Discussion

Main findings

This qualitative interview study demonstrated that the majority of the respondents favoured antibiotic treatment after cord clamping to avoid exposure to their infant. Even though increased risk of asthma and allergies is hypothetical for infants exposed to antibiotics in early infancy, women mentioned this as their primary concern. The three women who favoured antibiotic treatment before cord clamping considered effects of their own health, as they were primarily responsible for taking care of the infant immediately after birth. They argued that their decision was influenced by the prospect of a shorter hospitalization since the risk of postpartum infection was lower if antibiotics were given before cord clamping. They emphasized that theirs being an uncomplicated pregnancy, influenced their decision.

Interpretations

Some of the women found it difficult to make a deliberated decision, as they lacked more evidence-based information. As the women did not have the chance to look deeper into this issue before making a decision, this might indicate that their decision making was emotionally motivated – protecting their offspring from any harm - rather than factual insight. Hence, they seem to have chosen the safest option for their baby. In general, the women expressed a great trust in the health care professionals, which is interesting, as the majority of the women actually would choose the opposite treatment than recommended by the guidelines and healthcare professionals – something they were informed about. Possibly the wording of the informational pamphlet could have affected the outome of the women’s answers, but the post hoc interviews did not indicate that this was a concern: Six of the eight women commented it was written mostly neutrally and the last two women expressed they thought the informational pamphlet emphazised antibiotic treatment before cord clamping in accordance with the applicable guidelines.
The fact that most postpartum infections related to a caesarean delivery could be treated with oral antibiotics also seemed to affect the decision of at least one woman. A study from Denmark, found that women with endometritis or wound infection after caesarean delivery were only referred to hospital in less than one in four cases – the rest were seen in general practice only (15). Moreover another Danish study showed that of those treated in hospital, more than half were treated in an out-patient setting (6). This implies that most infections that could be prevented through timing of antibiotic prophylaxis before cord clamping, are not serious infections and are treatable with oral antibiotics. Hence, our findings regarding women’s plea for further evidence should inspire to expand the general knowledge concerning consequences of the timing of prophylactic antibiotic treatment during caesarean delivery.
The women’s decision to avoid antibiotic exposure to the fetus in order to prevent potentially long-term effects, was made at the expense of their own increased infection risk, even though the risk to the infant was hypothetical. Indeed, evidence regarding the effects on the infant gut microbiota is limited compared to the solid evidence concerning the relative infection risk of the mother. This raises the question whether women’s risk perception of the infant is intensified. Pregnant women are encouraged to be aware of the many substances that can affect the fetus and therefore they may be suspicious of medication in general during the pregnancy (16). The fear of harming the baby’s gut microbiota does in some way outweigh – in the women’s own perception – her own risk of getting a postpartum infection. Other studies also show a change in the women’s use of drugs when they become pregnant (16–18). In a qualitative study based on participants from the ORACLE study, findings also imply how pregnant women poorly understand the concept of risk. The participants decisions seemed to be drawn from common sense and emotions, rather than facts and scientific deliberation, if they thought it would result in better conditions for the baby (19,20). Regardless, patients must have autonomy in matters regarding their own healthcare and it is the role of the clinicians to guide them as best as possible (21).

Strengths and limitations

Prior to the current study, a focus group of seven women were interviewed in order to test the interview guide, discover new topics, and evaluate the dynamics between respondents in a group. However, individual single interviews may facilitate a more personal relationship between the interviewer and participant and may permit more focused, personal, and detailed answers (22). The women were all interviewed right after reading the informational pamphlet which allowed their answers to be intuitive and with no influence from their partners and families. In that way all the women had the same preconditions for answering the questions.
One of the strengths to the study is that the women were not informed about the local procedure regarding prophylactic antibiotic treatment until after the interview, as to avoid bias originating from demand characteristics (23) and where they might adjust their answers. Nevertheless, the women might have had an assumption of what we wanted to hear after having read the informational pamphlet, thereby affecting the outcome. However, the eight women we interviewed post hoc found the informational pamphlet to be either neutrally worded or leaning towards recommending antibiotics before cord clamping, which did not indicate demand characteristics bias.
This study is limited in that the interviews were restricted in length, due to practical circumstances and for that reason the longest interview took approximately 25 minutes. However, the transcribed text from the interviews revealed no further follow-up questions that were either unposed or unanswered.