Purpose: Cesarean deliveries account for 31.8% of births in the US. “Cesarean delivery on maternal request” (CDMR) has been suggested as contributing to this increase. However, little is known about how women value alternative delivery approaches and their potential outcomes, and to what extent they would choose to have a planned cesarean delivery if offered. We sought to assess pregnant women's mode of delivery preferences and to identify sociodemographic determinants of these preferences.
Method: Women receiving prenatal care at the University of California, San Francisco, or San Francisco General Hospital were invited to participate in an interview at 22-35 weeks gestation. Time tradeoff (TTO) and standard gamble (SG) utilities, with attempted vaginal delivery ending in cesarean or a cesarean with complications as bottom anchors, for 8 scenarios associated with either a planned vaginal or planned cesarean delivery were measured using a computerized preference elicitation tool (ELICIT). A demographic/attitudinal questionnaire also was administered.
Result: Of the 81 participants, 57% were multiparous and 6% had a prior cesarean delivery. 95% preferred vaginal delivery and, on average, were willing to accept a 74% chance of their planned vaginal delivery ending in a cesarean before switching their preference to a planned cesarean delivery. In a regression model adjusted for age, parity, and race/ethnicity, women with at least a college degree were more likely than those without a degree to indicate that they would attempt a vaginal delivery even with a 0% chance of success (SG=0, adjusted OR 14.1, 95% CI 2.1-94.7). In other words, these women highly valued experiencing labor even if it would not culminate in a vaginal delivery. Median SG and TTO scores for the remaining delivery scenarios ranged from 0.19-0.75 and 0.97-0.99, respectively.
Conclusion: The vast majority of participants preferred vaginal delivery and would attempt this approach even if the chance of success was low. The strength of this preference varied depending on maternal education and the specific delivery scenario being assessed. Few women would accept a reduced life expectancy to achieve their preferred mode of delivery. In this population, CDMR is unlikely to be a primary cause of the increasing cesarean delivery rate. Further studies in other geographic areas are needed to shed further light on the role of preferences in mode of delivery decisions.
Candidate for the Lee B. Lusted Student Prize Competition