Women and clinicians' views, preferences and experiences of caesarean section and vaginal birth in India: a qualitative substudy of the 'Misoprostol or Oxytocin for Labour Induction' (MOLI) trial.

Introduction: Caesarean use in India continues to rise and significant disparities exist. However, women and clinicians' views are under-researched. This paper aims to explore women and clinicians' views and preferences for mode of birth in two government hospitals in urban central India.

Methods: This qualitative study involved 53 semistructured interviews with high-risk women before and after induction of labour and eight focus groups with clinicians and researchers in two government hospitals in Maharashtra state. All women were recruited to the 'Misoprostol or Oxytocin for Labour Induction' (MOLI) randomised controlled trial (NCT03749902) and were induced for hypertensive disorders in pregnancy. Data were analysed using the framework approach to thematic analysis.

Results: Interactions between women, clinicians and families played an important role in women's birth experiences. Most women strongly preferred vaginal birth. While a vaginal birth was important to women for their long-term health and well-being, the safety of the baby was the priority. Both women and clinicians justified caesarean use to promote fetal safety. Contrary to clinicians' perceptions, women clearly understood their caesarean indications. The busy clinical environment was an important factor influencing the clinician's decision and threshold for caesarean. Three themes arose from the data: (1) women's preference for vaginal birth: a matter of 'Trouble for two hours or trouble for two months'; (2) clinicians' perspectives about caesarean use: 'Don't take a risk'; and (3) knowledge through experiences and interactions: 'The pain didn't come'.

Conclusion: Women strongly preferred 'normal delivery' but accepted caesarean birth to promote fetal safety. Clinicians felt labour and vaginal birth were often risky and prioritised fetal safety in this under-resourced context. Women who had a caesarean birth understood their indication for caesarean but, compared with vaginal birth, reported that caesarean caused them additional short- and long-term anxiety, health and social concerns.

Trial registration number: NCT04037683.