Midwives’ Perspective on Participation of Pregnant Women Planning an Elective Caesarean Section in Antenatal Classes: A Qualitative Interview Study 

Midwives’ Perspective on Participation of Pregnant Women Planning an Elective Caesarean Section in Antenatal Classes: A Qualitative Interview Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Midwives’ Perspective on Participation of Pregnant Women Planning an Elective Caesarean Section in Antenatal Classes: A Qualitative Interview Study Sandra Jaax, Jessica Breuing, Barbara Prediger, Nadja Könsgen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6417125/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Studies indicate that pregnant individuals sometimes feel inadequately prepared for caesarean section (CS) in antenatal classes. Unpublished data suggest that women planning a CS are less likely to attend antenatal classes compared to those planning a vaginal birth. However, antenatal classes provide valuable information beyond vaginal birth. The aim of this study is to assess barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes, how the topic (elective) CS is addressed in antenatal classes, pregnant individuals’ potential information needs and how they can be addressed. Methods Semi-structured interviews were conducted with midwives. The inclusion criteria required midwives who currently offer antenatal classes, have experience in conducting antenatal classes, and have had pregnant individuals with an elective CS attend their courses. Recruitment was carried out via telephone or email and through midwifery associations. Data analysis was performed using a content-structured approach (Mayring), employing the software MAXQDA. Results From October to December 2023, 15 semi-structured interviews have been conducted. Midwives reported that pregnant individuals with elective CS often assume that antenatal classes are not relevant for them. This is partly due to a lack of information regarding the importance of their participation as well as insufficient awareness about the content of antenatal classes. Moreover, midwives noted that sometimes, other participants and midwives in antenatal classes respond negatively to the decision of having a CS. For example, midwives reported during the interviews that CS is sometimes perceived as inferior to vaginal birth. Further, they reported about occasional attempts to persuade individuals to opt for vaginal birth. The majority of midwives consider addressing the informational needs of pregnant individuals with elective CS to be important. Therefore, the majority supports the provision of separate antenatal classes for those planning elective CS and those planning vaginal birth, given the differing informational requirements. Conclusions A more comprehensive education of pregnant individuals regarding the content of antenatal classes is necessary. Following additional research on the perspective of pregnant individuals, potential modifications to enhance targeted support, such as the implementation of a separate course, should be evaluated. Prenatal classes Childbirth Education Classes Childbirth Preparation Classes Cesarean Sections Pregnancy Germany Qualitative Study Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Background Antenatal classes are defined as structured programs for expectant parents that provide information and skills to prepare for childbirth, parenthood and postnatal care [ 1 ]. Pregnant individuals attend antenatal classes to reduce their fear of childbirth and labor [ 1 ], to prepare them for the process of giving birth and becoming parent as well as to feel confident in handling the newborn [ 2 ]. Additionally, antenatal classes provide a social network and an opportunity to share experiences [ 3 ]. In Germany, antenatal classes are mainly provided by midwives. In addition to topics and practical exercises related to vaginal birth, other topics related to pregnancy and preparation for parenthood are covered. These include information about the postnatal period, breastfeeding and newborn care. Out of a total of 667.705 individuals who gave birth in Germany in 2023, 217.852 had a caesarean section (CS). This represents a CS rate of 32.6% [ 4 ]. The operative CS, in which the baby is delivered through a surgical incision in the abdominal wall, is distinguished from the spontaneous vaginal birth (without surgery) and the operative vaginal birth (using instruments such as forceps or vacuum) [ 5 ]. CS is one of the most common surgical procedures performed on women [ 6 ] and is nowadays considered a safe surgical procedure that can prevent maternal and neonatal mortality and morbidity when medically indicated [ 7 ]. Qualitative studies have shown that CS are often associated with negative experiences of childbirth, and that pregnant individuals do not feel adequately prepared for this surgical procedure in antenatal classes [ 8 , 9 ]. Differentiated data on participation in antenatal classes based on the mode of delivery has not been published so far. Unpublished data suggests that pregnant individuals with elective CS are less likely to attend antenatal classes than those planning a vaginal birth. Elective CS is defined as a CS planned in advance in comparison to unplanned CS, which is performed because of complications during childbirth [ 10 ]. To date, there is no published data on the reasons of pregnant individuals with elective CS for attending or not attending antenatal classes. Thus a discussion of this is speculative. As antenatal classes cover topics that go beyond vaginal birth, they are also relevant to this group of pregnant individuals. Furthermore, it is important to include CS in antenatal classes for pregnant individuals planning a vaginal birth, because they may unexpectedly find themselves in a situation where an unplanned CS is required and proper preparation for a planned CS can benefit them. Our aim is to investigate the demand for antenatal classes among pregnant individuals with elective CS, as well as the barriers and facilitators that influence their attendance from the midwives’ perspective. Furthermore, the midwives’ perspective on the information needs of pregnant individuals with elective CS in antenatal classes, on the extent to which the (elective) CS is covered in antenatal classes, and on how addressing these information needs can be improved is assessed. 2. Methods 2.1 Design The study was approved by the Witten/Herdecke University Ethical Committee (S-240/2023). A semi-structured interview guide was developed to provide guidance and structure during the interview and comparability in the subsequent evaluation. The interview guide was developed by an interdisciplinary team comprising individuals with experience in developing interview guides (JB, NK) and those without such experience (SJ). The interview guide consisted of 6 sections: 1) General information about the antenatal classes, 2) the topic of (elective) CS in the antenatal classes, 3) the need for participation in antenatal classes by pregnant individuals with elective CS, 4) information needs of pregnant individuals with elective CS in antenatal classes, 5) addressing the information needs in antenatal classes, 6) factors influencing the participation of pregnant individuals with elective CS in antenatal classes. Before starting the study, a pretest of the interview guide has been performed with one midwife to ensure good comprehensibility and completeness of the questions [ 11 ]. The interview guide was subsequently adapted. It can be found in supplementary material 1. A priori, a study protocol has been published on protocols.io [ 12 ]. The introduction of the paper is based on the introduction of the protocol. Additionally, parts of the methods section are also taken from the protocol. The Text Recycling Research Project was followed as instrument of guidance [ 13 ]. Moreover, the consolidated criteria for reporting qualitative research (COREQ) [ 14 ] has been used to report the given study (Supplement 2: COREQ-checklist). 2.2 Data collection A convenience sample of midwives who have experience in conducting antenatal classes in Germany was included and offered these at the time of recruitment. Only midwives who have experience with pregnant individuals with elective CS in their antenatal classes have been included as it was possible to recruit enough midwives who meet these criteria. Experience with pregnant individuals undergoing elective CS in antenatal classes was defined as having participated in at least one antenatal class led by the midwife. If it had not been possible to recruit enough midwives with experience, midwives with no experience of pregnant individuals with elective CS in their antenatal classes would have been included. To recruit midwives, midwives based in Germany have been contacted by phone or email. Also, the midwifery associations were asked to share the invitation to take part in the interviews in their newsletters or on their social media channels. Influencers in the field of midwifery science were contacted on the social media platform Instagram and asked to share information about the study as well. In addition, the network of the Institute for Research in Operative Medicine (IFOM) was used to support recruitment and the information about the study was disseminated via private messengers and social media accounts. It was not possible to provide any financial incentives for participation. Midwives who were interested in participating received an email with the following study documents, prior to the interview: participation information, consent form and privacy statement. Furthermore, the email requested information on the characteristics relevant to heterogeneous composition of the sample, such as age, gender, and professional experience in conducting antenatal classes. SJ, who was a Master's student in Prevention, Sports Therapy and Health Management and an employee at IFOM at the time the interviews were carried out, conducted the interviews as part of her Master's thesis. She had no prior experience in conducting qualitative studies and was supervised by an individual with experience in conducting qualitative studies (NK). There was no relationship between the participants and the interviewer. The participants only knew that she was a Master's student and employee at IFOM and was conducting the study as part of her master's thesis. Prior to the interviews, detailed information about the study (background and duration) along with privacy statements was provided to each participant. The interviews were conducted by telephone in order to give the participants as much flexibility as possible regarding the time and place of the interview. The interviewer joined the interviews from home or from her workplace at IFOM in Cologne. The participants were free to take part from wherever they wanted. Accordingly, it cannot be guaranteed that other individuals were not present. Recruitment took place from October to December 2023 and ended when content saturation was reached. An audio recording device was used to record the interviews, which were then transcribed by an external service provider. Afterwards, the transcripts were reviewed by the interviewer. Field notes were not necessary because of the transcription. Therefore, they were not taken. The participants were not given the opportunity to correct or comment on the transcripts, and no interviews were repeated. There were no physical or mental risks to consider during the study. Participants were informed of the content and the objectives of the study and agreed to take part in advance. They provided written consent in advance for the conduct of interviews as well as data recording and processing. 2.3 Data analysis The interview analysis is based on Mayring’s qualitative content analysis [ 11 ] using MAXQDA data analysis software. The aim is to structure the transcribed interviews into main and sub-categories in order to analyze the material in a controlled and step-by-step manner. The development of the main and sub-categories is based on both a deductive and an inductive approach. In the deductive approach, main categories are defined on the basis of the interview guide. In the inductive approach, additional categories are derived from the data material. SJ and NK independently coded three interviews with regard to the main categories. Deviations were discussed in order to obtain a shared understanding of the coding procedure. The interviewer then continued the first step (main categories) of coding on her own. The subsequent inductive coding was carried out by both persons independently on the basis of 3 interviews. During this step, the deductive category system from the first step was inductively refined and supplemented by further categories and subcategories. Following this, SJ and NK discussed the results in order to obtain a shared understanding. Then, the interviewer carried out the more in-depth coding alone. The coding system can be found in supplementary material 3. 3. Results 3.1 Participants’ characteristics A total of 31 midwives with an interest in the study were recruited. Reasons for drop out were no provision of antenatal classes at the time of recruitment, lack of experience in the provision of antenatal classes or with pregnant individuals with elective CS in their antenatal classes, lack of time capacities, or the way the study was conducted (participants did not want any interview/audio recordings). Accordingly, 15 interviews with a mean length of 27 minutes (range 14–52) were conducted. All participants were female and the mean age was 39 years (range 23–60). They had an average work experience of 11 years (range 1–25). 3.2 Barriers and facilitators for participation in antenatal classes The participants mentioned several barriers and facilitators of the attendance of women with (elective) CS in antenatal classes. These relate to the information provided about antenatal classes, the way in which the topic of CS is dealt with in antenatal classes, the range of courses on offer and the choice of topics in antenatal classes, as well as individual and social factors. The care situation is an influencing factor as well. For instance, early contact with a midwife is seen as beneficial and purely doctor-based care as a hindrance. All mentioned barriers and facilitators for attendance are listed in Fig. 1 . In addition, the participants emphasize that regardless of the mode of birth, the level of education and financial situation influence participation in antenatal classes. 3.3 The need of pregnant individuals with elective CS for antenatal classes Most midwives estimated that the majority of pregnant individuals in antenatal classes have clear birth preferences, mostly in favor of a vaginal birth. Nevertheless, many participants consider the participation of pregnant individuals with elective CS in antenatal classes to be relevant in principle. One of the reasons given for this is the very broad range of topics, which goes far beyond the mode of delivery. It was also pointed out by the midwives that antenatal classes are important for the time during pregnancy. This is due to the provided information about nutrition and prevention, but also for the time with the baby including breastfeeding and newborn care. Other reasons mentioned are provided information, mainly about CS but also about vaginal birth, and networking with other parents-to-be. ID_6, Pos. 27: „Very high. Well, I think that everyone should attend a birth preparation course because the course also covers other topics. In other words, it's not just about the birthing process, but also about preparing for birth and parenthood. And then afterwards, the postnatal period, breastfeeding and so on. And there are still questions about the planned caesarean section. In other words, I would always highly recommend taking part, regardless of how you want to give birth.” However, there are also dissenting opinions, which argue that antenatal classes are primarily designed for women planning a vaginal birth. Further, stating that women with elective CS would benefit more from other preparations, and that they may feel uncomfortable with topics related to vaginal birth. 3.4 Consideration of (elective) CS in antenatal classes All of the midwives stated that they generally take the topic of CS into account in their antenatal classes. The most common reason they gave for this is that CS can result from the course of labor and is therefore relevant for all pregnant individuals. Others cited the high CS rate, the participants' desire for more information on CS or that the mode of birth is not yet known at the time of participation. Most of the midwives stated that they generally discuss the content of elective CS in the antenatal classes. A few participants pointed out that they would not include elective CS in their antenatal classes, because they think there is not much to address on the subject in advance. Further, they assumed that it has already been discussed with the gynecologist, or they offered their own separate preparation for pregnant individuals with elective CS. Others pointed out that they consider the topic as required, i.e. depending on enquiries or the number of patients with elective CS. Figure 2 provides an overview on topics on (elective) CS generally considered in the participants’ antenatal classes. It exhibits a high degree of overlap in terms of which topics relating to CS in general and elective CS are generally addressed in the antenatal classes. With regard to elective CS, more topics on preparation are mentioned and the health effects relate only to the mother, not the newborn. 3.5 Information needs of pregnant individuals with elective CS in antenatal classes Some midwives reported that pregnant individuals with elective CS have more specific information needs on the topic of (elective) CS in the antenatal classes than pregnant individuals planning a vaginal birth. Others, however, stated that the information needs of pregnant individuals with and without elective CS do not differ. Information needs of pregnant individuals with regard to CS in general and elective CS are exhibited in Fig. 3 . Overall, there is a high degree of overlap between the main topics addressed for (elective) CS in antenatal classes (Fig. 2 ) and the information needs of pregnant individuals on (elective) CS. Some midwives reported that pregnant individuals with elective CS ask few or no questions about (elective) CS in the antenatal classes. Some participants explained this by the fact that these pregnant individuals obtain the information elsewhere, e.g. in counselling sessions. Another reason they gave was that pregnant individuals with elective CS do not want to disclose their planned mode of labor in the antenatal classes. Overall, it was pointed out that the topic of elective CS depends heavily on the respective antenatal classes and that there is correspondingly great heterogeneity with regard to the information provided: ID_13, Pos. 69: B: „I suppose that depends very much on the course. I know that there are courses where the caesarean section is almost not discussed at all or only as emergency management, which is not advisable. I think that leaves many, many questions or uncertainties, or perhaps even encourages uncertainties. I sometimes experience that women, I also work in a clinic, say after a caesarean section that they have heard in their antenatal classes that it is so bad for the child and / So, where I think: “Oh God!” So, I think it really depends on the course. And, well, I hope it's different in my classes. But I don't know that for sure, of course. (laughs) Yes.“ 3.6 Modifications to address the information needs of pregnant individuals with elective CS in the antenatal classes The participants mentioned various modifications that can be used to improve addressing the information needs of pregnant individuals with elective CS in antenatal classes. For example, it was pointed out that the clinic often provides information about the operation at very short notice: ID_6, Pos. 65: „Well, the consultation about the caesarean section always takes place quite late. This means that it is usually only carried out shortly before the planned date of the caesarean section and the procedures are only discussed there. This means that the women otherwise only have an idea of how the whole thing will actually work at a very late stage, which of course also fuels fears.” Accordingly, one midwife suggested that a surgeon could be included in the course for the CS education section, although she doubted that this would be feasible in practice. Nonetheless, some participants also spoke out against addressing the information needs of pregnant individuals with elective CS more strongly. Reasons provided were that CS should not be given even more attention, an increased focus could promote the uncertainties/fears of other pregnant individuals, and that sufficient information about elective CS is already provided in antenatal classes. Several possibilities for change were mentioned that can mostly be assigned to the course format in a broader sense or to better inform about antenatal classes. An overview of these can be found in Fig. 4 . The most frequently mentioned reason for offering separate antenatal classes for patients with elective CS was that it would provide a safe space: ID_1, Pos. 55: „Because I could imagine that the safe space is a bit different, right? That they have the feeling that they are now perhaps among like-minded people or that they are all kind of in the same boat. So I can imagine that other topics easily come up as well. Maybe a bit more open discussion than / Because I said, no, up to now they've always been in the minority. If they talked about it at all, they were always in the minority. That's why I could imagine that perhaps a course aimed at precisely that could be helpful.” One midwife indicated that she already offered separate antenatal classes for pregnant individuals with elective CS. Many of the midwives emphasized the uncertainty regarding the need and demand of pregnant individuals with elective CS for separate antenatal classes, especially in rural areas, and the possible lack of profitability for midwives. The assessments of whether there would be a need for this on the part of the women were very heterogeneous. Difficulties with planning were also pointed out, as an indication for a CS can also be issued shortly before the birth and a decision in favor of a CS can also be made shortly before the birth. In view of this, it was suggested that the antenatal classes should be offered either as shorter, multi-part evening courses or as an intensive weekend course at short notice before the planned date of birth. 4. Discussion The present interview study with midwives identified various barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes. These include being (un)informed about antenatal classes, how the midwife performing the procedure deals with the topic of elective CS and class organization, e.g. if it is a crash course or if the partner is allowed to join. Most participants also see a need for pregnant individuals with elective CS to participate in antenatal classes. The topic of CS is generally included in the antenatal classes, and elective CS is addressed by most of the participating midwives in their antenatal classes. Several approaches were mentioned to address the information needs of pregnant individuals with elective CS better. Opinions on a separate course for pregnant individuals with elective CS were heterogeneous. Most midwives considered the participation of pregnant individuals with elective CS in antenatal classes as relevant. This is in line with other studies in which the participation of pregnant individuals in antenatal classes was also considered relevant for reasons other than the exclusive preparation for vaginal birth [ 2 , 15 ]. It is emphasized that topics beyond vaginal birth in particular are of equal importance for pregnant individuals with elective CS as for all pregnant individuals, and that the networking aspect has the same importance to all pregnant individuals do [ 3 ]. However, it was pointed out that not all potential participants are aware that many other topics beyond vaginal birth are covered in antenatal classes. Accordingly, some may mistakenly believe that it would not make sense for them to attend. These findings were also evident in a regional study of midwives, in which elective CS was given as a reason for non-participation in some cases [ 16 ]. We proposed several approaches to counteract this possible unawareness. These include increased information measures, for example through early education on the relevance of participation on the part of gynecologists. Measures addressing midwives were also mentioned, such as a more comprehensive description of the course and its content on the homepage or a renaming of the course so that the name no longer sounds as if the course mainly refers to vaginal birth. It was considered very important to signalize an open approach to the topic of elective CS. In the literature, a negative approach on the part of a midwife to a pregnant individual’s decision in favor of CS was observed [ 9 ]. In another study, vaginal birth was described as preferred and CS as less desirable, and that pregnant individuals felt stigmatized because of CS [ 17 ]. In line with this, a negative approach to (elective) CS by participants and midwives in antenatal classes, including pressure to justify and attempts to convince them to give birth vaginally, was identified as a possible barrier to participation in antenatal classes. Targeted signaling of a non-judgmental approach can encourage the participation of women with elective CS in antenatal classes. All midwives indicated that they generally address the topic of CS in their antenatal classes. The rationale provided was that a CS could result from the course of labor. Additionally, the high CS rate of approximately 30% was cited as a justification. Similarly, Murphy et al. recommended informing about the possibility of a CS and its associated implications, even when a vaginal birth is planned [ 8 ]. In line with this, the present study was able to show that the midwives also address some aspects of (elective) CS in their antenatal classes. Many of the aspects addressed by the midwives in the antenatal classes are also frequently requested by pregnant individuals. Study participants repeatedly emphasized that certain content can be ‘too much’ for different groups of pregnant and therefore lead to individuals feeling anxiety or discomfort. This was mentioned both in the context of pregnant individuals who are planning an elective CS and receive information on vaginal birth, as well as pregnant individuals who are planning a vaginal birth and receive information on a CS. Contrary to this, studies have shown that reliable information on complications during labor can reduce anxiety [ 15 ]. Therefore, the quality of the information seems to be important here, indicating that missing or inadequate information can increase anxiety [ 18 ]. It therefore seems reasonable to ensure that pregnant individuals with an elective CS also have access to high-quality information. First, it is important to increase the overall number of antenatal classes in general, regardless of the planned mode of birth. This would benefit all pregnant individuals and provide access to high-quality information. In a regional midwife study conducted in 2018, around 44% of the midwives surveyed stated that they had a significant excess demand for antenatal classes [ 19 ]. In another regional midwife study from 2015, 75% of the midwives stated that there was excess demand [ 16 ]. A special focus of the antenatal classes was mentioned as conducive to the participation of pregnant individuals with elective CS. Greater consideration of the information needs of pregnant individuals with planned CS could lead to a reduction in the perceived stigmatization by some participants, both on the part of other course participants and midwives. In this regard, many suggestions revolve around the separation of pregnant individuals with elective CS and other pregnant individuals, sometimes only for individual units of the course, but sometimes also by offering a separate course only for pregnant individuals planning an CS. To offer such a course was evaluated in divergent ways. On the one hand, it was pointed out that this would provide a safe space that would lower the inhibition threshold for disclosing fears, concerns and worries. Sufficient time for the content of the (elective) CS and an open exchange would enable an intensive discussion of the topic of (elective) CS. This paper could provide guidance on which topics should be addressed in detail. On the other hand, some doubted that there was sufficient demand and that such courses could be realized economically. Municipalities could support midwives in organizing antenatal classes by providing free rooms in order to achieve economic efficiency even with a low number of participants. This has already been realized in individual municipalities in the past [ 20 ]. Another option is offering digital antenatal classes. Even though the participating midwives only mentioned supplementary digital counseling options and did not suggest a completely digital course, this can be an approach to offering such courses economically, especially in more rural areas. Overall, the existence of separate antenatal classes for pregnant individuals with elective CS (one participant already offers such courses) shows that the implementation of such antenatal classes is possible in principle. 4.1 Strengths and limitations As part of the study, the midwives' view on the information needs of pregnant individuals with elective CS and the increased addressing of these in antenatal classes can be analyzed in detail. However, it must be emphasized that the midwives cannot directly assess what the actual feelings of the pregnant individuals are. Further, it can be assumed that a considerable number of pregnant individuals with elective CS may not participate in antenatal classes. Therefore, the information needs of the pregnant individuals presented here can be incomplete and distorted by the subjective interpretation of the midwives. This limitation emphasizes the necessity and relevance of investigating the perspective of pregnant individuals with elective CS in addition to this study. Since the study is part of a master's thesis, the interviewer had no prior experience in conducting qualitative interviews. However, supervision was provided by a person with expertise in qualitative methods. Overall, the study comprises a small sample, which is common in qualitative research methods. A systematic review suggests that data saturation can be reached even with small sample sizes (9–17 interviews) [ 21 ]. Due to this and the study design, generalizability is limited. The number of participants is also determined by the fact that the study took place as part of a thesis and therefore a limited amount of time was available. Nevertheless, in the course of the interviews it emerged that no further topics were added, meaning that data saturation is reached. It can be assumed that the majority of midwives who took part in the study had already dealt with the consideration of (elective) CS in antenatal classes in advance, were interested in the topic or were open to it. Due to this, the sample size, and the study design, generalizability is limited. Nevertheless, it was possible to include a sample with a high degree of heterogeneity, for example in terms of age and professional experience. A male midwife could not be recruited, but this can also be explained by the gender-specific distribution in this female-dominated occupational group [ 22 , 23 ]. The heterogeneity indicates that it was possible to include midwives with different perspectives and opinions. Since the midwives knowingly took part in interviews, it cannot be ruled out that the response behavior was (unknowingly) influenced at some points. However, the analysis shows that it was possible to include critical views. 4.2 Implications for research and practice Currently, the supplementary conduct of interview studies with pregnant individuals planning an elective CS is being pursued. The aim is to gain a comprehensive perspective on their informational needs and prior experiences within the context of antenatal classes. If the need for a stronger focus on addressing their informational requirements is confirmed in the interviews with the pregnant individuals, as suggested by several participants in the current study, the modifications proposed in this paper should be implemented and evaluated. This paper suggests which topics should be addressed in detail. For example, as part of a research project, a separate course for pregnant individuals planning a CS could be developed. The development of this course should involve pregnant individuals, midwives, and health insurers to ensure alignment with the needs of the target group. Additionally, it would allow to evaluate ways to design such an offering in a feasible manner. A subsequent evaluation could assess its practical feasibility. 5. Conclusion The present interview study with midwives identifies various barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes. These include being (un)informed about antenatal classes, how the midwife performing the procedure deals with the topic of elective CS and the implementation of antenatal classes. In summary, a more comprehensive education regarding the content of antenatal classes is necessary. Most participants also see a need for pregnant individuals with elective CS to participate in antenatal classes. The topic of CS is generally included in the antenatal classes, and elective CS is addressed by most of the participating midwives in their antenatal classes. Several approaches were mentioned to better address the information needs of pregnant individuals with elective CS. A separate course for pregnant individuals with elective CS was assessed heterogeneously. Following additional research on the perspective of pregnant individuals, potential modifications to enhance targeted support, such as the implementation of a separate course, should be evaluated. Abbreviations CS caesarean section IFOM Institute for Research in Operative Medicine Declarations Ethics approval and consent to participate The study was approved by the Witten/Herdecke University Ethical Committee (S-240/2023). All methods performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. There was no incentive for participation. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Open Access funding enabled and organized by Projekt DEAL. Authors' contributions NK, BP and JB conceived and designed the study. SJ developed the interview guide, recruited the participants, conducted the interviews, developed and tested the coding system, and analyzed the data. NK performed a supervision, tested the coding system, analyzed the data, and drafted the manuscript. All authors reviewed drafts of the manuscript and approved the final manuscript. Acknowledgements We would like to sincerely thank all participating midwives for taking the time and for their contribution to this research project. References Gagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database of Systematic Reviews. 2007;(3). doi: 10.1002/14651858.CD002869.pub2. PubMed PMID: CD002869. Ahldén I, Ahlehagen S, Dahlgren LO, Josefsson A. Parents’ Expectations About Participating in Antenatal Parenthood Education Classes. J Perinat Educ. (1):11-7. doi: 10.1891/1058-1243.21.1.11. Fabian HM, Rådestad IJ, Waldenström U. Childbirth and parenthood education classes in Sweden. Women's opinion and possible outcomes. Acta Obstetricia et Gynecologica Scandinavica. 2005;84(5):436-43. doi: https://doi.org/10.1111/j.0001-6349.2005.00732.x. Statistisches Bundesamt. Krankenhausentbindungen in Deutschland. 2023. Huang L, Chen Q, Zhao Y, Wang W, Fang F, Bao Y. Is elective cesarean section associated with a higher risk of asthma? A meta-analysis. Journal of Asthma. 2015;52(1):16-25. doi: 10.3109/02770903.2014.952435. gbe-bund.de. Häufigste Operationen 1 in deutschen Krankenhäusern bei Frauen im Jahr 2023: Statista; 2024 [cited 2025 January 27th]. Available from: https://de.statista.com/statistik/daten/studie/1061143/umfrage/die-haeufigsten-operationen-im-krankenhaus-bei-frauen/. WHO H. WHO statement on caesarean section rates. Geneva, Switzerland. 2015. Murphy DJ, Pope C, Frost J, Liebling RE. Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study. BMJ. 2003;327(7424):1132. doi: 10.1136/bmj.327.7424.1132. Guittier M-J, Cedraschi C, Jamei N, Boulvain M, Guillemin F. Impact of mode of delivery on the birth experience in first-time mothers: a qualitative study. BMC Pregnancy and Childbirth. 2014;14(1):254. doi: 10.1186/1471-2393-14-254. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe ÖGfGuG, & Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe. S3-Leitlinie Die Sectio caesarea. (AWMF-Registernummer 015 - 084). Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V; 2020. Mayring P. Einführung in die qualitative Sozialforschung: Beltz; 2016. Jaax S, Prediger B, Könsgen N. Consideration of the information needs of pregnant women with elective caesarean section in antenatal classes – a qualitative study from the perspective of midwives. protocols.io. 2023. doi: https://dx.doi.org/10.17504/protocols.io.kqdg3x7dpg25/v1. Hall S, Moskovitz C, Pemberton M. Text Recycling Research Project V.1, 2021 [cited 2025 January 27th]. Available from: https://textrecycling.org/resources/best-practices-for-researchers/. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349-57. doi: 10.1093/intqhc/mzm042. Spiby H, Stewart J, Watts K, Hughes AJ, Slade P. The importance of face to face, group antenatal education classes for first time mothers: A qualitative study. Midwifery. 2022;109:103295. doi: https://doi.org/10.1016/j.midw.2022.103295. Loos S. Hebammenversorgung in Thüringen. Ergebnisbericht für das Thüringer Ministerium für Arbeit, Soziales, Gesundheit, Frauen und Familie Berlin: IGES Institut GmbH. 2015. Cobuzio M. Caesarean birth in a social context: A content analysis of childbirth narratives. 2019. Fenwick J, Toohill J, Creedy DK, Smith J, Gamble J. Sources, responses and moderators of childbirth fear in Australian women: A qualitative investigation. Midwifery. 2015;31(1):239-46. doi: https://doi.org/10.1016/j.midw.2014.09.003. Sander M, Albrecht M, Loos S, Stengel V. Studie zur Hebammenversorgung im Freistaat Bayern. Studie für das Bayerische Staatsministerium für Gesundheit und Pflege Berlin. 2018. Sander M, Albrecht M, Temizdemir E. Hebammenstudie Sachsen. 2019. Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Social Science & Medicine. 2022;292:114523. doi: https://doi.org/10.1016/j.socscimed.2021.114523. Kantrowitz-Gordon I, Adriane Ellis S, McFarlane A. Men in Midwifery: A National Survey. Journal of Midwifery & Women's Health. 2014;59(5):516-22. doi: https://doi.org/10.1111/jmwh.12191. Sannomiya M, Morie K, Kubota A, Kanai-Pak M. The evaluation of men introduced in midwifery in the United Kingdom: A gender perspective. Sexuality, Gender & Policy. 2023;6(4):180-97. doi: https://doi.org/10.1002/sgp2.12076. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial1.Interviewguide.docx Supplementarymaterial2.Coreq.docx Supplementarymaterial3.Codingtree.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Witten/Herdecke","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Breuing","suffix":""},{"id":451796739,"identity":"cf9b96f1-70bf-4570-bbb3-d0d57cc86d93","order_by":2,"name":"Barbara Prediger","email":"","orcid":"","institution":"University of Witten/Herdecke","correspondingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Prediger","suffix":""},{"id":451796740,"identity":"03d3b58a-4dae-472c-813e-88476073d237","order_by":3,"name":"Nadja Könsgen","email":"data:image/png;base64,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","orcid":"","institution":"University of Witten/Herdecke","correspondingAuthor":true,"prefix":"","firstName":"Nadja","middleName":"","lastName":"Könsgen","suffix":""}],"badges":[],"createdAt":"2025-04-10 06:38:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6417125/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6417125/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82276363,"identity":"9f7b50eb-8013-4c1a-a764-2393f1ad7ca4","added_by":"auto","created_at":"2025-05-08 14:46:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":195100,"visible":true,"origin":"","legend":"\u003cp\u003eFactors influencing the attendance of women with (elective) CS in antenatal classes positively (+) or negatively (-)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/88b95aab4511b802ed867761.png"},{"id":82279339,"identity":"98c14489-c6a7-415c-a5a0-3798f55e8e33","added_by":"auto","created_at":"2025-05-08 15:02:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72754,"visible":true,"origin":"","legend":"\u003cp\u003eGeneral consideration of topics relating to (elective) CS\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/540ffb65d65b63a02c31b3ff.png"},{"id":82276382,"identity":"999336a9-c75e-49f9-be29-5de7ea19bf49","added_by":"auto","created_at":"2025-05-08 14:46:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":126813,"visible":true,"origin":"","legend":"\u003cp\u003eInformation needs of pregnant individuals\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/022d2f58f438fafe67982adf.png"},{"id":82278201,"identity":"01d0caf5-c25d-410f-9e47-52c7a7ab3e99","added_by":"auto","created_at":"2025-05-08 14:54:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":386573,"visible":true,"origin":"","legend":"\u003cp\u003eChanges to the course format to address the information needs\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/778ad40c2d21e19bbf0c9c6e.png"},{"id":100356198,"identity":"03d4b57f-bf57-4d35-be91-4717a2bb02d1","added_by":"auto","created_at":"2026-01-16 06:57:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1522004,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/9e666539-3056-4892-b5f0-292cebe90aed.pdf"},{"id":82276366,"identity":"7cd56688-d8cc-4c1a-b99e-05c5ac59a982","added_by":"auto","created_at":"2025-05-08 14:46:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20558,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial1.Interviewguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/6f148918ba10592c5c7d4e6a.docx"},{"id":82278197,"identity":"83ac3f97-5a6b-4c10-9c41-18a4d3b9bde1","added_by":"auto","created_at":"2025-05-08 14:54:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":27547,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial2.Coreq.docx","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/6d56eb170f074dd03f996074.docx"},{"id":82276372,"identity":"0c256110-6d96-44eb-b61c-2464a13aad3a","added_by":"auto","created_at":"2025-05-08 14:46:06","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":21014,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial3.Codingtree.docx","url":"https://assets-eu.researchsquare.com/files/rs-6417125/v1/488188d4dcad25b8f2986289.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Midwives’ Perspective on Participation of Pregnant Women Planning an Elective Caesarean Section in Antenatal Classes: A Qualitative Interview Study ","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAntenatal classes are defined as structured programs for expectant parents that provide information and skills to prepare for childbirth, parenthood and postnatal care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pregnant individuals attend antenatal classes to reduce their fear of childbirth and labor [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], to prepare them for the process of giving birth and becoming parent as well as to feel confident in handling the newborn [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, antenatal classes provide a social network and an opportunity to share experiences [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Germany, antenatal classes are mainly provided by midwives. In addition to topics and practical exercises related to vaginal birth, other topics related to pregnancy and preparation for parenthood are covered. These include information about the postnatal period, breastfeeding and newborn care.\u003c/p\u003e \u003cp\u003eOut of a total of 667.705 individuals who gave birth in Germany in 2023, 217.852 had a caesarean section (CS). This represents a CS rate of 32.6% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The operative CS, in which the baby is delivered through a surgical incision in the abdominal wall, is distinguished from the spontaneous vaginal birth (without surgery) and the operative vaginal birth (using instruments such as forceps or vacuum) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. CS is one of the most common surgical procedures performed on women [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and is nowadays considered a safe surgical procedure that can prevent maternal and neonatal mortality and morbidity when medically indicated [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQualitative studies have shown that CS are often associated with negative experiences of childbirth, and that pregnant individuals do not feel adequately prepared for this surgical procedure in antenatal classes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Differentiated data on participation in antenatal classes based on the mode of delivery has not been published so far. Unpublished data suggests that pregnant individuals with elective CS are less likely to attend antenatal classes than those planning a vaginal birth. Elective CS is defined as a CS planned in advance in comparison to unplanned CS, which is performed because of complications during childbirth [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. To date, there is no published data on the reasons of pregnant individuals with elective CS for attending or not attending antenatal classes. Thus a discussion of this is speculative. As antenatal classes cover topics that go beyond vaginal birth, they are also relevant to this group of pregnant individuals. Furthermore, it is important to include CS in antenatal classes for pregnant individuals planning a vaginal birth, because they may unexpectedly find themselves in a situation where an unplanned CS is required and proper preparation for a planned CS can benefit them.\u003c/p\u003e \u003cp\u003eOur aim is to investigate the demand for antenatal classes among pregnant individuals with elective CS, as well as the barriers and facilitators that influence their attendance from the midwives\u0026rsquo; perspective. Furthermore, the midwives\u0026rsquo; perspective on the information needs of pregnant individuals with elective CS in antenatal classes, on the extent to which the (elective) CS is covered in antenatal classes, and on how addressing these information needs can be improved is assessed.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Design\u003c/h2\u003e \u003cp\u003e The study was approved by the Witten/Herdecke University Ethical Committee (S-240/2023). A semi-structured interview guide was developed to provide guidance and structure during the interview and comparability in the subsequent evaluation. The interview guide was developed by an interdisciplinary team comprising individuals with experience in developing interview guides (JB, NK) and those without such experience (SJ). The interview guide consisted of 6 sections: 1) General information about the antenatal classes, 2) the topic of (elective) CS in the antenatal classes, 3) the need for participation in antenatal classes by pregnant individuals with elective CS, 4) information needs of pregnant individuals with elective CS in antenatal classes, 5) addressing the information needs in antenatal classes, 6) factors influencing the participation of pregnant individuals with elective CS in antenatal classes. Before starting the study, a pretest of the interview guide has been performed with one midwife to ensure good comprehensibility and completeness of the questions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The interview guide was subsequently adapted. It can be found in supplementary material 1.\u003c/p\u003e \u003cp\u003eA priori, a study protocol has been published on protocols.io [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The introduction of the paper is based on the introduction of the protocol. Additionally, parts of the methods section are also taken from the protocol. The Text Recycling Research Project was followed as instrument of guidance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, the consolidated criteria for reporting qualitative research (COREQ) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] has been used to report the given study (Supplement 2: COREQ-checklist).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data collection\u003c/h2\u003e \u003cp\u003eA convenience sample of midwives who have experience in conducting antenatal classes in Germany was included and offered these at the time of recruitment. Only midwives who have experience with pregnant individuals with elective CS in their antenatal classes have been included as it was possible to recruit enough midwives who meet these criteria. Experience with pregnant individuals undergoing elective CS in antenatal classes was defined as having participated in at least one antenatal class led by the midwife. If it had not been possible to recruit enough midwives with experience, midwives with no experience of pregnant individuals with elective CS in their antenatal classes would have been included.\u003c/p\u003e \u003cp\u003eTo recruit midwives, midwives based in Germany have been contacted by phone or email. Also, the midwifery associations were asked to share the invitation to take part in the interviews in their newsletters or on their social media channels. Influencers in the field of midwifery science were contacted on the social media platform Instagram and asked to share information about the study as well. In addition, the network of the Institute for Research in Operative Medicine (IFOM) was used to support recruitment and the information about the study was disseminated via private messengers and social media accounts. It was not possible to provide any financial incentives for participation.\u003c/p\u003e \u003cp\u003eMidwives who were interested in participating received an email with the following study documents, prior to the interview: participation information, consent form and privacy statement. Furthermore, the email requested information on the characteristics relevant to heterogeneous composition of the sample, such as age, gender, and professional experience in conducting antenatal classes.\u003c/p\u003e \u003cp\u003eSJ, who was a Master's student in Prevention, Sports Therapy and Health Management and an employee at IFOM at the time the interviews were carried out, conducted the interviews as part of her Master's thesis. She had no prior experience in conducting qualitative studies and was supervised by an individual with experience in conducting qualitative studies (NK). There was no relationship between the participants and the interviewer. The participants only knew that she was a Master's student and employee at IFOM and was conducting the study as part of her master's thesis.\u003c/p\u003e \u003cp\u003ePrior to the interviews, detailed information about the study (background and duration) along with privacy statements was provided to each participant. The interviews were conducted by telephone in order to give the participants as much flexibility as possible regarding the time and place of the interview. The interviewer joined the interviews from home or from her workplace at IFOM in Cologne. The participants were free to take part from wherever they wanted. Accordingly, it cannot be guaranteed that other individuals were not present.\u003c/p\u003e \u003cp\u003eRecruitment took place from October to December 2023 and ended when content saturation was reached. An audio recording device was used to record the interviews, which were then transcribed by an external service provider. Afterwards, the transcripts were reviewed by the interviewer. Field notes were not necessary because of the transcription. Therefore, they were not taken. The participants were not given the opportunity to correct or comment on the transcripts, and no interviews were repeated.\u003c/p\u003e \u003cp\u003eThere were no physical or mental risks to consider during the study. Participants were informed of the content and the objectives of the study and agreed to take part in advance. They provided written consent in advance for the conduct of interviews as well as data recording and processing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data analysis\u003c/h2\u003e \u003cp\u003eThe interview analysis is based on Mayring\u0026rsquo;s qualitative content analysis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] using MAXQDA data analysis software. The aim is to structure the transcribed interviews into main and sub-categories in order to analyze the material in a controlled and step-by-step manner. The development of the main and sub-categories is based on both a deductive and an inductive approach. In the deductive approach, main categories are defined on the basis of the interview guide. In the inductive approach, additional categories are derived from the data material. SJ and NK independently coded three interviews with regard to the main categories. Deviations were discussed in order to obtain a shared understanding of the coding procedure. The interviewer then continued the first step (main categories) of coding on her own. The subsequent inductive coding was carried out by both persons independently on the basis of 3 interviews. During this step, the deductive category system from the first step was inductively refined and supplemented by further categories and subcategories. Following this, SJ and NK discussed the results in order to obtain a shared understanding. Then, the interviewer carried out the more in-depth coding alone. The coding system can be found in supplementary material 3.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participants\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eA total of 31 midwives with an interest in the study were recruited. Reasons for drop out were no provision of antenatal classes at the time of recruitment, lack of experience in the provision of antenatal classes or with pregnant individuals with elective CS in their antenatal classes, lack of time capacities, or the way the study was conducted (participants did not want any interview/audio recordings). Accordingly, 15 interviews with a mean length of 27 minutes (range 14\u0026ndash;52) were conducted. All participants were female and the mean age was 39 years (range 23\u0026ndash;60). They had an average work experience of 11 years (range 1\u0026ndash;25).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Barriers and facilitators for participation in antenatal classes\u003c/h2\u003e \u003cp\u003eThe participants mentioned several barriers and facilitators of the attendance of women with (elective) CS in antenatal classes. These relate to the information provided about antenatal classes, the way in which the topic of CS is dealt with in antenatal classes, the range of courses on offer and the choice of topics in antenatal classes, as well as individual and social factors. The care situation is an influencing factor as well. For instance, early contact with a midwife is seen as beneficial and purely doctor-based care as a hindrance. All mentioned barriers and facilitators for attendance are listed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In addition, the participants emphasize that regardless of the mode of birth, the level of education and financial situation influence participation in antenatal classes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 The need of pregnant individuals with elective CS for antenatal classes\u003c/h2\u003e \u003cp\u003eMost midwives estimated that the majority of pregnant individuals in antenatal classes have clear birth preferences, mostly in favor of a vaginal birth. Nevertheless, many participants consider the participation of pregnant individuals with elective CS in antenatal classes to be relevant in principle. One of the reasons given for this is the very broad range of topics, which goes far beyond the mode of delivery. It was also pointed out by the midwives that antenatal classes are important for the time during pregnancy. This is due to the provided information about nutrition and prevention, but also for the time with the baby including breastfeeding and newborn care. Other reasons mentioned are provided information, mainly about CS but also about vaginal birth, and networking with other parents-to-be.\u003c/p\u003e \u003cp\u003eID_6, Pos. 27: \u0026bdquo;Very high. Well, I think that everyone should attend a birth preparation course because the course also covers other topics. In other words, it's not just about the birthing process, but also about preparing for birth and parenthood. And then afterwards, the postnatal period, breastfeeding and so on. And there are still questions about the planned caesarean section. In other words, I would always highly recommend taking part, regardless of how you want to give birth.\u0026rdquo;\u003c/p\u003e \u003cp\u003eHowever, there are also dissenting opinions, which argue that antenatal classes are primarily designed for women planning a vaginal birth. Further, stating that women with elective CS would benefit more from other preparations, and that they may feel uncomfortable with topics related to vaginal birth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Consideration of (elective) CS in antenatal classes\u003c/h2\u003e \u003cp\u003eAll of the midwives stated that they generally take the topic of CS into account in their antenatal classes. The most common reason they gave for this is that CS can result from the course of labor and is therefore relevant for all pregnant individuals. Others cited the high CS rate, the participants' desire for more information on CS or that the mode of birth is not yet known at the time of participation. Most of the midwives stated that they generally discuss the content of elective CS in the antenatal classes. A few participants pointed out that they would not include elective CS in their antenatal classes, because they think there is not much to address on the subject in advance. Further, they assumed that it has already been discussed with the gynecologist, or they offered their own separate preparation for pregnant individuals with elective CS. Others pointed out that they consider the topic as required, i.e. depending on enquiries or the number of patients with elective CS.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides an overview on topics on (elective) CS generally considered in the participants\u0026rsquo; antenatal classes. It exhibits a high degree of overlap in terms of which topics relating to CS in general and elective CS are generally addressed in the antenatal classes. With regard to elective CS, more topics on preparation are mentioned and the health effects relate only to the mother, not the newborn.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Information needs of pregnant individuals with elective CS in antenatal classes\u003c/h2\u003e \u003cp\u003eSome midwives reported that pregnant individuals with elective CS have more specific information needs on the topic of (elective) CS in the antenatal classes than pregnant individuals planning a vaginal birth. Others, however, stated that the information needs of pregnant individuals with and without elective CS do not differ. Information needs of pregnant individuals with regard to CS in general and elective CS are exhibited in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Overall, there is a high degree of overlap between the main topics addressed for (elective) CS in antenatal classes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and the information needs of pregnant individuals on (elective) CS.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSome midwives reported that pregnant individuals with elective CS ask few or no questions about (elective) CS in the antenatal classes. Some participants explained this by the fact that these pregnant individuals obtain the information elsewhere, e.g. in counselling sessions. Another reason they gave was that pregnant individuals with elective CS do not want to disclose their planned mode of labor in the antenatal classes. Overall, it was pointed out that the topic of elective CS depends heavily on the respective antenatal classes and that there is correspondingly great heterogeneity with regard to the information provided:\u003c/p\u003e \u003cp\u003eID_13, Pos. 69: B: \u0026bdquo;I suppose that depends very much on the course. I know that there are courses where the caesarean section is almost not discussed at all or only as emergency management, which is not advisable. I think that leaves many, many questions or uncertainties, or perhaps even encourages uncertainties. I sometimes experience that women, I also work in a clinic, say after a caesarean section that they have heard in their antenatal classes that it is so bad for the child and / So, where I think: \u0026ldquo;Oh God!\u0026rdquo; So, I think it really depends on the course. And, well, I hope it's different in my classes. But I don't know that for sure, of course. (laughs) Yes.\u0026ldquo;\u003c/p\u003e\u003ch2\u003e3.6 Modifications to address the information needs of pregnant individuals with elective CS in the antenatal classes\u003c/h2\u003e\u003cp\u003eThe participants mentioned various modifications that can be used to improve addressing the information needs of pregnant individuals with elective CS in antenatal classes. For example, it was pointed out that the clinic often provides information about the operation at very short notice:\u003c/p\u003e \u003cp\u003eID_6, Pos. 65: \u0026bdquo;Well, the consultation about the caesarean section always takes place quite late. This means that it is usually only carried out shortly before the planned date of the caesarean section and the procedures are only discussed there. This means that the women otherwise only have an idea of how the whole thing will actually work at a very late stage, which of course also fuels fears.\u0026rdquo;\u003c/p\u003e \u003cp\u003eAccordingly, one midwife suggested that a surgeon could be included in the course for the CS education section, although she doubted that this would be feasible in practice.\u003c/p\u003e \u003cp\u003eNonetheless, some participants also spoke out against addressing the information needs of pregnant individuals with elective CS more strongly. Reasons provided were that CS should not be given even more attention, an increased focus could promote the uncertainties/fears of other pregnant individuals, and that sufficient information about elective CS is already provided in antenatal classes.\u003c/p\u003e \u003cp\u003eSeveral possibilities for change were mentioned that can mostly be assigned to the course format in a broader sense or to better inform about antenatal classes. An overview of these can be found in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe most frequently mentioned reason for offering separate antenatal classes for patients with elective CS was that it would provide a safe space:\u003c/p\u003e \u003cp\u003eID_1, Pos. 55: \u0026bdquo;Because I could imagine that the safe space is a bit different, right? That they have the feeling that they are now perhaps among like-minded people or that they are all kind of in the same boat. So I can imagine that other topics easily come up as well. Maybe a bit more open discussion than / Because I said, no, up to now they've always been in the minority. If they talked about it at all, they were always in the minority. That's why I could imagine that perhaps a course aimed at precisely that could be helpful.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOne midwife indicated that she already offered separate antenatal classes for pregnant individuals with elective CS. Many of the midwives emphasized the uncertainty regarding the need and demand of pregnant individuals with elective CS for separate antenatal classes, especially in rural areas, and the possible lack of profitability for midwives. The assessments of whether there would be a need for this on the part of the women were very heterogeneous. Difficulties with planning were also pointed out, as an indication for a CS can also be issued shortly before the birth and a decision in favor of a CS can also be made shortly before the birth. In view of this, it was suggested that the antenatal classes should be offered either as shorter, multi-part evening courses or as an intensive weekend course at short notice before the planned date of birth.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present interview study with midwives identified various barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes. These include being (un)informed about antenatal classes, how the midwife performing the procedure deals with the topic of elective CS and class organization, e.g. if it is a crash course or if the partner is allowed to join. Most participants also see a need for pregnant individuals with elective CS to participate in antenatal classes. The topic of CS is generally included in the antenatal classes, and elective CS is addressed by most of the participating midwives in their antenatal classes. Several approaches were mentioned to address the information needs of pregnant individuals with elective CS better. Opinions on a separate course for pregnant individuals with elective CS were heterogeneous.\u003c/p\u003e \u003cp\u003eMost midwives considered the participation of pregnant individuals with elective CS in antenatal classes as relevant. This is in line with other studies in which the participation of pregnant individuals in antenatal classes was also considered relevant for reasons other than the exclusive preparation for vaginal birth [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It is emphasized that topics beyond vaginal birth in particular are of equal importance for pregnant individuals with elective CS as for all pregnant individuals, and that the networking aspect has the same importance to all pregnant individuals do [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, it was pointed out that not all potential participants are aware that many other topics beyond vaginal birth are covered in antenatal classes. Accordingly, some may mistakenly believe that it would not make sense for them to attend. These findings were also evident in a regional study of midwives, in which elective CS was given as a reason for non-participation in some cases [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We proposed several approaches to counteract this possible unawareness. These include increased information measures, for example through early education on the relevance of participation on the part of gynecologists. Measures addressing midwives were also mentioned, such as a more comprehensive description of the course and its content on the homepage or a renaming of the course so that the name no longer sounds as if the course mainly refers to vaginal birth. It was considered very important to signalize an open approach to the topic of elective CS. In the literature, a negative approach on the part of a midwife to a pregnant individual\u0026rsquo;s decision in favor of CS was observed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In another study, vaginal birth was described as preferred and CS as less desirable, and that pregnant individuals felt stigmatized because of CS [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In line with this, a negative approach to (elective) CS by participants and midwives in antenatal classes, including pressure to justify and attempts to convince them to give birth vaginally, was identified as a possible barrier to participation in antenatal classes. Targeted signaling of a non-judgmental approach can encourage the participation of women with elective CS in antenatal classes.\u003c/p\u003e \u003cp\u003eAll midwives indicated that they generally address the topic of CS in their antenatal classes. The rationale provided was that a CS could result from the course of labor. Additionally, the high CS rate of approximately 30% was cited as a justification. Similarly, Murphy et al. recommended informing about the possibility of a CS and its associated implications, even when a vaginal birth is planned [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In line with this, the present study was able to show that the midwives also address some aspects of (elective) CS in their antenatal classes. Many of the aspects addressed by the midwives in the antenatal classes are also frequently requested by pregnant individuals.\u003c/p\u003e \u003cp\u003eStudy participants repeatedly emphasized that certain content can be \u0026lsquo;too much\u0026rsquo; for different groups of pregnant and therefore lead to individuals feeling anxiety or discomfort. This was mentioned both in the context of pregnant individuals who are planning an elective CS and receive information on vaginal birth, as well as pregnant individuals who are planning a vaginal birth and receive information on a CS. Contrary to this, studies have shown that reliable information on complications during labor can reduce anxiety [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, the quality of the information seems to be important here, indicating that missing or inadequate information can increase anxiety [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It therefore seems reasonable to ensure that pregnant individuals with an elective CS also have access to high-quality information.\u003c/p\u003e \u003cp\u003eFirst, it is important to increase the overall number of antenatal classes in general, regardless of the planned mode of birth. This would benefit all pregnant individuals and provide access to high-quality information. In a regional midwife study conducted in 2018, around 44% of the midwives surveyed stated that they had a significant excess demand for antenatal classes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In another regional midwife study from 2015, 75% of the midwives stated that there was excess demand [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA special focus of the antenatal classes was mentioned as conducive to the participation of pregnant individuals with elective CS. Greater consideration of the information needs of pregnant individuals with planned CS could lead to a reduction in the perceived stigmatization by some participants, both on the part of other course participants and midwives.\u003c/p\u003e \u003cp\u003eIn this regard, many suggestions revolve around the separation of pregnant individuals with elective CS and other pregnant individuals, sometimes only for individual units of the course, but sometimes also by offering a separate course only for pregnant individuals planning an CS. To offer such a course was evaluated in divergent ways. On the one hand, it was pointed out that this would provide a safe space that would lower the inhibition threshold for disclosing fears, concerns and worries. Sufficient time for the content of the (elective) CS and an open exchange would enable an intensive discussion of the topic of (elective) CS. This paper could provide guidance on which topics should be addressed in detail. On the other hand, some doubted that there was sufficient demand and that such courses could be realized economically. Municipalities could support midwives in organizing antenatal classes by providing free rooms in order to achieve economic efficiency even with a low number of participants. This has already been realized in individual municipalities in the past [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Another option is offering digital antenatal classes. Even though the participating midwives only mentioned supplementary digital counseling options and did not suggest a completely digital course, this can be an approach to offering such courses economically, especially in more rural areas. Overall, the existence of separate antenatal classes for pregnant individuals with elective CS (one participant already offers such courses) shows that the implementation of such antenatal classes is possible in principle.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eAs part of the study, the midwives' view on the information needs of pregnant individuals with elective CS and the increased addressing of these in antenatal classes can be analyzed in detail. However, it must be emphasized that the midwives cannot directly assess what the actual feelings of the pregnant individuals are. Further, it can be assumed that a considerable number of pregnant individuals with elective CS may not participate in antenatal classes. Therefore, the information needs of the pregnant individuals presented here can be incomplete and distorted by the subjective interpretation of the midwives. This limitation emphasizes the necessity and relevance of investigating the perspective of pregnant individuals with elective CS in addition to this study.\u003c/p\u003e \u003cp\u003eSince the study is part of a master's thesis, the interviewer had no prior experience in conducting qualitative interviews. However, supervision was provided by a person with expertise in qualitative methods.\u003c/p\u003e \u003cp\u003eOverall, the study comprises a small sample, which is common in qualitative research methods. A systematic review suggests that data saturation can be reached even with small sample sizes (9\u0026ndash;17 interviews) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Due to this and the study design, generalizability is limited. The number of participants is also determined by the fact that the study took place as part of a thesis and therefore a limited amount of time was available. Nevertheless, in the course of the interviews it emerged that no further topics were added, meaning that data saturation is reached.\u003c/p\u003e \u003cp\u003eIt can be assumed that the majority of midwives who took part in the study had already dealt with the consideration of (elective) CS in antenatal classes in advance, were interested in the topic or were open to it. Due to this, the sample size, and the study design, generalizability is limited. Nevertheless, it was possible to include a sample with a high degree of heterogeneity, for example in terms of age and professional experience. A male midwife could not be recruited, but this can also be explained by the gender-specific distribution in this female-dominated occupational group [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The heterogeneity indicates that it was possible to include midwives with different perspectives and opinions.\u003c/p\u003e \u003cp\u003eSince the midwives knowingly took part in interviews, it cannot be ruled out that the response behavior was (unknowingly) influenced at some points. However, the analysis shows that it was possible to include critical views.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Implications for research and practice\u003c/h2\u003e \u003cp\u003eCurrently, the supplementary conduct of interview studies with pregnant individuals planning an elective CS is being pursued. The aim is to gain a comprehensive perspective on their informational needs and prior experiences within the context of antenatal classes. If the need for a stronger focus on addressing their informational requirements is confirmed in the interviews with the pregnant individuals, as suggested by several participants in the current study, the modifications proposed in this paper should be implemented and evaluated. This paper suggests which topics should be addressed in detail. For example, as part of a research project, a separate course for pregnant individuals planning a CS could be developed. The development of this course should involve pregnant individuals, midwives, and health insurers to ensure alignment with the needs of the target group. Additionally, it would allow to evaluate ways to design such an offering in a feasible manner. A subsequent evaluation could assess its practical feasibility.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe present interview study with midwives identifies various barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes. These include being (un)informed about antenatal classes, how the midwife performing the procedure deals with the topic of elective CS and the implementation of antenatal classes. In summary, a more comprehensive education regarding the content of antenatal classes is necessary. Most participants also see a need for pregnant individuals with elective CS to participate in antenatal classes. The topic of CS is generally included in the antenatal classes, and elective CS is addressed by most of the participating midwives in their antenatal classes. Several approaches were mentioned to better address the information needs of pregnant individuals with elective CS. A separate course for pregnant individuals with elective CS was assessed heterogeneously. Following additional research on the perspective of pregnant individuals, potential modifications to enhance targeted support, such as the implementation of a separate course, should be evaluated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecaesarean section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIFOM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitute for Research in Operative Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Witten/Herdecke University Ethical Committee (S-240/2023). All methods performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. There was no incentive for participation.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFunding\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Open Access funding enabled and organized by Projekt DEAL.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eNK, BP and JB conceived and designed the study. SJ developed the interview guide, recruited the participants, conducted the interviews, developed and tested the coding system, and analyzed the data. NK performed a supervision, tested the coding system, analyzed the data, and drafted the manuscript. All authors reviewed drafts of the manuscript and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWe would like to sincerely thank all participating midwives for taking the time and for their contribution to this research project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. 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Caesarean birth in a social context: A content analysis of childbirth narratives. 2019.\u003c/li\u003e\n\u003cli\u003eFenwick J, Toohill J, Creedy DK, Smith J, Gamble J. Sources, responses and moderators of childbirth fear in Australian women: A qualitative investigation. Midwifery. 2015;31(1):239-46. doi: https://doi.org/10.1016/j.midw.2014.09.003.\u003c/li\u003e\n\u003cli\u003eSander M, Albrecht M, Loos S, Stengel V. Studie zur Hebammenversorgung im Freistaat Bayern. Studie f\u0026uuml;r das Bayerische Staatsministerium f\u0026uuml;r Gesundheit und Pflege Berlin. 2018.\u003c/li\u003e\n\u003cli\u003eSander M, Albrecht M, Temizdemir E. Hebammenstudie Sachsen. 2019.\u003c/li\u003e\n\u003cli\u003eHennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Social Science \u0026amp; Medicine. 2022;292:114523. doi: https://doi.org/10.1016/j.socscimed.2021.114523.\u003c/li\u003e\n\u003cli\u003eKantrowitz-Gordon I, Adriane Ellis S, McFarlane A. Men in Midwifery: A National Survey. Journal of Midwifery \u0026amp; Women\u0026apos;s Health. 2014;59(5):516-22. doi: https://doi.org/10.1111/jmwh.12191.\u003c/li\u003e\n\u003cli\u003eSannomiya M, Morie K, Kubota A, Kanai-Pak M. The evaluation of men introduced in midwifery in the United Kingdom: A gender perspective. Sexuality, Gender \u0026amp; Policy. 2023;6(4):180-97. doi: https://doi.org/10.1002/sgp2.12076.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prenatal classes, Childbirth Education Classes, Childbirth Preparation Classes, Cesarean Sections, Pregnancy, Germany, Qualitative Study","lastPublishedDoi":"10.21203/rs.3.rs-6417125/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6417125/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStudies indicate that pregnant individuals sometimes feel inadequately prepared for caesarean section (CS) in antenatal classes. Unpublished data suggest that women planning a CS are less likely to attend antenatal classes compared to those planning a vaginal birth. However, antenatal classes provide valuable information beyond vaginal birth. The aim of this study is to assess barriers and facilitators for the participation of pregnant individuals with elective CS in antenatal classes, how the topic (elective) CS is addressed in antenatal classes, pregnant individuals\u0026rsquo; potential information needs and how they can be addressed.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSemi-structured interviews were conducted with midwives. The inclusion criteria required midwives who currently offer antenatal classes, have experience in conducting antenatal classes, and have had pregnant individuals with an elective CS attend their courses. Recruitment was carried out via telephone or email and through midwifery associations. Data analysis was performed using a content-structured approach (Mayring), employing the software MAXQDA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom October to December 2023, 15 semi-structured interviews have been conducted. Midwives reported that pregnant individuals with elective CS often assume that antenatal classes are not relevant for them. This is partly due to a lack of information regarding the importance of their participation as well as insufficient awareness about the content of antenatal classes. Moreover, midwives noted that sometimes, other participants and midwives in antenatal classes respond negatively to the decision of having a CS. For example, midwives reported during the interviews that CS is sometimes perceived as inferior to vaginal birth. Further, they reported about occasional attempts to persuade individuals to opt for vaginal birth. The majority of midwives consider addressing the informational needs of pregnant individuals with elective CS to be important. Therefore, the majority supports the provision of separate antenatal classes for those planning elective CS and those planning vaginal birth, given the differing informational requirements.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA more comprehensive education of pregnant individuals regarding the content of antenatal classes is necessary. Following additional research on the perspective of pregnant individuals, potential modifications to enhance targeted support, such as the implementation of a separate course, should be evaluated.\u003c/p\u003e","manuscriptTitle":"Midwives’ Perspective on Participation of Pregnant Women Planning an Elective Caesarean Section in Antenatal Classes: A Qualitative Interview Study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 14:46:02","doi":"10.21203/rs.3.rs-6417125/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3534cb59-ecba-42fc-ab7a-5ab3af0c30df","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-02T04:08:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 14:46:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6417125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6417125","identity":"rs-6417125","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}