Influencing Factors to Delivery Selection in Pregnant Women; A Case study in Tehran


Fatemeh Rahmati-Najarkolaei1, Tayebeh Eshraghi2, Nooredin Dopeykar3*, Parisa Mehdizadeh4


1 Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran

2 Department of Consultation,� Faculty of Psychology, Azahra University, Tehran, Iran

3 Hospital Management Research Center, Iran University of Medical Sciences, Tehran, Iran

4 Health Economics Department, Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran


Received: 2014/06/01 ������������ Accepted: 2014/09/16



Introduction: Considering the side-effects of Cesarean Section, attempts have been made to reduce the rate in different societies. The present study aimed to explore the issue. Particularly, the study focused on what it is that makes Cesarean as the first childbirth option.�

Methods:� This is a descriptive study. The participants of the study were 226 pregnant women referring to a Tehran-located clinic, Iran, during Jan to March 2012that were selected based on purposeful method. Qualitative content analysis was used to analyze the data. A questionnaire consisting of open-ended and demographic-related items was employed to collect data. SPSS (Ver. 16) was used for statistical analysis.

Results: A total of 226 pregnant women studied that 101 (44.7%) and 125 (55.3%) selected vaginal delivery and Cesarean Section, respectively. The women selecting Cesarean Section mentioned fear of vaginal delivery and its side-effect (55.3%), vaginal delivery inability (16.78%), and past Cesarean Section experience as the reasons behind their preference.

Conclusion: Given that requests for Cesarean Section have been associated with fear of a vaginal delivery and its side-effects, it is recommended that Cesarean seekers be provided with technical counseling in hospitals and clinics.�

Keywords: Cesarean Section, Delivery, Obstetric, Hospital


Cesarean section (CS) with appropriate indications is an essential invasive procedure in modern obstetrics, which can certainly save the lives of mothers and fetuses. Nevertheless, a large number of CS are currently performed without medical necessity and are associated with higher risks than benefits (1).

CS rates are progressively rising in many parts of the world. This rate is becoming a major public health concern and cause of considerable debate due to potential maternal and prenatal risks, cost issues and inequity in access (2).

In the developed countries the percentage of births by CS rates is around 22% (range 12.9% to 33.3%) whereas in developing countries the total rate is near 12% but diverse widely by region (0.40% to 40%s) (3).

The World Health Organization (WHO) considers CS rates of 5�15% to be the optimal range for targeted provision of this life saving interventions for mother and infant. (4) Lower rates suggest unmet need, while higher rates suggest improper selection. No standard classification system exists for Cesarean indications (5).

�In Iran, the published data in 2005 showed that CS constituted 47% of all deliveries (around one million) among which 52% of deliveries in Tehran and 64% of deliveries in the private sector (6). The Demographic and Health Survey (DHS) conducted in Iran in 2000 reported the CS rate in the country to be as high as 35% (7). Thus we faced with increasing cases of Cesarean in Iran in recent years. In turn, proves costly for families, insurers, and society.

Although CS is a modern method which has the merits of a planned delivery and lack of childbirth pain, like all other surgical operations it may result in bleeding, infection, pulmonary embolism, and vein thrombosis. Also, in comparison with vaginal childbirth, those undergoing CS are two times more likely to be re-hospitalized after a month. It is estimated that mortality and morbidity rates following emergency and selected CS are respectively nine and three times more that the vaginal childbirth.

The increasing rates of CS have been associated with different economic, cultural, social, and health factors including electronic fetal heart rate monitoring, cesarean experience, the decrease in the number of childbirth, physicians� fear of being sued as a result of their weak monitoring performances, and selected Cesarean delivery (8).

In Iran, pregnant women have a lot of issues such as the popularity of CS in the society, the pressure coming from relatives, and financial ability to undergo the procedure, which make Cesarean as the first childbirth option (9). Mentally speaking, women giving childbirth through CS have a more negative perception of their children and deliver experience and show weaker child-nurturing performances (10).

Understanding and responding to women�s beliefs and attitudes during the childbearing period is an important focus of international maternity health policy. Considering the side-effects of CS, attempts have been made to reduce the rate in different societies. One of the ways to fulfill this is to identify factors influencing women in their selection of vaginal or CS childbirth. There are several reasons for this trend, including medical, social, as well as psychological reasons. Most studies did not determine the main indications contributing to a higher rate of CS.(11) Therefore, the present study aimed to explore this issue. Particularly, the study focused on what factors makes Cesarean delivery as the first childbirth option for pregnant women.�



This is a descriptive study that performed by purposeful sampling method. Qualitative content analysis was conducted on pregnant women coming to a Tehran-located clinic during January to March 2012. Sample size was calculated using below equation: �P=0.15 ,�=0.5, �و0.1.

The participanted populations were 226 pregnant women which selected through convenience purposeful sampling. All the participants were required to be at their last pregnancy stage. Those reporting hypertension, pre-eclampsia, other abnormal pregnancies and not informed consent were excluded from the study.��

The applied questionnaire had two sections including demographic information of the participants and open-ended questions to explore the preferred childbirth method and a question on the reasons behind the preference. Participants� responses to the open-ended question were coded. For example, responses such as fear of vaginal delivery and its side-effects and sexual organ deformation as the reasons for selecting CS were categorized under fear of vaginal delivery and its side-effects. Firstly, for analyze the sentences were coded and classified. Of the 53 categories were recognized then reduced to 24 and finally was divided into two major categories (vaginal and cesarean delivery) (Table 1, 2).

Content validity of the questionnaire was checked by five experts of the area. SPSS16 were used for statistical analysis. The study was approved by the ethics committee of Baqiyatallah University of Medical Sciences and ethical principles were adhered to throughout the study. Pregnant women were provided informed consent, confirmed in writing, after explaining of the purpose and procedures of the study. Time of the completion of the questionnaire was (30�90 min) were held at a private room in clinic.



The mean of the participants� ages was 27.7�4.67. A total of 205 of the participants (90.7%) were housewife and others were employed. The 53.1% of participants had academic education degree. Previous history of infertility had in 20 (9.2%) participants. Of the participants 125 (55.3%) and 101 (44.7%) selected CS and vaginal delivery, respectively.

Table1. Self reporting of Reasons for selecting Cesarean Section

Mentioned Reasons



Fear of vaginal childbirth and its side-effects



vaginal childbirth inability



Husbands� disagreement with vaginal childbirth



Past CS� experience



Suffering from some diseases



A set date for delivery



Being pregnant with twins or more



Being negatively affected by others� ideas on vaginal childbirth�



Low risk of Cesarean



Negative vaginal delivery experience



Low standards of vaginal childbirth in Iran



Familial and rest problems



Cesarean� knowledge and learning






Table 2.Self reporting of Reasons for selection vaginal delivery

Mentioned Reasons



Fewer side-effects



Knowing about the benefits of vaginal childbirth



benefits of vaginal childbirth for infants



Positive spiritual effects of vaginal childbirth



Fear of Cesarean and its side-effects



Availability of modern vaginal childbirth procedures� �



Physicians� recommendation of the procedure



positive vaginal delivery experience



Better development of fetus in vaginal childbirth



Negative experience of Cesarean and its side-effects



vaginal childbirth ability






Those preferring CS mentioned fear of vaginal delivery and its side-effects (56.4%), vaginal delivery inability (16.8%), and past CS experience (11.4%) as the main reasons for their selection. On the other hand, participants favoring vaginal delivery mentioned fewer side-effects (69%), benefits of vaginal delivery for children (21.1%), positive experience with vaginal delivery (4.9%), and positive spiritual effects of vaginal delivery (4%) as the major factors influencing their selection.


Discussion and Conclusion

Of the participants of the study 54.4% preferred CS whose preference was mainly due to the participants� fear of vaginal delivery and its side-effects, vaginal delivery inability, and past CS experience. Also, 45.6% of participants chose vaginal delivery since they believed it has fewer side-effects (60.98%) and positive spiritual effects (4.06%), and finally, it benefits their children (21.13%). From among the factors influencing women in preferring CS fear of vaginal delivery and its side-effects (55.3%) was found to be the most important one. Strom (2013) reported that Women living in urban areas, of high socioeconomic status, more educated and delivering in private facilities had higher rates of cesarean deliveries. But the shift from births taking place in homes to births occurring in medical centers was the major factor accounting for the increase in CS birth rates among Salvadoran women (12).

The only psychological variable associated with the choice for CS on maternal request was the fear of childbirth (13). In the study by conducted by (14), 33% of the participants preferred CS. The authors reported fear of childbirth pains, GPs� recommendation, and past CS experience as the main reasons of selecting the procedure. The authors, also, mentioned fewer side-effects, quicker healing, and lower expenditures as the factors affecting their decision to undergo a vaginal delivery. According to (15), predictors such as past Cesarean experience, negative delivery experience, and fear of delivery can predict 20% to 70% of Cesarean requests. Of the pregnant women participating in the study by Ghasvari et al. (2012) 68% and 32% preferred vaginal delivery and CS, respectively. According to the findings of the study fear of vaginal childbirth and ease of CS accounted for 43.3% of Cesarean requests (16). Shakeri (2008) (17) found that 43% of the deliveries in Zanjan, Iran, were through selected Cesarean and most of the participants linked their selection with fear of childbirth. In addition, (18) associated fear of vaginal childbirth with CS requests (19). states that 81% the women participating in her study considered vaginal childbirth frightening. According to (20), Cesarean requests are associated with factors such as fear of the stages of delivery, past negative childbirth experiences, and concerns about rectal and urinary system damages. Pregnant women preferring CS are more frightened of childbirth pains, suggesting that the group think of CS as a painless childbirth. This can influence women childbirth preferences. It has been shown that enhanced negative attitudes towards vaginal delivery pains can affect women�s preferences regarding the childbirth procedure and reduce significantly their tendency to undergo a vaginal childbirth. Moreover, Spice et al. (2009) and Katri et al. (2009) note that there is a relationship between fear of delivery and CS requests (21, 22). Fears of childbirth pains make women feel unable to tolerate the pains. Haines et al (2012) observes that fear affects emotional health of pregnant women negatively and raises the likelihood of CS (23). Hence, pregnant women are required to be monitored by experts during the pregnancy period.

�Fear of childbirth pains is related to a general fear of pain and women�s personality traits. Cesarean requests can be reduced up to 50% through supportive treatments to cope with stress during delivery period (24). Nerum (2006) explains the links between women�s fear of vaginal�� childbirth and Cesarean requests and notes that the women requesting for selected CS did not really intend to undergo the procedure, and in turn, wanted to be helped so as to make themselves mentally to go through a vaginal childbirth.� Another reported reason was inability of have vaginal delivery that was showed low self -efficacy of these women. It appears low self-efficacy was relationship to fear of childbirth among pregnant women. It is imperative to identify pregnant women with fear of childbirth and efficacy beliefs to help and support them. Verbal persuasion can be enhancing self-efficacy (25).

Therefore, women should not be allowed to select CS without receiving counseling on how to solve their mental problems. In the study, 86% of the women had a second mind regarding their CS requests and turned to vaginal childbirth (26). According to khorsandi, et al study (2012), educational intervention was effective in reducing the rate of primary caesarean section (27). Based on neuromatrix theory of pain, pains including childbirth pains are physical, emotional, and mental experiences (28).���

This means that if pregnant women develop a positive attitude towards pregnancy and pain, they do not consider the experience as terrible. This, in turn, reduces the fear of vaginal delivery. It seems that attending the aforementioned counseling sessions prepares pregnant women to deal with delivery in a better way and in so doing, negative attitudes (such as fear of childbirth) turn into positive ones. Therefore, considering the high rate of selected CS in our country and the most important factor influencing it, i.e., fear of vaginal delivery, it is suggested that women having a tendency to CS be provided with technical counseling in hospitals and clinics. Prenatal education and support program was offered to pregnant woman and obstetric doctors.����

This study had other similar qualitative study limitation and result of this not refers total pregnant woman in Iran. Also self �reported data was other limitation of this study.���



1. Arrieta A. Health reform and cesarean sections in the private sector: The experience of Peru. Health Policy. 2011 Feb;99(2):124-30.

2. Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, et al. Classifications for cesarean section: a systematic review. PLoS One. 2011;6(1):e14566.��

3. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane database syst rev. 2010 (1):CD007482. ������ �

4.WHO. Appropriate technology for birth. Lancet. 1985 Aug 24;2(8452):436-7.

5.Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres. PLoS One. 2012;7(9):e44484.

6. Ostovar R, Rashidian A, Pourreza A, Rashidi BH, Hantooshzadeh S, Ardebili HE, et al. Developing criteria for cesarean section using the RAND appropriateness method. BMC Pregnancy Childbirth. 2010;10:52.

7. Ahmad-Nia S, Delavar B, Eini-Zinab H, Kazemipour S, Mehryar AH, Naghavi M. Caesarean section in the Islamic Republic of Iran: prevalence and some sociodemographic correlates. East Mediterr Health J. 2009 Nov-Dec;15(6):1389-98.

8. F.Cunningham, KennethLeveno� , StevenBloom� , John Hauth , DwightRouse , Spong C. Williams obstetrics and gynecology. 23 rd ed. New york McGraw-Hill Professional; 2009.

9. Jamshidi Manesh Mh, Oskouie S.F, Jouybary L, Sanagoo A. The Process of Women�s Decision Making for Selection of Cesarean Delivery. Iran J Nurs. 2009;21(56):55-67.(persian)

10. Lobel M, DeLuca RS. Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Soc Sci Med. 2007 Jun;64(11):2272-84.

11. Charoenboon C, Srisupundit K, Tongsong T. Rise in cesarean section rate over a 20-year period in a public sector hospital in northern Thailand. Arch Gynecol Obstet. 2013 Jan;287(1):47-52.

12. Strom S. Rates, Trends and Determinants of Cesarean Section Deliveries in El Salvador: 1998 to 2008: University of Washington; 2013.

13. Handelzalts JE, Fisher S, Lurie S, Shalev A, Golan A, Sadan O. Personality, fear of childbirth and cesarean delivery on demand. Acta obstet gynecolScandinavica. 2012;91(1):16-21.

14. Nouri Zadeh R, Mohammadpour A, Kazempour R, Bakhtari Aghdam F. SELECTION OF MODE OF DELIVERY AND ITS RELATED FACTORS IN PREGNANT WOMEN IN MARAND. J� Nurs Midwifery Urmia Univ� Med Sci. 2009;7(1):51-7.(persian)

15. Fuglenes D, Aas E, Botten G, �ian P, Kristiansen IS. Why do some pregnant women prefer cesarean? The influence of parity, delivery experiences, and fear. Am J Obstet Gynecol. 2011;205(1):45. e1-. e9.

16. Ghasvari M, Rahmanian V, Rahmanian K. Knowledge of pregnant women in the southwest Iran about complications of cesarean section, 2009. J Jahrom Univ� Med Sci. 2012;10(2):37-42. (persian)

17. Shakeri M, Mazloumzade S, Mohamaian F. Factors Affecting the Rate of Cesarean Section in Zanjan Maternity Hospitals in 2008. Zanjan Univ Med Sci� J. 2012;20(80):98-104. (persian)

18. Jamshidi Evanaki F, Khakbazan Z, Babaei G, Seyed Noori T. Reasons of choosing Cesarean section as the delivery method by the pregnant women referred to healthtreatment centers in Rasht. Hayat. 2004;10(3):50-60. (persian)

19. Etghayi M, Nouhi E, Khaje pour M. Investigating attitude of labor pain and choosing the type of Delivery in pregnant women refering to health centers in Kerman. J Qual Res� Health Sci. 2010;10(1):36-41. (persian)

20. Ecker J. Elective cesarean delivery on maternal request. JAMA. 2013 May 8;309(18):1930-6. PubMed PMID: 23652524.

21. Spice K, Jones SL, Hadjistavropoulos HD, Kowalyk K, Stewart SH. Prenatal fear of childbirth and anxiety sensitivity. J Psychosomatic Obstet Gynecol. 2009;30(3):168-74.

22. Nieminen K, Stephansson O, Ryding EL. Women's fear of childbirth and preference for cesarean section�a cross‐sectional study at various stages of pregnancy in Sweden. Acta obstet et gynecol Scandinavica. 2009;88(7):807-13.

23. Haines H, Rubertsson C, Pallant J, Hildingsson I. The influence of women�s fear, attitudes and beliefs of childbirth on mode and experience of birth. BMC Pregnancy and childbirth. 2012;12(1):55.

24. Saisto T, Halmesm�ki E. Fear of childbirth: a neglected dilemma. Acta obstet� gynecol Scandinavica. 2003;82(3):201-8.

25. Salomonsson B, Berter� C, Alehagen S. Self-Efficacy in Pregnant Women with Severe Fear of Childbirth. J Obstet, Gynecol, Neonatal Nurs. 2013;42(2):191-202.

26. Nerum H, Halvorsen L, S�rlie T, �ian P. Maternal Request for Cesarean Section due to Fear of Birth: Can It Be Changed Through Crisis‐Oriented Counseling? Birth. 2006;33(3):221-8.

27. Khorsandi M, Ghofranipour F, Hidarnia A, Faghihzadeh S, Ghobadzadeh M. The Effect of PRECEDE PROCEED Model Combined with the Health Belief Model and the Theory of Self-Efficacy to Increase Normal Delivery Among Nulliparous Women. Procedia - Social Behav Sci. 2012;46(0):187-94.

28. Trout KK. The neuromatrix theory of pain: implications for selected nonpharmacologic methods of pain relief for labor. J Midwifery Womens Health. 2004 Nov-Dec;49(6):482-8.




  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.

Creative Commons License
Journal of Health Policy and Sustainable Health is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.