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Caesarean birth: The impact of clinical uncertainty on professional decision making

Green, B. (2006). Caesarean birth: The impact of clinical uncertainty on professional decision making. (Unpublished Doctoral thesis, City, University of London)


The reasons why the caesarean section rate continues to rise in the western world have become a major issue in relation to contemporary maternity health care. One key factor put forward to explain the rise in caesarean section rates is the increasing influence of the biomedical model on childbirth. This model is built on the belief that obstetrics can structure the birth process so as to make birth happen in an orderly, safe and controlled way. However, much of the obstetric knowledge on which decisions are based is uncertain, or, in some cases, non-existent. In consequence, questions about the efficacy and efficiency of biomedical decision-making about childbirth have been raised in the political, consumer and professional arenas. Despite the ambitions of UK maternity policies to the contrary, and indications derived from evidence-based medicine, hopes of reducing the caesarean section rate have not been realised.

This thesis examines different parameters of caesarean section decision-making to those which have been studied previously. Using Fox’s (1957) research on medical uncertainty as a framework for this study, the impact of uncertainty on midwives’ and doctors’ decision-making, the structural and organisational factors which impact on this process and the strategies which health professionals use to cope with uncertainty were explored. The method used was participant observation, supplemented by 16 semi- structured interviews with doctors and midwives, undertaken over a six month period from June 2000-December 2000. The field work was situated predominantly on a labour ward managing about 3000 births per year. The qualitative data were analysed in relation to the management of uncertainty through thematic analysis.

The study identified problems which midwives experience in their work on account of medical uncertainty, problems which lead to midwives becoming concerned about the limits of their own knowledge and feeling individually incompetent. Doctors, in contrast, are able to manage uncertainty by focussing on the limits of the body of knowledge available to them, rather than on their own individual lack of knowledge. Nonetheless, doctors’ tolerance or intolerance of uncertainty impacts on decisions to undertake caesarean sections. If caesarean section rates are to decrease, clinicians must learn better ways to deal with complexity in decision-making, and organisational support needs to be in place to facilitate this process.

Publication Type: Thesis (Doctoral)
Subjects: R Medicine > RG Gynecology and obstetrics
Departments: School of Health & Psychological Sciences > Midwifery & Radiography
School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses
Doctoral Theses
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