. (2012) study.      35 Figure 7 Those Involved in the Decision-Making/Counseling Process   As seen in Figure 7, in six of the twelve articles, those involved in the decision-making process for CSMR were pregnant women and their primary care providers, them being physicians, obstetricians, and/or midwives (Alnaif & Beydoun, 2012; Ecker, 2013; Galvao et al., 2018; Kaimal & Kuppermann, 2012; Sun et al., 2020; Sydsjö et al., 2012). In the USA, Brazil, and China, primary care providers for pregnant women are most often physicians, specifically obstetricians (Alnaif & Beydoun, 2012; Ecker, 2013; Galvao et al., 2018; Kaimal & Kuppermann, 2012; Sun et al., 2020). In Sweden, primary care providers during pregnancy can commonly be midwives or obstetricians and in some cases, women would only have their appointments with one of these providers, with the decision-making process for CSMR occurring during their regular consultations (Sydsjö et al., 2012). Sydsjö et al. (2012) reported that most women saw an obstetrician when they had one to two appointments discussing CSMR.     Another category for those involved in the decision-making and counseling process for CSMR were pregnant women and specialized care providers or teams, which was mentioned in 0	1	2	3	4	5	6	7	Primary	Care	Providers	Only	 Specialized	Care	Providers/Team	 Pregnant	Women	(May/May	Not	Involve	Family/Friends)	Number	of	Articles		Those	Involved	in	the	Decision-Making/Counseling	Process	with	Pregnant	Women	  36 five of the twelve articles (Eide et al., 2020; Hildingsson et al., 2011; Steel & Jomeen, 2015; Sydsjö et al., 2012; Wiklund et al., 2010). Pregnant women were referred to these specific care providers/teams after they had vocalized their desire to have a CSMR. The types of care providers pregnant women saw for counseling varied amongst the literature and country of origin, with three of the five articles being based out of Sweden. Hildingsson et al. (2011) referred to women meeting with organized groups called the Aurora teams, which included specially educated midwives, psychologists, and social workers. Although also based out of Sweden, Sydsjö et al. (2012) did not specifically mention Aurora teams, however they did discuss how some women requesting a CSMR would have consultations with specially trained midwives, psychotherapists, and/or psychologists, while others would see their midwives and/or obstetricians to discuss their choice. Lastly, Wiklund et al. (2010) stated that pregnant women underwent counseling with their obstetricians, midwives, and other appropriate providers of counseling (not specified whom) in order to ensure they had an informed understanding about CSMR and their reason for requesting it. In the UK, the study by Steel and Jomeen (2015) reported a similar team approach to counseling and decision-making. Pregnant women discussed their request for CSMR with obstetricians and then were referred to the appropriate team members (ie. specially trained midwives and/or psychologists) to further review the decision based on the woman’s individual needs. In Norway, those involved in the decision-making process for CSMR were pregnant women, obstetricians, and midwives (Eide et al., 2020). The midwives that met with these women specifically worked in counseling regarding mode of delivery, building a trusting relationship, and helped the women to find the best solution for themselves.    37 In two qualitative studies, there were no formal providers involved and the choice to have a CSMR was made solely by the pregnant woman, with social or family influences sometimes contributing to her decision (Hatamleh et al., 2019; Huang et al., 2013). In Taiwan, the women studied primarily went about the decision-making process on their own accord (Huang et al., 2013). They relied on their personal feelings, views, and cultural perceptions, as well as their individual situations and risks related to factors such as efficiency, safety, and time. There was no mention of specific family members or support people contributing to their decision-making regarding CSMR. The choice to seek a CSMR was rarely changed once decided upon and obstetricians were sought and persuaded by the pregnant women to complete the CSMR rather than for health information (Huang et al., 2013). Finally, in Jordan, pregnant women also made the choice on their own, however, there was more involvement of family and friends in the decision-making process (Hatamleh et al., 2019). Husbands were the most influential person when making the decision for mode of delivery, though lived experiences of other friends and family were also considered.  Amongst the twelve articles that were reviewed, only two made mention of family involvement in the decision-making/counseling process for CSMR. As mentioned, women in Jordan took into consideration the influences and experiences of their family when deciding their mode of delivery (Hatamleh et al., 2019). Ecker (2013), based out of the USA, also mentioned that partners, family and support members, should be involved in the dialogue and decision-making process when women were considering a CSMR. However, this was only suggested if appropriate, and ultimately the decision was made based on conversations between the pregnant woman and her obstetrician (Ecker, 2013).  3.2.3 Decisions Made as an Outcome of Counseling   38   Of all the articles reviewed, only a few (n=2) discussed how the decision-making/counseling process influenced the woman’s final choice of having a CSMR. One of these articles was Eide et al.’s (2020) qualitative study, in which pregnant women from Norway were receiving specific counseling sessions with care providers to help them build trust, create birth plans, and guide them through their thought process. According to the midwives who provided the in-depth counseling, this type of counseling resulted in 70% of women changing their minds about having a CSMR and opting for trialing a vaginal birth instead (Eide et al., 2020). Hildingsson et al. (2011) also found that if pregnant women seeking a CSMR received counseling with the purpose of building their coping skills during birth, there was a change in preference of mode of delivery, with women increasingly preferring to attempt vaginal birth.   3.3 Summary of Findings  Twelve articles were reviewed for the purpose of this SPAR project. Half of the articles (n=6) mentioned that pregnant women underwent the decision-making/counseling process for CSMR during their appointments with their primary care providers, them being obstetricians, physicians, or midwives. Five of the articles described how women seeking a CSMR were referred for counseling with a specialized care provider(s) or teams, which included specially trained midwives, psychologists, and social workers. Two studies found that pregnant women were making the decision to have a CSMR without any professional counseling, conducting their research independently, taking into consideration factors such as personal comfort, cultural perceptions, and advice from family and friends.  Common themes were identified when examining the information presented to pregnant women during professional counseling, whether it came from their primary care provider or a specialized team member. This included care providers explaining the risks and benefits of both   39 cesarean and vaginal delivery, discussing birth plans and the woman’s fears/concerns, alternate options in labour, and future reproductive family planning. Care providers were expected to obtain informed consent prior to finalizing a CSMR, although this was not always found to be done. Two qualitative studies found that no formal information was presented, as women made the decision to have a CSMR on their own, taking into consideration personal and social influences. Lastly, only two studies described the effect that the counseling process had on the woman’s final decision of undergoing a CMSR.  The following chapter further discusses the scoping review findings, as they pertain to the purpose of this SPAR project and nursing practice.    40 Chapter 4: Discussion This chapter provides a detailed discussion of the key findings from this scoping review. Gaps in the literature and areas of potential future research are also outlined. Additionally, implications of the findings of this SPAR project for nursing practice and limitations to this scoping review are discussed.  4.1 Key Findings  4.1.1 Rates of Cesarean Section and the Decision-Making/Counseling Process  Conducting this scoping review brought to light many aspects of the decision-making process for CSMR. The fact that many countries around the world acknowledge the rising trend in elective surgical deliveries and have investigated the approach behind such incidences demonstrates that this truly is a global issue. The World Health Organization (WHO) has also made a statement in regard to cesarean deliveries, for any indication, noting that cesarean section rates beyond 10-15% at the population level are not associated with prevention of maternal, neonatal, and infant mortality (2015).  Interestingly, the majority of articles reviewed in which the primary care provider (most commonly an obstetrician) was the sole provider of counseling for CSMR (n=6) came from countries with relatively higher rates of cesarean deliveries. Three of these studies were from the USA and were published in the years 2012 and 2013 (Alnaif & Beydoun, 2012; Ecker, 2013; Kaimal & Kuppermann, 2012). In the USA, the rate of primary cesarean delivery in 2012 was reported at 21.5% and remained steady in 2018 when it was reported at 21.7% (Osterman et al., 2014; Martin et al., 2019).  The Brazilian approach to counseling for CSMR also involved the pregnant woman only seeing her obstetrician for discussion in regard to mode of delivery (Galvao et al., 2018). In   41 2014, the primary cesarean delivery rate amongst all live births in Brazil averaged 46%, one of the highest rates globally (Rudey et al., 2020). The Brazilian government attempted to control the rate of primary cesarean sections occurring with the implementation of regulations, prenatal cards, and holding physicians responsible for obtaining informed consent as outlined in Galvao et al.’s 2018 qualitative study, which was reviewed in this project. However, the average rate of primary cesarean section hardly shifted, sitting at 45% of all live births in 2017 (Rudey et al., 2020).  Women in China also obtain guidance from their obstetrician when seeking a CSMR. In Sun et al.’s 2020 cross-sectional study, they referred to a 2011 report of CSMR accounting for 38% of all cesarean deliveries occurring that year. Generally, the rate of cesarean section in China amongst all live births in 2014 was 35% and rose to 37% in 2018 (Li et al., 2020). A report published in 2020 by Li et al., describes that the cesarean section rates in China plateaued between 2012-2016, which may have been due to initiatives such as the nation-wide Baby Friendly Hospital program. They also noted that the rates rose between 2016-2018, coinciding with the end of the Baby Friendly program and the introduction of the 2-child policy in 2016.  As aforementioned, the study by Sydsjö et al. (2012) stated that sometimes women only saw one care-provider, usually an obstetrician, during the decision-making process. However, the article described that most women received individual psychological support via other care providers; therefore the findings of this Swedish study are discussed further below. Similarly to articles above, the two studies that described no formal counseling from any care providers, with women deciding to have a CSMR ultimately on their own, came from countries with higher rates of cesarean deliveries. Huang et al.’s 2013 qualitative study described how Taiwan’s cesarean section rate rose from 35% to 39% between 2007 and 2011, with a   42 substantial volume of them being done without medical indication and/or upon maternal request. A 2018 report described Taiwan’s rate of cesarean section as 27%, which, while lower than 2011, is still considered a higher rate for cesarean delivery globally (Black & Bhattacharya).   The qualitative study based out of Jordan that was included in this scoping review also had women making the decision to have a CSMR without formal counseling from a care provider. Published in 2019, Hatamleh et al. stated that Jordan’s overall cesarean section rate sat at 29% in 2012. Although there were no statistics available on how many of these types of births were a CSMR, it was reported that most cesarean deliveries were occurring without a clear medical reason (Hatamleh et al., 2019). A more recent survey based out of Jordan in 2017-2018 reported a very similar cesarean section rate of 27% (Al-Rawashdeh et al., 2020).  A common factor of the articles that involved mostly a team-based approach to counseling pregnant women for CSMR, whether it be with Aurora teams (groups of specially educated midwives who collaborate with obstetricians, psychologists, and social workers) or specialized midwives and psychologists individually seeing women for the purpose of counseling, was that they were based out of European countries. The highest numbers of these originated from Sweden (n=3) (Hildingsson et al., 2011; Sydsjö et al., 2012; Wiklund et al., 2010), while the most recent publication was a qualitative study out of Norway (Eide et al., 2020). The Swedish studies reviewed in this SPAR project were published between 2010 and 2012; in the year 2010, Sweden’s rate of cesarean section was 17% per 100 births and one of the lowest in Europe (Panda et al., 2018). The 2017 rate remained the same and continued to be one of the lowest not only in Europe, but also globally (Organisation for Economic Co-operation and Development [OECD], 2021). Similarly, Norway has maintained relatively low and stable rates   43 for cesarean section compared to other countries, from 15% reported in 2004 to 16% in 2017 (OECD, 2021; Tollanes et al., 2010).  The article by Steele and Jomeen included in this scoping review was a narrative overview of the decision-making/counseling process for women in the UK considering a CSMR. The approach they outlined also involved team members, based on the patient’s specific needs (e.g. being referred to a psychologist for counseling if the woman was experiencing anxiety about vaginal birth). The article outlines that in 2012, the UK’s cesarean section rate was 26% and although it was difficult to clearly determine how many of these surgical deliveries were occurring due to maternal request, they estimated the range to be between 15-28% (Steel & Jomeen, 2015). This was considered a significant increase from the 2001 CSMR rate of 7% (Marx et al., 2001). More recently, a 2018 study reported an estimated 6-8% of primary cesarean sections in the UK were occurring due to maternal request (Ared-Adib et al.).   Statistics are not available to determine the indications for cesarean sections in each country described in this section and there are numerous contributing factors one may consider (e.g. public versus private healthcare, mean age and education levels of child-bearing women, availability of health resources). However, there does appear to be a link between the type of counseling provided to pregnant women and the rates of cesarean delivery. Countries where the primary care provider (most often the obstetrician) provided counseling during prenatal appointments had higher rates of cesarean delivery compared to those countries that described having a team-based and often multi-sessional approach to decision-making. Amongst the studies in which the woman usually decided to have a CSMR without formal counseling from a care provider also reported higher rates of cesarean deliveries. These findings seem to suggest that providing team-based counseling for women requesting a CSMR is an effective way to   44 decrease rates of unnecessary elective surgical deliveries. This is an area where future research should be conducted to confirm the effects of team-based counseling, which is discussed further in section 4.2 of this chapter.  4.1.2 A Woman’s Right to Choose Her Mode of Delivery   After a thorough examination of the literature selected for this scoping review, it was interesting to see the different perspectives from various countries and care providers on a woman’s right to choose her mode of delivery. Not all studies included in this scoping review referred to the woman’s right to choose, but those which did are discussed in this section.   The Society of Gynecology and Obstetrics in China states that when a pregnant woman is requesting a CSMR, she should be provided information, including risks and benefits of cesarean and vaginal delivery, in order to change her preference (Sun et al., 2020). However, in Sun et al.’s (2020) cross-sectional study, which included participation of 526 obstetricians from China, 35% of them felt it was the woman’s right to choose a CSMR if she felt it was the best decision for herself. Despite the regulating body’s stance on CSMR, more than 33% of participating obstetricians reported that no measures, such as face-to-face health education or discussion of indications or guidelines for cesarean section, were occurring at their hospitals (Sun et al., 2020). This leaves a significant number of pregnant patients not receiving all of the information that they should be presented; however many may feel happy with their physician supporting their delivery choice of CSMR without any objections. Obstetricians in Brazil share a similar view on the woman’s right to choose mode of delivery as a CSMR. Although mandated by the Brazilian government to provide thorough counseling about the medical risks of surgical delivery and obtain informed consent, many physicians were not found to be doing so (Galvao et al., 2018).   45 According to Galvao et al. (2018), in most cases, if the woman is requesting a cesarean section, the physician will simply agree and often no clinical justification is documented.   In the two studies where no formal counseling from a care provider was part of the decision-making process, the woman’s right to choose a CSMR seems abundantly clear. In Taiwan, once a woman independently chooses to have an elective surgical delivery, it is very difficult to change her mind (Huang et al., 2013). In fact, in their qualitative exploratory study, Huang et al. (2013), found that these women sought and persuaded obstetricians who would follow their preference for a CSMR. In Jordan, the lack of ongoing and open-minded conversation between pregnant women and obstetricians was thought to be a contributing factor to the high incidence of CSMR in the country (Hatamleh et al., 2019).  Another noteworthy aspect found when reviewing the studies was that in particular countries, despite thorough counseling and information-sharing, some women appeared to have less of a right to choose their mode of delivery as a CSMR. For example, as outlined previously, the Swedish approach to the decision-making process for women seeking CSMR mostly involves care providers referring to specialized team members to provide appropriate and often numerous counseling sessions regarding mode of delivery (Hildingsson et al., 2011; Sydsjö et al., 2012; Wiklund et al., 2010). Despite the thorough counseling to create an informed birth plan, it is unclear if the woman completely has her own right to choose a CSMR if that is what she wishes. Hildingsson et al. (2011) state that it is an obstetrician who must approve the final decision for mode of delivery. Although it seems obstetricians most often support this decision, as the other Swedish studies state, after receiving support, education, and having a sufficiently serious reason, if a woman chooses to continue with her request after receiving counseling, it is considered justified to accommodate her wish (Sydsjö et al., 2012; Wiklund et al., 2010).   46 Similarly, in the UK, different team members, additional to the primary care providers, provide counseling to pregnant women seeking a CSMR (Steel & Jomeen, 2015). After a discussion and support has been provided, if the woman feels that vaginal birth is not an acceptable option for her, a CSMR can be planned; still, if the obstetrician involved in the consultation and discussion does not agree with performing the surgery, a referral is made to another care provider who will do so (Steel & Jomeen, 2015).  In the USA, the AOGC supports women’s autonomy to choose their mode of delivery, which may be a CSMR (Alnaif & Beydoun, 2012). However, despite the American studies outlining that detailed and informed conversations should occur between the physician and pregnant woman about mode of delivery, the obstetrician still holds the right to decline the women’s request, leaving her to seek care with another provider (Alnaif & Beydoun, 2012; Ecker, 2013).   It is interesting that in the studies where there may have been a lack of informed counseling between care provider and patient, the woman seems more supported in her right to choose a CSMR. However, in countries that provide more detailed counseling, often involving multiple team members, the woman’s right to choose her mode of delivery may be dependent on the obstetrician’s approval. Considering these different perspectives, it brings to light an ethical debate of when is it appropriate for the mode of delivery that a woman’s body is to experience be her choice rather than that of the care provider? This is an area for further inquiry, as it is an important consideration that has not been discussed much in the literature thus far.  4.1.3 Lack of Nursing Representation in the Decision-Making/Counseling Process  It is important to acknowledge that amongst the literature examined in this scoping review, nurses did not play a role in the decision-making or counseling approaches. However, it   47 is also significant to note that almost half of the studies reviewed were based out of Europe (n=5) and included midwifery involvement (Eide et al., 2020; Hildingsson et al., 2011; Steel & Jomeen, 2015; Sydsjö et al., 2012; Wiklund et al., 2010).  In Europe, the midwife’s scope is not only that of being a primary care provider for pregnant women, but also the direct and majority care provider of women during their birthing experience when they enter the hospital; many European midwives are also required to be registered nurses (Li et al., 2018). In British Columbia, midwives hold the role of primary care provider for pregnant patients and also provide care while they are birthing in the hospital (Midwives Association of British Columbia [MABC], 2021). According to the Canadian Association of Midwives annual report for 2019, 25% of all births in British Columbia were midwifery-led (2021). Nonetheless, nurses are considered trusted members of the healthcare team, and most often provide the majority of the direct patient care and education during the perinatal hospital experience, regardless of primary care provider (Collard et al., 2008; Levine & Lowe, 2014). In some instances, nurses work as part of the multidisciplinary team during pregnancy, providing support during prenatal visits and education (South Community Birth Program, 2021). Thus, despite the lack of nursing representation in the articles reviewed, the findings are still applicable to nursing practice, which is discussed in section 4.3 of this chapter.  4.2 Gaps in the Literature and Suggestions for Future Research  By conducting this scoping review, several gaps were identified amongst the literature in regard to the decision-making process for CSMR. Alongside recognizing the gaps, suggestions for future research are also recommended.   Despite the increase in CSMR being a national, and especially a provincial, trend that is being recognized by CIHI (2019) and PSBC (2018b), there still remains a major gap within   48 Canadian literature describing the decision-making process and what that entails. Although there are studies and reports that acknowledge the increased incidence of CSMR locally (CIHI, 2019; Hutton & Kornelsen, 2012), they lack detail in regard to the information and counseling pregnant women receive prior to making a delivery decision, as outlined by many other nations. This is an area where further research would be beneficial, as the information-sharing process within Canada leading to CSMR could be delineated and compared to that of other countries with lower rates, potentially leading to changes which could affect the rates of elective surgical deliveries in British Columbia and/or Canada.   While reviewing the articles, although the approaches to decision-making/counseling were detailed, it became evident that there was a gap in determining if the processes were truly adequate. ‘Adequacy’ of counseling is very subjective for individual women and in the literature, it was not always stated whether expecting mothers felt that the counseling process was thorough enough and met their needs. Although it could be argued that the more dedicated and individualized the counseling process, the more ‘adequate’ it was, this could not be confirmed. Often the authors did not specify the amount or length of the counseling sessions. Also, only two studies (Eide et al., 2020; Hildingsson et al., 2011) discussed the influence that the counseling had on the women’s choice of birth method in their findings. These gaps highlight areas for further inquiry, which include examining the frequency and length of counseling sessions, as well as surveying how satisfied women felt after the decision-making support they received and subsequent birth experience, regardless of the mode of birth chosen. This could help determine the adequacy of prenatal counseling for mode of delivery and if the women truly felt informed. Additionally, conducting studies describing the number of women that change their requests for   49 CSMR after having received counseling would help determine the impact that the different decision-making approaches have on a woman’s final decision.  4.3 Implications for Nursing Practice in British Columbia  As previously mentioned, although nurses were not represented as part of the decision-making process in the articles reviewed, the findings could have an effect on nursing practice both within British Columbia and nation-wide. By taking into consideration the role that midwives in Europe have in the outlined articles, in building trusting relationships with pregnant women, supporting, counseling, and educating them in the antenatal period, advanced practice positions could be created for perinatal nurses in British Columbia to do the same, as it is also part of their scope of practice (British Columbia College of Nurses and Midwives [BCCNM], 2020). Nurses are trusted members of the healthcare team and have the ability to support longer discussions compared to primary healthcare providers in the antenatal period (Collard et al., 2008). These lengthy conversations would include reviewing options in labour, risks and benefits of different modes of delivery, and seeking out the reason a woman is requesting a CSMR (Collard et al., 2008). The woman’s negative experiences and/or fears could be explored in these sessions with the nurse. Additionally, nurses are knowledgeable with collaborating and referring to other care providers (e.g. psychologists, social workers) if they identify this is best for the pregnant woman during the counseling process (BCCNM, 2021; Collard et al., 2008). Informed consent for a CSMR ultimately would need to be signed off after a conversation between the patient and obstetrician. However, prior counseling sessions with a nurse could ensure that the pregnant woman has a thorough understanding of the procedure she is choosing and is able to make an informed decision (Collard et al., 2008).   50 If these nurse-involved counseling sessions were to be established in practice, they should be evaluated to determine if they are as effective as they were found to be in countries like Norway (Eide et al., 2020). If after nurse-led counseling, more women were to opt against undergoing a CSMR, nursing practice could be impacted. British Columbia, which held the highest rate of cesarean deliveries amongst Canadian provinces in 2017-2018 (CIHI, 2019), could see a reduction in their rates. Indeed, less elective surgical deliveries would mean that perinatal nurses could potentially have fewer post-operative maternal patients, decreasing their workload and allowing them to spend more time to focus on family-centered care and education in the postpartum period. Some strain on our province’s public health system could also be alleviated as surgical deliveries are both costly and resource heavy (BCPHP, 2008).  4.4 Limitations  Some limitations were identified while completing this SPAR project. There were a limited number of articles that provided thorough detail about the decision-making/counseling process women undergo when choosing a CSMR. Many articles referred to the rise and reason for elective surgical deliveries but failed to detail the process behind the decision-making. None of the articles that met the selection criterion were Canadian-based; therefore there was a limitation on national data about this process. There were also limitations in the level of evidence amongst the studies included in this scoping review. No systematic reviews met inclusion criteria. Most of the articles included were literature and narrative reviews, as well as qualitative studies. Additionally, only articles that were available or published in English were included in this scoping review, which may have eliminated non-English articles that could have contributed to this project.     51 4.5 Conclusions  The purpose of this SPAR project was to outline the current state of evidence in relation to women’s decision-making when electing to have a cesarean delivery without medical indication. The research sought for this scoping review outlined the kinds of information and counseling pregnant women receive prior to making the delivery decision of a CSMR. The articles reviewed included qualitative and quantitative studies, literature and evidence reviews, and a narrative overview. Various approaches were noted globally, in terms of who was the provider of counseling (ie. the primary care provider, team members, or pregnant women themselves) and how counseling was provided (ie. during regular prenatal appointments, dedicated counseling sessions, or independent research by the woman). Similar themes were identified amongst the type of information expected to be shared with women during counseling, including explanation of the risks and benefits of both cesarean and vaginal delivery, discussion of birth plans and the woman’s fears/concerns, alternate options in labour, and future reproductive family planning. The findings suggested that a team-based (ie. involving providers such as specially trained midwives, psychologists) and multi-sessional counseling approach when discussing mode of delivery may decrease the number of women choosing to pursue a CSMR.  Cesarean section rates were higher amongst countries with no formal counseling or only a primary care provider being involved in the decision-making process with pregnant women compared to the nations with a team-based approach. It is also important to consider how women can be supported in making informed decisions and the right to choose the birth experience their bodies will undergo. There are gaps in the current literature and areas requiring further research, especially in regard to Canadian studies detailing the decision-making approaches utilized when   52 a women requests a CSMR. These gaps in knowledge about the provincial and/or national counseling process for mode of delivery are important to address, as cesarean deliveries accounted for 29% of all in-hospital births in Canada (excluding Quebec) in 2016-2017 (Gu et al., 2020). This is a relatively high rate compared to some of the countries included in this review, especially those with a team-based counseling approach to decision-making. Further research determining adequacy of counseling and the effects it has on the woman’s final decision for mode of delivery would be beneficial as well.  Although nursing was not represented in the counseling approaches amongst the articles reviewed, European midwives were, and many of them are also registered nurses (Li et al., 2018). Therefore, the findings of this scoping review may have implications for practice, as it is within a perinatal nurse’s scope to educate, support, and counsel pregnant women, as done by midwives in Europe (BCCNM, 2021; Collard et al., 2008). If team-based counseling, as seen in Europe, is adapted provincially, it could create more nursing positions and potentially lower the rate of women choosing a CSMR. Additional to this, perinatal nurses in the hospital could have less post-operative maternal patients and complications to manage, focusing more on caring for and educating families during this transitional and exciting time in their lives.    53 References Al-Rawashdeh, I., Kharboush, I., & Al-Kubaisy, W. (2020). Disparities in cesarean section   among women in Jordan: Analysis of the 2017-18 Jordan population and family health survey (JPFHS) data. 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