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ORIGINAL ARTICLES

 

The experience of women regarding cesarean section from the perspective of social phenomenology

 

Greyce Pollyne Santos Silva1, Maria Cristina Pinto de Jesus2, Miriam Aparecida Barbosa Merighi3, Selisvane Ribeiro da Fonseca Domingos3, Deíse Moura de Oliveira4

1Centro Universitário do Espírito Santo
2Universidade Federal de Juiz de Fora
3Escola de Enfermagem da Universidade de São Paulo                                                  
4Universidade Federal de Viçosa


ABSTRACT
Aim: to understand the experience of primiparous women with cesarean section.
Method: this is a qualitative research based on the social phenomenology of Alfred Schütz. Eight puerperal were interviewed in the year of 2012, who gave birth in maternities supported by health plans in the Brazilian state of Minas Gerais.
Results: women are influenced by close people when choosing to have a cesarean section, and their decision is supported by the fear of vaginal delivery, associated to pain and suffering. Once the decision is made, the fear is associated to the surgery and the anesthesia. The puerperals show satisfaction regarding the limitations in post-operation. It is important to highlight the need of professional support and the caring of the newborn. In the case of a second pregnancy, women desire to have another cesarean section.
Conclusion: the results demonstrate a necessity of professional attitudes that corroborate with the experiences and expectancies of women under cesarean section.
Descriptors: Women’s Health; Cesarean Section; Nursing; Qualitative Research.


 

INTRODUCTION

Cesarean section is an indispensable surgery in modern obstetrics, however it is also the focus of worldwide discussions due to its indiscriminate use(1). This proceeding can be programmed when the woman already has a clinic indication, and in the cases of relative urgency due to complications during the moment of labor(2).

All over the world there is a high number of cesarean section in many countries, such as Iran and Dominican Republic (41.9%), Italy (38.2%), Mexico (37.8%), Argentina and Cuba (around 35%) and the United States (30.3%)(3). This situation is also seen in Brazil, which presents one of the highest world records in cesarean section – near 80% in supplementary health and 30% in the Brazilian Unified Health System(4).

The uncontrolled used of cesarean section brings to attention the issue of maternal death. There is a study which focused on maternal deaths in a public maternity hospital located in Fortaleza, Brazil, and found that the causes of death due to gestational hypertension syndrome and infection were associated to the use of cesarean section(5).

In Sweden, an investigation showed that some women regretted they had their children through cesarean section because of fear of complications during delivery and other possible difficulties in future pregnancies. It was believed that this proceeding was responsible for maternal deaths, a prolonged post-partum recovery, and complains regarding the moments after the intervention and analgesia. Yet, these women preferred this type of proceeding, which explains the high rate of cesarean sections in this country(6).

A systematic review using meta-analysis, including studies published in different languages, showed that the global average of the preference of women for cesarean sections in these compiled studies was 15.6%. The occurrence of preference for this type of labor is higher in those women who already had previous cesarean sections and in those countries with a medium per capita income. In Latin American countries, there is a higher preference if women for cesarean sections (24.4%), while in the United States and in Canada, the registered percentage is 16.8%. The authors concluded that, in a global scale, the women that prefer cesarean section is a minority(7).

In Brazil, this data is confirmed. A study demonstrated that 70% of women do not mention they desired to have a cesarean section, despite the fact, indifferent from their wish, the interaction with the health service used the cesarean section during the delivery(8). Despite the preference for the vaginal labor, it is evident that some factors, such as taboos and fears related to pain, to the delay during pre-partum and to the negative experience of women regarding previous vaginal labor may lead to choose the cesarean section(9).

An integrative review study revealed that, despite the fact women mentioned pain in postoperative moments, difficulties in recovery and when restarting sexual activities, they consider cesarean section a pleasant experience because it is fast and subject to planning(10).

Taking into consideration the high rates of cesarean section and morbidities related to this surgical proceeding, specially in Brazil, it is important to elucidate the questions beyond the numerical perspective, such as how cesarean sections occur from the point-of-view of the women who had it.

The following questions arose in this study: how do women decide to have a cesarean section? How is the experience, for the mother, to have her first child delivered through cesarean section? After the experience of cesarean section, what are the expectancies of the mother regarding the next child?

Based on the exposed queries, we aimed to understand the experience of the primiparous woman in regards to cesarean section. The comprehension of this experience will enable the development of professional position compatible with the needs and beliefs of women regarding the delivery.

 

METHOD

This is a qualitative research, based on the social phenomenology of Alfred Schütz. It was performed with eight puerperals who had cesarean section as their first experience of delivery, through private health plans, located in a city located in the Brazilian state of Minas Gerais. The choice of this scenario is justified by demonstrating a high number of cesarean sections.

Primiparous women with low risk pregnancies and that had cesarean sections in the last 30 days were included in this study. The primiparity was taken into consideration, based on a vast spectrum of probabilities involved in the first experience of delivery. It was considered that, during the first days after the cesarean section, the mother is dedicated to caring for the baby, breastfeeding and to the changes in her body. After the initial month, this woman may have already built and reflected upon her own experience with the cesarean section, which culminates in a higher range of meanings.
We opted to exclude from this research teenage mothers, taking into consideration they are in a age group filled with incongruent specificities if compared to the adult mother; those mothers who had emergency cesarean sections were also removed from this study, as in this case there was not an option coming from the woman, but as an indication to surgical intervention.

The choice of the puerperals was done through the consultation of the delivery record book supported by private health plans. Those who fulfilled the criteria of inclusion were approached by phone, scheduling a date, time and place for an interview, according to their availability. The interviews were performed in the month of October 2012, at their homes, when they also signed the Free and Clear Consent Agreement (FCCA), and authorized the use of a recorder during the proceedings of this research. The questions that guided the interviews were: how was your experience having a cesarean section? Considering this experience, what to you expect your next delivery will be?

The average time of the meetings between researcher and interviewee was around 30 minutes, considering the initial approach and the interview itself. The number of participants was not a priori defined, as the collection of data ended in the moment the questions were answered and the aim of this study was reached. All puerperal women were married, with ages between 23 and 35 years old, and the majority did not finish College degree.

To guarantee the anonymity of the deponents, they were identified with the letter “P”, followed by numbers according to the moment of their interviews (P1 to P8). 

The organization and the categories of the material obtained through the interviews followed the steps adopted in studies performed by researchers of the social phenomenology of Alfred Schütz(11): a careful reading of the interviews and selection of the units of meanings that allow the construction of concrete categories regarding the experience of women, and the discussion of the results from the standpoint of the theoretical-methodological reference and theme. This project was approved by the Committee of Ethics in Research with Human Beings, from the São Paulo University Nursing School, under protocol #114.173/2012.

 

RESULTS

The organization of the results was conducted by the theory of social action proposed by Alfred Schütz, in which the subject interprets the facts from his own existential motivations, derived from the experiences lived within subjectivity. These experiences lead to the behavior/action in the social world; the reasons that are related to fulfill the objectives are called “reasons for” and those that are based on the experience lived within the biopsychosocial spectrum are named “reasons why”(12).

The experience of puerperals regarding cesarean section demonstrates the reasons “why” and “for” of the behavior of the people/group in a social world, translated in this study in the categories “the decision for cesarean section”, “the surgical postpartum”, “the need for caring” and “the idealization of the next delivery.

Category 1: The decision for cesarean section
When reflecting upon the experience regarding the cesarean section, women initially demonstrate the reasons that justified their decisions for this type of labor process, highlighting their fear for vaginal delivery, associated with pain and suffering from the labor process:

I had all the time in my head the suffering of the mothers during labor [...] why should I feel all that pain for so long if I had another option? ] I was sure of my decision (P1).

] in the end of pregnancy, I went many times to see my doctor afraid of having a normal delivery [...]. Since I found out I was pregnant, I chose the cesarean section (P8).

 

Women show the influence of near people to them – such as the husband and the mother – to decide for the cesarean section:

] I wanted the normal delivery [...] but my husband was against this idea. The decision for a cesarean section came from him, and I only had to say yes (P4).

The decision to have a cesarean section was influenced by my mother, because when I was born, [...] the doctor used the forceps. And my mother tells me how hard it was [...] so, during my entire life I heard this story [...] (P6).

 

Women also had the opportunity to discuss with their physicians about the decision regarding the type of delivery, and they mention that they had advice to proceed with normal delivery and the benefits of this proceeding, they had already taken their decision to have the cesarean section:

] during my first consultation, the doctor mentioned many benefits of the normal delivery. [...] Then when my bag broke, he asked: “are you going to have a normal delivery or the cesarean section?” Then I said: “you know what? I want to have the cesarean section.” [...] then he respected my decision and did not ask again [...] he left it open for me to decide [...] I had already decided for the cesarean section (P5).

My doctor calmed me down since the beginning. [...] She used to say: “we will try the normal delivery, as this is your first child and you have all the conditions to have an easy delivery”, but I did not want that! [...] during the eighth month, she even insisted: “let’s try it, everything is going well”. I said: “no, I want the cesarean section” (P6).

 

Because she was decided to have a cesarean section, one woman reported she searched for a professional knowingly favorable for this type of delivery:

] my doctor does not perform normal deliveries [...]. I knew that. [...] I wanted cesarean section, and that’s why I looked for him (P2).


After women opted for cesarean section, fear and anxiety were still present, however in another dimension. Such feelings were then associated to the anesthesia and the postoperative recovery:

What worried me was the anesthesia, because I hear so many different thins from every one [...] (P1).

I was afraid. I did not want to do the cesarean section because of the postoperative recovery [...] (P5).

 

Category 2: The surgical postpartum moment
The puerperals reported they were satisfied with the cesarean section, but mentioned that the immediate postoperative moment was difficult because of the reactions from anesthesia, pain, difficulty in mobility and caring with the baby:

It was really exciting to see the baby right after he was born [...]. The hardest part was to stand up right after the surgery, to leave bed to have a shower [...] and also taking care of the baby [...] because I was dizzy, discomforted. [...] (P6).

] the cesarean section went out very well. [...] but, after the second day, I felt a lot of pain (P2).

] the recovery was excellent, but [...] I needed help to move around, to breastfeed (P5).

 

One of the participants evaluates as negative the experience of the cesarean section:
] at the moment of the cesarean section, I was shaking in fear. [...] I was going through a surgery. I thought I was not going to see my baby [...]. The anesthesia was really painful [...] I felt a lot of pain after the delivery. It was too hard to take care of the baby [...]. I couldn’t because I had a lot of flatulence. I was horrible [...]. (P4)

 

Category 3: The need for caring
Considering cesarean section a surgical proceeding that requires postoperative caring, women mention the importance of professional support to watch over the newborn, specially regarding the early contact between mother and baby, and the support in breastfeeding:

What I missed in the cesarean section proceeding was the contact with my baby. Even lying down, I tried to breastfeed, but it didn’t work well. [...] they tried to but him in my breast, but he couldn’t catch it. The position wasn’t easy for me [...] he sucked it, but nothing came out (P1).

] I couldn’t get up from the bed [...] it’s hard to take care of the baby [...] it’s complicated, because the nurses are not there all the time available for you (P6).

 

Category 4: The idealization of the next delivery
The positive experience of the women that had cesarean section is also seen as in the idealization of the future delivery:

I would have cesarean section again [...]. It was a good experience. I didn’t feel a thing (P2).

There is no way I would have a normal delivery.  [...] the experience I had
with cesarean section was really good (P8).

 

When demonstrating their desire to have another cesarean section, the mothers bring up their fears regarding vaginal delivery to justify their decisions:

I want a cesarean section again. I am afraid of normal delivery [...]. if possible, I want everything organized in a way I won’t feel any pain [...] (P3).

] If I have another child, he will come through a cesarean section again [...]. I think I wouldn’t adapt to the agony of the normal delivery (P6).

I think it will be a cesarean section again. [...] I got scared with the contractions (P7).

 

One of the women whose decision for cesarean section was not motivated by her makes a clear statement about her frustration in not having a vaginal delivery and the desire to not have any more children:

 [...]. I wanted a normal delivery. If it is for me to have another cesarean section, I don’t want to have any more children. I don’t want to go through everything again [...] (P4).

 

DISCUSSION

The decision for the cesarean section was demonstrated, in this study, as a relevant aspect of the experience of women of this type of delivery. This decision started in the pregnancy period and it was bly influenced by the fear of pain during the moment of delivery.

Culturally, the choice of the mother for the cesarean section is impacted by the fear and by the worries linked to the pain of vaginal labor, normally generated from experiences reported by people from the near social environment. These experiences re sociocultural phenomena that lead women to see normal delivery associated to pain, originated in the dynamics of the process of parturition(13).

To understand the questions presented in the ordinary lives of these women, it is necessary to observe the set of acquired understandings each mother built throughout her life. This set is constituted first by the progenitors, and later on, by the educators and by concrete experiences, which all provide a continuous structure of this set of understandings, according to one person’s position in the social world – the biographical situation(12). Therefore, the mother who is waiting for her child brings, within this set of understandings, a large amount of values and beliefs that were culturally transmitted, thus showing a fear for the vaginal delivery, specially associating it to pain.

In many cultures and social groups, including in Brazil, the delivery is associated to anxiety and fear. Such feelings generate a negative connotation in regards to birth, which is later transmitted by generations, constituting a cultural component that strengths the representation of pain during normal delivery as a synonym to suffering(14).

This understanding is socially built and accessible through typing that can be expressed in positive or negative situations. Typing is constituted through an objective elaboration, which in turn can be expressed in a meaningful language, recognized and understood by those that experience a similar situation(12).

In this sense, fear and pain are types related to normal delivery that, if understood by health professionals, can be overcame, making the mothers to decide for the model of delivery that will bring more benefits.

A study performed with pregnant women in their last three months, in the public and in the private health system of the municipality of Joinville, Brazil, showed that the cesarean section chosen by the mother was bly influenced by the fear about pain during the labor process. Among other factors, it also showed the fear of their own performance during the labor process, in compromising the fetus well-being, the fear for the unknown and unpredictable, also acknowledging the stories experienced by other parturient women(13).

As the other side of the results of this research, a study conducted with primiparous women residing in the Brazilian state of Goiás demonstrated that, from the experience with normal delivery, the majority of the participants considered pain as a natural phenomenon inherent to the process of labor and belonging to the feminine domain, thus demystifying the idea of pain as a part of the process of suffering.

This feeling ws built when there was a legitimization of each parturient as an active agent during the labor moment. It was identified that the pain during labor is part of women’s nature, being one important element for the dynamics of parturition and to reveal the strength of women and their empowerment(14).

Yet, in regards to the decision for the cesarean section, it was observed in the testimonies that women, despite the fact they have a desire to go through the experience of normal delivery, they opted for the cesarean section under influence of important people for them, such as their mothers and husbands.

In a similar way, a transversal study, which occurred in two maternity hospitals located in the Brazilian state of Rio de Janeiro, was about the role of women choosing cesarean sections as their delivery process, and showed the influence of the partner in their decision. Furthermore, the meaningful components in the decision-making process of women were the fear and the previous stories heard linked to normal delivery(8).

In regards to the participation of the physician in the process of decision-making for a cesarean section, one woman reported that this professional simply complied with her decision for this type of delivery.

She also reinforces the participation of this professional, demonstrating the benefits of vaginal labor and/or motivating her to have this type of proceeding; despite that, she did not change her position.

This information corroborates with a study done with pregnant women assisted by private health plans, which revealed that, during the process of negotiation between the woman and the obstetrics physician favorable to normal delivery, the position of the mother for the cesarean section was prevailing(15).

On the other side, there are professionals who are advocates for cesarean sections, among which are approached by some women who want this type of procedure, as it was observed with a deponent in the present study. There are even cases in which the women have not yet made a final decision for the cesarean section and the physician influences her to take the stance of the cesarean delivery. One research performed in the city of Rio de Janeiro, Brazil, among primiparous women assisted by both public and private health plans showed the influence, sometimes explicit, other times, subtle, of the physician in the decision-making process of the women towards the cesarean section. The relationship of trust between the mother and her obstetrician, built through the pre-natal care moments, made the mother more influenced to have a cesarean section – the favorite type of labor of the health professional – because they are afraid some negative situation occurs, in the case they insist in having a vaginal labor(16).

In the routine of health care services, in Brazil, it is seen that obstetricians many times do not provide clear information regarding the benefits and disadvantages of the different types of labor for the mothers(8). Even when the professional gives some information to the pregnant woman, the dialogue between physician and patient about the questions related to the types of delivery are considered insufficient to support her during her decision-making process(13), which leaves her even more vulnerable to foreign influences, either relatives or health professionals that assist/support this woman.

We must mention that, within this context, there is an importance to establish a face-to-face relationship between the health professional and the patient, being such relationship permitted to generate an authentic and reciprocal interaction among them. This reciprocity is seen when real or potentially common objects are chosen and interpreted identically by the subjects in the same social world(12). In this sense, besides they are positioned biographically in different situations, the woman and the obstetrician, mediated through a reciprocal relationship, move themselves towards the same goal, in order to understand the what is involved in the situation of the labor and birth, permitting a intelligible and congruent dialogue between them.

This fact demonstrates the importance to give women a positive experience of labor, differently from the type, through a relationship that generates safety and information to the women in the process of delivery and birth(17).

It is important to highlight that, despite the fact women evaluates cesarean sections positively and chooses to use this procedure, the fear can still be present, linked to the anesthesia and the postoperative recovery process, as seen in this study’s testimonies. This finding matches what was previously mentioned in a study with women who had cesarean sections. They associated this type of delivery to the occurrence of counter-effects from the anesthesia and difficulties in the postoperative recovery(10)

When reflecting upon their own experience with the cesarean section, women usually evaluate it as a positive procedure. This is also reflected in literature, which shows that, even with the possible obstetric complications, mothers can consider the cesarean section experience as a positive one(17). Furthermore, the lack of pain during the labor process places the cesarean section as a desired surgical proceeding, which also permits the tubal ligation procedure and the safety of a medical procedure during the delivery(10).

In regards to the necessities in caring pointed out by the participants, it is important to mention those related to breastfeeding and the caring to the newborn. A study performed in the cities in the interior of the Brazilian state of São Paulo, with 60 women that underwent to cesarean section in maternities that belong to the Brazilian Unified Health System, showed that all presented limitations to perform ordinary, daily activities during the postoperative moment. Among them, 40% showed difficulties when breastfeeding. It is important to highlight that these puerperals present particular conditions, related to a higher necessity to move around to take care of the baby and of themselves(18).

Based on the fact that the majority of the experiences with the cesarean section was considered positive, the women demonstrates the desire to, in the case of having more children, having the same procedure, due to the satisfactory recovery and the lack of pain during labor time. The experience of parturition, being it negative or positive, provides subsidies in the decision-making processes of future deliveries. The positive reinforce the choice in having the same way of delivery, while the negative work as doing the opposite, leading to choose the other type of procedure. For example: if the mothers are satisfied with the cesarean section, the tendency is to repeat the procedure in the next delivery; if the experience with the cesarean section is traumatic, the mothers tend to change their opinion in future pregnancies(13).

A study performed in North Carolina, in the United States of America, demonstrated the belief of women, in which the decision for the type of delivery must come from the choices informed and advised by their physicians. This evidence shows, once more, the influence of the physician in the decision-making process of the women, once even if they do not want to have a cesarean section, they were repeating the procedure because they were following the information given by the health professionals, such as obstetric issues that would impede them to opt for normal delivery(19).

The expectancy to not have more children in the case of having another cesarean section was observed by one of the participants, after a negative experience with the surgery. Her previous decision by the cesarean section occurred due to the influence of near people, being submitted to the surgery, with an idea of vaginal labor as the best option for delivery. This evidence matches a study that showed the possibility for the women to feel frustrated after experiencing cesarean section, when they really wanted to have a normal delivery(16).

Besides that, women with health problems and obstetric complications during the postpartum period are less inclined to have the same choice for the delivery of their next child, as they reflect upon their experiences and make other choices(20). On the other hand, some women, even after experiences some difficulties during the procedures, do not consider them as negative moments. This demonstrates that labor is an individual experience and may not be directly linked to the obstetric history of the mother(17).

Once this study was performed with women using a certain health plan inserted in a certain sociocultural reality, therefore it brings a perspective of the understanding of the experience of women that had cesarean section, which derails any generalization of these results.

 

CONCLUSION

The understanding of the experience of the primiparous woman with cesarean section shows that the fear of vaginal labor, as seen the generator of pain and suffering, goes through the whole pregnancy until the puerperal moment. This fear influences her expectancy regarding the next delivery, in which she may elect this procedure as a standard one.

The participation of the health professional is considered relevant to provide tools for this woman, in order to demystify taboos and beliefs that are linked to normal delivery. In regards to the cesarean section, it is important to orientate the reactions that come from this type of delivery and the implications seen in the postpartum moment, specially when discussing the surgical recovery and the difficulties when taking care of the newborn. This empowerment can be a way to pay respect to the autonomy of the woman in her decision-making process to decide which delivery procedure will make her feel safer.

The theoretical-methodological approach of social phenomenology contributed in understanding the experience of women under cesarean section, from a perspective that valorize the circumscribed social dimension of the experience of each woman.

To the health professionals and other researchers, it is important to pay more attention to the factors that involve the decision process in the favor of the cesarean section, and the results of this decision in the life of women, specially regarding to the caring towards the newborn. In this matter, it is worth investing in assistive actions in consonant to the demands presented by the women, since pregnancy to the puerperal period.

 

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Contribution from the authors: Concept and design: all; Analysis and interpretation: all; Writing of the article: all; Critical review and final approval of the article: Maria Cristina Pinto de Jesus.

 

 

Received: 02/21/2013
Revised:03/16/2014
Approved:03/16/2014