Tabassum Shoaib  ( Department of Obstetrics/Gynaecology, Jinah Postgraduate Medical Centre, Karachi. )
Sheena Memon  ( Department of Obstetrics/Gynaecology, Aga Khan University, Hyderabad. )
Iffat Javed  ( Department of Obstetrics/Gynaecology, Jinah Postgraduate Medical Centre, Karachi. )
Saba Pario  ( Department of Obstetrics/Gynaecology, Jinah Postgraduate Medical Centre, Karachi. )
Shereen Zulfiqar Bhutta  ( Department of Obstetrics/Gynaecology, Jinah Postgraduate Medical Centre, Karachi. )

Objective: To determine the attitude and factors leading to decision regarding the mode of delivery in women with previous experience of C-section.
Methods: The cross-sectional study was conducted at Maternity Unit of Jinnah Postgraduate Medical Centre, Karachi, from January to August 2008, and involved 150 women with one previous C-section without any recurrent cause. All women had a parity of two or more. Women with more than one caesarean section and women who lost contact were excluded. The women were recruited from antenatal clinic and were briefed by medical professionals before the questionnaire was filled out. SPSS version 10 and Chi square test were used for statistical analysis.
Results: Of the total 29 (19.3%) preferred a repeat caesarean section, and 121 (80.7%) opted for the trial of scar. No significant difference was seen in the mode of delivery when the decision was taken by women alone or when it was taken jointly by doctors and women. When the decision was taken by doctors, there was significant difference in the mode of deliveries. The patients expressed satisfaction towards the information received. Previous associated factors, like negative birth experience, had an influence on decision-making regarding the mode of delivery.
Conclusion: Decision by women is extremely important regarding their mode of delivery and should be respected. Psychological support during pregnancy may provide an alternative to caesarean section for women with previous negative experience.
Keywords: C-section, Mode of delivery, Previous negative experience. (JPMA 62: 1038; 2012).

Delivery by Caesarean section occurs in 10% to 25% of births.^1-5 Although CS rates have increased over the last 10 to 15 years, the four major clinical determinants of the CS rate have not changed much. These remain foetal compromise (22%), \\\'failure to progress\\\' in labour (20%), repeat CS (14%) and breech (11%). The fifth most common reason given for performing a CS has changed and is now reported to be \\\'maternal request\\\' (7%).⁶ The rates of preference for CS expressed by women who were surveyed during pregnancy in UK, Australia and Sweden range from 6% to 8%.^6-10
Current medical evidence indicates that 70-80% of women can achieve a vaginal delivery following a previous lower uterine segment caesarean delivery.^11,12 Some of this decline is due to changes in hospital policies.¹³
Changing childbirth Report by Expert Maternity Group from the Department of Health (DH) in 1993 explained the right of women to be involved in their care during pregnancy and childbirth and for that they need to be provided with evidence-based information so they can take part in discussion with their caregivers about their decisions.^14,15 With an increase in the rate of primary CS, obstetricians face difficult decisions while planning for subsequent mode of delivery. Previous childbirth experience has a great influence on the decision for the mode of delivery of the current pregnancy. Preference for repeat CS was seen in women with previous negative experience and on the contrary, preference for vaginal birth is common for experiencing a natural event.^10,16
Jinnah Post Graduate Medical Centre (JPMC) is a tertiary care hospital in Karachi, receiving a large number of referrals from district hospitals, maternity clinics, traditional birth attendants and general practitioners. Due to a large number of un-booked and referred patients, this institution has a wide experience of dealing with high-risk pregnancies. The rate of CS at JPMC is 15%-20%. The majority of people it caters to are from low socioeconomic group with a low literacy rate.¹ Pakistan being a male-dominated society where women are usually not involved in major decisions. They too are used to accepting the decision imposed on them. The aim of this study was to encourage our women to get involved in the decision related to their mode of delivery and enquire their delivery preferences and assess the outcomes.

The cross-sectional study, carried out at Unit-I of the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi, consisted of 150 patients and lasted from January to August 2008. All women with one previous CS due to non-recurrent cause with a parity of two or more were recruited in the study. Patients who presented with more than one CS and who lost contact after registration were excluded from the study. The interviews were conducted by medical professionals through questionnaires, which included socio-demographic and obstetric background, attitudes to decision-making, experience of previous birth and present pregnancy, preferences for mode of delivery and additional questions to explore issues specific to each woman.
They were provided with evidence-based information regarding risks and benefits of CS versus vaginal birth after caesarean delivery. The women were interviewed in the antenatal clinic at 18 to 20 weeks and then again in the third trimester from 34 weeks onwards. The women were followed until delivery and their experience at delivery and outcome was noted. Data feeding and statistical analysis was done on SPSS version 10. Chi-square test was used for further analysis.

Majority of women 120 (80.0%) had parity less than or equal to 5 (Table-1).

The mean age of enrolled patients was 28.5 ± 5.7 years, while 110 (73.3%) women were illiterate and 40 (26.7%) had either higher secondary school or more level of education. Besides, 110 (73.3%) of the women belonged to poor socio-economic classes on the basis of per capita monthly income. Obstetrics characteristics indicated that the majority of CS were performed in emergency (Table-2)

and the ratio of women having bad experience at previous delivery were high. Attitude towards decision-making regarding the mode of delivery were also noted (Table-3).

In this study the rate of joint decision by doctors and patients was high, and the majority of women opted for the trial of scar. The patients felt satisfaction towards the information received and showed highly significant difference (P=0.001) with both CS and vaginal delivery.

In our study majority our women (80%) preferred vaginal delivery, suggesting the rising CS rates are not related to women\\\'s wishes. Similar trend was observed by women in an earlier study.¹⁶ Previous birth experience and mode of delivery are important variables depicting the present mode of delivery. However, few women requested CS in the absence of any unfortunate previous experience. Similar, to our results, Gamble and Creedy⁷ reported that a few women requested CS in the absence of any obstetric complications. Previous negative birth experience and poor outcome in previous pregnancy like stillbirth are major worries for childbirth which contributed to the wish for CS in this study. The results are supported by other studies.^17-19 Women\\\'s involvement in their mode of delivery is a neglected part in the management of our women. However, the study showed that women feel happy with their involvement and were able to contribute to the decision.

Patient\\\'s choice is extremely important in modern obstetrics. Psychological support during pregnancy may offer an alternative to CS for women who fear vaginal birth due to some previous negative birth experience.

1. McMahon MJ, Luthier ER, Bowes WA Jr, Olshan AF. Comparison of a trial of labor with an elective second Cesarean section. N Engl J Med 1996; 335: 689-95.
2. Davies GA, Hahn PM, McGrath MM. Vaginal birth after cesarean section. Physicians\\\' perceptions and practice. J Reprod Med 1996; 41: 515-20.
3. Society of Obstetricians and Gynaecologists of Canada. Vaginal birth after previous Caesarean birth. Clinical Practice Guideline No. 68. Ottawa (ON): SOGC; December 1997.
4. Biswass A. Management of previous cesarean section. Curr Opin Obstet Gynecol 2003; 15: 123-9.
5. Ghafarzadeh M, Namdari M, Ashraf H. Vaginal birth after caesarean section: A retrospective study. Pak J Med Sci 2010; 26: 987-9.
6. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. London: RCOG Press; 2001.
7. Gamble JA.Creedy DK. Women\\\'s request for a cesarean section: a critique of the literature. Birth 2000; 27: 256-63.
8. Johanson RB, El Timini S, Rigby C, Young P, Jones P. Caesarean section by choice could fulfil the inverse care law. Eur J Obstet Gynecol Reprod Biol 2001; 97: 20-2.
9. Edwards GJ, Davies NJ. Elective caesarean section - the patient\\\'s choice? J Obstet Gynaecol 2001; 21: 128-9.
10. Hildingsson I, Radestad I, Rubertsson C, Waldenstrom U. Few women wish to be delivered by caesarean section. BJOG 2002; 109: 618-23.
11. Taj G, Sohail N, Cheema SZ, Zahid N, Rizwana S. Review of study of vaginal birth after caesarean section (VBAC). Annals 2008; 14: 13-6.
12. Kashif S, Mansoor M. Vaginal birth after caesarean section; To Evalute factors forsuccessful out come. Professional Med J 2010; 17: 665-9.
13. Grobman WA, Lai Y, Landon MB, Spong CY, Rouse DJ, Yaener MW, et al. The change in the rate of vaginal birth after caesarean section. Paediatr Perinat Epidemiol 2010; 25: 37-43.
14. Department of Health. Changing Childbirth. Report of the Expert Maternity Group. Part 1. London: HMSO; 1993.
15. Bekker H, Thornton JG, Airey CM, Connelly JB, Hewison J, Robinson MB, et al. Informed decision making: An annotated bibliography and systematic review. Health Technol Assess 1999; 3: 1-156.
16. Angela AC, Washington AE, Vargas JE, Gomez R, Rojas I, Caughey AB, et al. Chilean womens preferences regarding mode of delivery: which do they prefer and why? BJOG 2006; 1253-8.
17. Sjogren B ,Thomassen P.Obsttetric outcome in 100 women with severe axiety over childbirth.Acta Obstet Gynecol Scand 1997; 76: 948-52.
18. Siasto T,YlikorkalaO,Halmesmaki E.Factors associated with fear in second pregnancies .Obstet Gynecol 1999; 94: 679-82.
19. Ryding EL, Wijma B, Wijma K, Rydstorm H. Fear of childbirth during pregnancy may increase the risk of emergency caesarean section. Acta Obstet Gynecol Scand 1998; 77: 542-7.