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.