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BMC Pregnancy Childbirth. 2018 Sep 17;18(1):377. doi: 10.1186/s12884-018-2007-7.

Factors influencing decision-making for caesarean section in Sweden - a qualitative study.

Author information

School of Nursing and Midwifery, Trinity College Dublin, 2 Clare Street, D02 CK80, Dublin, Ireland.
School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin, D02 T283, Ireland.
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Department of Nursing, Mid Sweden University, 86170, Sundsvall, Sweden.
Department of Women's and Children's health, Uppsala University, Uppsala, Sweden.



Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden.


A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin.


The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes.


Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.


Caesarean section; Decision-making; Midwife-led care; Midwives; Normal birth; Nulliparous; Obstetricians; Qualitative

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