Pregnancy is a physiological phenomenon with multidimensional processes including physical, social, physiological, cultural and mental aspects (1). Parturition ends pregnancy and entails a spontaneous process without any intervention (2). The final goal of the parturition team is to provide a safe birth while maintaining the health of the mother and her neonate (3).
Due to advancements in surgical procedures in the past decades, elective cesarean section has increasingly become popular and emerged as an urgent issue for maternity practitioners, hospitals, policy makers, as well as maternity clients (2).
Cesarean section has an important role in reducing the risk of maternal and fetal death due to parturition. But the emerging problem of modern midwifery today is the high rates of cesarean section performed (4).
Cesarean section itself not only causes and enhances obstetric complications, but also it may place more financial burden on families, governments and insurance companies (5). Accordingly, concerns have been raised about the rising rate of cesarean section around the world. Therefore, this study was conducted to clarify factors which could affect women's preference for cesarean section over vaginal delivery without medical indications in Zahedan, Iran during 2010 to 2011.
This qualitative study was carried out on 200 pregnant women in the third trimester of pregnancy in Zahedan, Iran during 2010 to 2011. The study group included women who attended obstetric offices and Imam Ali Women’s Clinic in the city. All the clients were determined to undergo elective cesarean section without any medical indication.
Women with premature parturition, twin pregnancy, small pelvis, diabetes mellitus and high blood pressure were excluded from the study.
The participants were subsequently invited to attend group discussions (29 sessions) which were held from January 2010 to August 2011. As it was not possible to evaluate all the participants in one session, group discussions were repeated to include all. Each group discussion lasted for 45 minutes and it was conducted under the supervision of a trained facilitator. The participants discussed topics such as the person(s) who might make the decision on the type of delivery and events happening before, during and after the delivery. The following questions were proposed by the instructor: "At what stage of pregnancy, do you make decision about cesarean section? What was your perception of delivery type in the first months of pregnancy? Do you have any painful experience from vaginal delivery or events in delivery room? What problem(s) did you face in your pervious elective cesarean section? Why do you prefer cesarean section when you have not experienced any pain from vaginal delivery? Who else is involved in your decision making? What are your reasons for selecting cesarean section?
Subsequently, all the details of the group discussions were recorded by a professional note-taker and a tape recorder. These data were transcribed into categories by the investigators. In addition, a constant comparative method was used to analyze the data. Later, the data were coded as follows: all (about 90% to 100%), majority (more than or about 55%), half (about 45% to 55%), minority (about 25% to 45%), very limited (less than 25%).
The mean age of the participants was 27.185.27 years. Nearly half (49.5%) of them had high school diploma or associate degrees and the majority (70.5%) of the women were housewives. Half of the study group were primiparas. A very limited number of participants (n38) had previous vaginal deliveries and one-fourth had had previous elective cesarean sections.
The responses were coded using content analysis for four major categories as follows:
1- The most distressing factors were psychological reasons, including: fear of pain (all), improper treatment by parturition room personnel (major), vaginal delivery outcomes (major), as well as shame and pungency (minor).
2- Low perceived behavioral control: lack of ability to control parturition pain (major) and parturition pain intolerance (major) and inability to withstand parturition pain (major).
3- Improper subjective norms: encouragement from family members (half), husband (minor) and physician (minor) to have elective cesarean section for parturition.
4- Wrong attitudes about vaginal delivery: confidence about the baby's health (major), unawareness about parturition process and anesthesia duration (major), comfort in cesarean section in comparison to vaginal delivery (major) and earlier preparation knowledge of exact time of delivery (very limited).
A study by Karlstrom et al. showed that one-third of cesarean sections were optional. Fear and anxiety about child's health and previous history of elective cesarean section were reported as the main reasons for elective cesarean sections (6). Saisto also reported that parturition fear has led to 8% to 22% increase in elective cesarean sections in a very limited number of women (7).
Negahban and Ansari demonstrated the popularity of elective cesarean section among primiparous women and its relation with fear intensity and parturition type (8). Anxiety about pregnancy and natural parturition fear were also observed among primiparous women attending training classes for delivery (9). In another study, Johanson reported that pregnant mothers preferred elective cesarean section because of its comfort in comparison with vaginal delivery (10). The findings of the current study are in line with the results of the abovementioned studies.
Most developed countries have tried to reduce the rate of cesarean section with effective interventional programs (11). For example, in European countries elective cesarean rate has decreased to lower than 15% (12). In comparison, in Iran, medical care during pregnancy is limited to orderly monitoring and sonography. This seems inadequate as the pregnant mothers’ ignorance about parturition lead to anxiety, related complications and subsequent increase in medical interventions.
On the other hand, training physical and neural exercises, correct breathing, concentration exercises and proper birth positioning will help mothers overcome parturition to with least complications. Additionally, post-partum depression will be reduced after parturition and desire for breast-feeding will increase. Boysdon showed that training classes and mental support could reduce rates of elective cesarean section up to 25% (13).
Sharifi-Rad and et al. conducted a study on the effects of husbands’ education on knowledge and attitude of pregnant women in reducing elective cesarean sections. Their showed that elective cesarean section without medical indications was meaningfully fewer in the intervention group than the observation group (minority vs. half) (14). Likewise, another study by Malier revealed that training the medical staff and pregnant mothers at health care centers will reduce optional elective cesarean section up to 54%. Additionally, safety parturition training reduced optional elective cesarean section up to 24% in another study (15). Guihard and Blondel suggested that different policies should be developed to stop the increasing rate of elective cesarean sections including increasing women's knowledge about the risks and complications of elective cesarean section, developing parturition room management system at the time of parturition and offering some incentives and encouragement in the national level (16).
The results of this study suggest that continuous psychological skills training classes and preparatory, sessions for parturition be held for pregnant mothers along with communication skills workshops for the operation room personnel to increase their skills, as well as awareness about the issue.
Moreover educational movie-clips should be shown and successful mother, with positive view should be invited to such sessions to share their experience. Furthermore, sending useful educational materials through post, telephone or internet messages seems to be effective in influencing their husbands and other close relatives of pregnant mothers for reducing elective cesarean sections.
The authors express their deep gratitude to the authorities of Zahedan University of Medical Sciences, its Student Research Committee and Health Promotion Research Center who supported the study.
Conflict of Interest
Authors declare no conflict of interest.