• Holly Powell Kennedy, Jane Grant, Cathy Walton, and Jane Sandall.
• Yale University School of Nursing, 100 Church Street South, PO Box 9740, New Haven, CT 06536, USA. Electronic address: holly.kennedy@yale.edu.
• Midwifery. 2013 Dec 1;29(12):e138-44.

Backgroundthe rates of primary, repeat, and elective caesarean deliveries have risen dramatically over the past several decades. The reasons for the rise are complex and likely reflect a cultural shift to a greater acceptance of surgical birth as a reasonable option, which may favour infant over maternal outcomes. The purpose of this interpretive qualitative study was to explore the complexities of women's and clinicians' choices around elective caesarean delivery.Methodthis analysis was part of an institutional ethnography to understand the complex issues of childbearing care. Two English National Health Service Maternity Service Providers in an inner city setting were chosen for their reputation for commitment to normalising birth and decreasing caesarean birth rate. A sample of 27 women and 34 clinicians (midwifery, obstetric, anaesthesia) were interviewed and/or observed in practice settings. We also conducted a documentary analysis of local policy guidelines on elective caesarean delivery. Narrative analysis was conducted on interview, field observation, and document review data. Coding was conducted by three independent analysts and checked for consistency using Atlas.ti qualitative software.Resultsvariations on elective caesarean choice and outcomes seemed to reflect how the team worked together and their underlying philosophies and commitments about caesarean birth. Four themes reflected the issues around elective caesarean birth: (1) the culture of caesarean, (2) caesarean counseling, (3) perceptions of choice and (4) negotiating the rules.Conclusionscounselling about elective caesarean and vaginal birth after a prior caesarean is complex and reflects an intersection of culture and science. Women and clinicians enter the discussion with different backgrounds and concerns, but ultimately want the best outcome possible. Future exploration should address shared decision-making, evidence-based clinical guidelines, and the social context of care.Copyright © 2012 Elsevier Ltd. All rights reserved.

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