Women's preferences for caesarean or vaginal birth with a perspective of future fertility: A discrete choice experiment.

Objective: To investigate pregnant women's preferences for risks of vaginal and caesarean birth, including possible impacts on future fertility.

Methods: In this discrete choice experiment, low-risk nulliparous pregnant women recruited after 28 weeks of gestation evaluated eight choice sets, each between two different hypothetical births scenarios which intermixed the risks of planned caesarean or vaginal birth. Scenarios consisted of six attributes: pain, maternal health, neonatal health, risk of unplanned intervention, impact on fertility and risk of complications in the next pregnancy. All scenarios contained risks to neonatal health as neither vaginal nor caesarean birth guarantee an ideal outcome. Choice data were analysed using a conditional logistic regression model.

Results: Between June and September 2023, 211 participants, including 34 from pilot interviews, completed the questionnaire. Influential attributes were maternal health (conditional odds ratio [COR] 1.29, 95% CI 1.17 to 1.42, p<0.001) and risk of unplanned intervention (COR 1.37, 95% CI 1.24 to 1.51, p<0.001), favouring caesarean birth. Conversely, impact on fertility (COR 0.75, 95% CI 0.68 to 0.83, p<0.001) and complications in the next pregnancy favoured vaginal birth (COR 0.90, 95% CI 0.82 to 1.00, p = 0.045).

Conclusions: Participants weighed the included morbidity risks of planned caesarean and vaginal birth in a low-risk pregnancy approximately equally. To facilitate an informed birth decision, clinicians should, apart from neonatal outcomes, particularly consider discussing impacts on fertility, maternal health and the risks of unplanned intervention or future pregnancy complications.