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Predictors of choice of childbirth in primiparous women in islamshahr.


Despite advances in maternity care, basic physiology of childbirth remains unchanged, and what has changed is the greater use of technology and intervention in process of childbirth. Elective cesarean section is considered one of these interventions [1]. Regrettably, in recent years, demand for elective cesarean delivery has increased. An increase in unnecessary cesarean deliveries is indicative of inappropriate performance of healthcare systems of countries [2, 3].

According to a report by World Health Organization(WHO) (1985), cesarean section rate over 15% endangers maternal and neonatal health, and imposes a huge financial burden on the health system [4]. According to another report by WHO (2010), cesarean section rate in Iran was 42%in 2008, accumulative unnecessary cesareansection rate was 71.5%, with overall cost of unnecessary cesareans 108 million USD [5]. When mothers' request for unnecessary cesarean section is routinely accepted, it can drain the limited healthcare funds [4, 6]. Elective cesarean section is associated with high risks of maternal mortality, hysterectomy, ureteral and bladder injuries, abdominal pain, neonatal respiratory complications, fetal death, placenta previa, and uterine rupture in subsequent pregnancies [6].

Maternal request for caesarean delivery is a complex subject. It seems there are factors involved in this issue that cannot be easily explained. There is little information available on how decisions are made for elective cesarean surgery in clinical settings. Demographic, psychological and structural variables may affect people's perceptions, and indirectly, their health behaviors [7]. Unfortunately, some women believe that cesarean section is the safest delivery method for their baby [8], while women with spontaneous vaginal delivery report more positive experiences of giving birth, and their acceptance of maternal role is greater than in instrumental vaginal deliveries and cesarean section [9].

Other suggested reasons for increasing cesarean rate include fear of vaginal delivery and physical harm, fear of neonatal harm [8], maternal aging, high socio-economic status, reduced number of deliveries and advances in surgery techniques [10], physical and mental comfort, sharing experiences, concern about complications, fear of loneliness and death, improper medical staff behaviors and frequent vaginal examinations [11].

Given the high rates of cesarean section in Iran, and its negative effects on maternal and neonatal health, the present study was conducted with the aim to determine predictors of choice of delivery in primiparous women.


Study type and participants ' details:

This cross-sectional study was conducted on 208 primiparous women of gestational age 36-39 weeks presenting to medical centers in Islamshahr. Study exclusion criteria were unwillingness to take part, non-Iranian nationality, multiple pregnancy, education below 1st year high school, proven contraindications for cesarean section or natural delivery according to doctor's report (placenta previa, previous myomectomy, fetal macrosomia, and fetal congenital anomalies), and acute or chronic diseases that may affect type of delivery, (for example: heart diseases, diabetes, immune-suppressive diseases, and psychiatric problems that can affect type of delivery, and ...), vertex presentation, use of drugs that affect decision-making and focus according to the patient (such as: diphenhydramine, metoclopramide, SSRI, psychotropic drugs, and ...), particular domestic crisis in the last 6 months (such as: disease or death of dear ones, divorce, or financial crisis in the family) and other medical contraindications to natural delivery or cesarean section.


First, of 17 health centers 6, and out of 26 medical bases 9 were selected randomly and proportionally using and the list of all women in their 36-39 weeks gestational age, covered by health/medical units were extracted, and samples were randomly selected proportional to each center. Explanations were given about study objectives, and written consents were obtained from participants. Next, questionnaires were completed via interviews. For greater generalizability of the study, the reasons for declining were asked of those who declined to participate, and recorded.

Data collection tool:

This comprised 4 parts: A-personal and social details, B-obstetrics history, C-study of maternal anxiety, and D-acceptance of maternal role. Content and face validities were used to assess validity of the questionnaire, and to assess reliability, test-retest method was used on 30 people, and reliability was assessed from both repeatability (ICC=Intra Class Correlation) and internal consistency aspects (Cronbach'salpha). Values of ICC and a for acceptance of maternal role were found 0.84 and 0.72, respectively. For perceived maternal anxiety, ICC was found 0.94.

Personal-social details consisted of 8 items on age, race, education of mother and spouse, occupation of mother and spouse, income, history of tobacco use. Obstetrics details included the number of planned children, history and the number of abortions, history of infertility, intention to breastfeed in this pregnancy, maternal care provider (midwife or obstetrician), and self-description of pregnancy. Anxiety was measured using one item according to 5-option Likert scale scoring from 1 (not anxious at all) to 5 (very anxious), which referred to maternal anxiety about the coming delivery. Participants were asked to estimate their level of anxiety about delivery. This item was part of Mothers Health Beliefs Questionnaire (MHBQ). Acceptance of maternal role was measured according to subscale of maternal acceptance in MHBQ. This 8-item scale requires women to respond to questions about their perception of pregnancy, to examine and clarify their acceptance of maternal role. To score each item, 5-option Likert scale was used from "strongly agree" to "strongly disagree", with range of scores from 8 to 40, in which lower scores indicated high acceptance level of maternal role.

Data analysis:

Data were analyzed with SPSS-13 software. Descriptive statistics, including frequency, percentage, mean, and standard deviation were used to explain social-personal details, obstetrics details, perceived anxiety, and acceptance of maternal role. To determine predictors of choice of delivery: first, bivariate tests including Chi-square, Mann-Whitney, and t-test were used to find the relationship between personal-social details, perceived anxiety, acceptance of maternal role, and choice of delivery. To determine the effect of each independent variable (personal-social details, obstetrics details, perceived anxiety, and acceptance of maternal role) on the dependent variable (choice of delivery) and also to determine oddsratio, independent variables with P<0.2 in bivariate tests entered Binary Logistic Regression model with LR-Backward strategy.


Personal-social details, perceived anxiety, and acceptance of maternal role:

Mean (standard deviation) of participating mothers was 25.1 (4.3) years. Nearly half mothers (44.5%) were older than 25 years of age. More than half mothers (58.6%) and almost half spouses (49.5%) had high school diplomas. The majority of women (85.1%) were housewives, and more than one third of spouses (37.5%) were manual workers. About two thirds of women considered their income sufficient for living expenses. More than half (55.2%) had Turkish ethnicity. The majority (87.5%) had never smoked. Of women, 11% had a history of abortion, and 6% had a history of infertility. More than three fourth of women had planned pregnancies, and a vast majority (98.1%) intended to breastfeed after delivery. 72.5% of women declared 1 to 2 planned children. 44.7% of mothers were seen by midwives and 25.9% by obstetricians (table 1).

Mean (standard deviation) score of mothers' acceptance of maternal role in natural delivery and cesarean section were 31.7 (6.7) and 31.1 (6.7) respectively, from range of scores 8-40 (table 2). The highest frequency (%) of perceived anxiety in mothers having natural delivery was 35 (31.5%) out of score range 1-5, indicating somewhat anxious status, and in mothers having cesarean section 29 (29.9%) from 1-5 range of scores, indicating moderate anxiety (table 3).

Frequency of choice of natural birth or cesarean section, and its relationship with perceived anxiety, acceptance of maternal role, and personal-social details:

Frequency of choice of natural birth or cesarean section in pregnant mothers was 53.3% and 46.6%, respectively.

According to Chi-square and Mann-Whitney tests, significant relationships were found between choice of delivery and, anxiety, age, and maternity care provider (P<0.05), and finally, according to multivariate logistic regression test, anxiety, age, and maternity care provider were identified as predictors of choice of delivery. According to the results of this analysis, the odds for choosing cesarean section in women under 20 years of age was 95% CI: 0.1 to 0.8, OR:0.3, and in those of 20-25 years, 95% CI: 0.1 to 0.6, OR: 0.2, which were significantly higher than in women older than 25 years of age. The odds for cesarean in mothers visited by obstetrician was 7 times that of mothers visited by midwives (95 % CI: 3.03 to 16.9; OR: 7.1). The odds for cesarean in highly anxious group was (95% CI: 2.5 to 24.1; OR: 7.8), in very anxious group (95% CI: 1.8 to 18; OR: 5.7) and in moderately anxious (95% CI: 1.2 to 8.8; OR: 3.3), which was significantly greater than in mothers with no anxiety (table 4).

There was an insignificant relationship between acceptance of maternal role and choice of delivery. In this study, the relationship of choice of delivery was insignificant with personal details such as household income, mother's education, occupation of mother and spouse, ethnicity, unplanned pregnancy, mother's intention to breastfeed, the number of planned children, or the history of smoking.


The prevalence of choosing cesarean section in participating mothers was 47%. Studies conducted in various provinces and cities have produced different results. The frequency of choosing elective cesarean section was found 9.6% in a study conducted in Isfahan province, [12], 20.8% in Rasht city [13], and 43% in Zanjan province [14], which were significantly lower than the figure obtained in the present study. In a study by Mac Milan et al. (2010) to assess health belief perception of primiparous mothers seeking elective cesarean section and natural delivery, 11.8% of mothers opted for elective cesarean section [15]. According to several studies conducted in Iran, the rate of cesarean section in Iran is much higher than world standards, and a high number of cesarean sections are performed according to mothers' request, which requires greater educational planning to reduce primiparous mothers' demand for cesarean section.

Age was a predictor of choosing cesarean section, and choosing elective cesarean section increased with aging. In another study in 2010 conducted on pregnant women in Isfahan city hospitals, most cesarean sections were performed in 25-29 years age group, in which, the majority involved primiparous mothers as the most common reason for elective cesarean [12]. In Shakeri et al. study in 2008 on pregnant women in Zanjan, over 35 years of age was reported as an influential factor in choosing cesarean section [14]. According to Mac Milan et al. study (2010) on perception of health belief in primiparous mothers demanding cesarean section and natural delivery, mothers that selected cesarean section were older [15].

The cause of increased risk is still unknown. However, according to Byron study (2004), concerns of doctors and mothers about pregnancy outcomes in older women may be a reason for elective cesarean section [9].

Maternal care provider was another factor in choice of delivery. The odds for choosing cesarean section in women visited by obstetricians were 7.1 times greater than in women visited by midwives. Monker et al. (2001) studied reasons for increased demand for cesarean section among women with no indications for it, and cited the significant role of obstetricians in mothers' choice [16]. According to a study conducted in 2009 in East-Azerbaijan province, 33.7% of obstetricians and 17.6% of midwives recommended cesarean section to women

with no indication for cesarean section [17]. Allocation of equal or even greater tariffs as earnings for doctors and midwives in natural delivery should be considered by national organizations as a successful strategy to reduce cesarean section rates. Familiarity of obstetricians and midwives with physiological delivery, sufficient number of midwives to control the process of labor in public and private hospitals, frequent inspections of medical records, and heavy fines for hospitals with high rates of elective cesarean can provide another strategy to reduce cesarean section.

In addition to variables mentioned above, maternal perceived anxiety was another predictor of choosing cesarean section in pregnant mothers, such that, odds for choosing cesarean at all anxiety levels were shorter compared to severe level of anxiety. The relevant results in other studies are in line with the present study results [8, 11, 14, 20, and 21]. In Weaver et al. study (2007), fear and anxiety of delivery, was reported another reason for choosing cesarean section [8]. In a study by Jamshidimanesh et al. (2011), mother's fear was reported a reason for choosing cesarean section [11]. In Shakeri et al. study (2008), fear of pain was reported a reason for opting for cesarean section [14]. Many other studies have also produced similar results to those found in the

present study [18, 19]. Maternal fear and anxiety can be due to their lack of proper knowledge about the process of delivery and lack of knowledge of cesarean complications, which indicates importance of enhancing women's knowledge. Interventions and educational programs should be so designed to make women aware of cesarean section complications and benefits of natural birth.

In the present study, there was an insignificant relationship between acceptance of maternal role and type of delivery, while, the results of many studies reveal more positive experiences of giving birth are reported by women with spontaneous vaginal deliveries, and greater acceptance of maternal role in these mothers compared to mothers undergoing instrumental vaginal deliveries and cesarean sections [9]. A possible reason for this can be the planned pregnancies in more than two thirds of participating mothers that were happy about their pregnancies, and even 21.6% of mothers with unplanned pregnancies were happy about it. Only 1.9% of mothers were unhappy about being pregnant that can affect their acceptance of maternal role. Meanwhile, in the first trimester of pregnancy, women's focus is rather on their own health, which shifts toward the fetus through fetal movements in the third trimester. Moreover, desire and ability for personal sacrifices for fetal/neonatal health (as a common goal in pregnant women) is associated with high level of acceptance of maternal role and attachment to pregnancy, which can explain high acceptance of maternal role in the present study.


Considering the results obtained and 47% frequency of elective cesarean section , and also the importance of neonatal and maternal complications of cesarean section, and its increasing prevalence, especially in developing countries, it is essential to conduct further studies on factors influencing reduction of choosing cesarean section by primiparous mothers, so that, strategies and interventions can be designed accordingly to reduce elective cesarean section rates, and implementing these strategies, opting for elective cesarean can be prevented in all mothers, especially in primiparous mothers, and ultimately, an effective step can be taken to improve maternal health, and thereby, health of the community. Given the effect of anxiety on mothers' choice of delivery, conducting qualitative studies seems necessary to identify factors affecting mothers' fear and anxiety in choosing cesarean section. Also, given the role played by obstetricians in choice of delivery, familiarizing obstetricians with physiological delivery and encouraging them to perform such deliveries can have a major role in reducing elective cesarean.

Therefore, considering that pregnant women have a determining role in choosing delivery, and that it is their basic right, educating women can play an important role in decision-making and opting for the right choice of delivery. To control feelings of pregnant women in the process of decision-making, encouraging doctors for natural childbirth, expressing benefits of natural birth, physiological birth training, and teaching delivery pain reduction methods during prenatal period can form effective educational programs.


Article history:

Received 11 June 2014

Received in revised form 21 August 2014

Accepted 25 September 2014

Available online 25 November 2014


I appreciate the head of Care centers in Islamshahr, research and deputy of Tabriz University of medical Science for financial support and all of the mothers that helped us in this study.


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Zahra Fathollahi, Shirin Hasanpour, Mozhgan Mirghafourvand, Soheila Bani

Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Corresponding Author: Soheila Bani, Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.

Tel:09144151456; E-mail:
Table 1: the relationship between personal-social details, obstetric
and choice of delivery based on chi-square test (total number = 208).

Variable                    N      NVD        C/S

                                   n(%)       n(%)
Age group *
<20                        40     28(70)     12(30)
20-25                      67    41(61.2)   26(38.8)
>25                        101   42(41.6)   59(58.4)
Mother's education level
High School                28    16(57.1)   12(42.9)
Diploma                    122   65(53.3)   57(46.7)
University                 58    30(51.7)   28(48.3)
Spouse Education level
Primary school              9    8(88.9)     1(111)
Secondary school           30    10(33.3)   20(66.7)
High School                22    14(63.6)   8(36.4)
Diploma                    103   55(53.4)   48(46.6)

University                 35    20(57.1)   15(42.9)
mother's occupation
with house                 177   94(53.1)   83(46.9)
work outside the home      31    17(54.8)   14(45.2)
Spouse occupation
Labour                     78     39(50)     39(50)
Employee                   56    33(58.9)   23(41.1)
free                       74    39(52.7)   35(47.3)
Adequacy of income
Completely                 49     25(51)     24(49)
Somewhat                   141   71(50.4)   70(49.6)
Not at all                 18    15(83.3)   3(16.7)
Persian                    52    29(55.8)   23(44.2)
azary                      115   67(58.3)   48(41.7)
Other                      15    15(36.6)   26(63.4)

Variable                                    Variable

Age group *                             Smoking history
<20                                          Never
20-25                                     In the past
>25                                       Infertility
Mother's education level                       No
High School                                   Yes
Diploma                                     Abortion
University                                     No
Spouse Education level                        Yes
Primary school                      Describe this pregnancy
Secondary school             Planned pregnancy and happy pregnancy
High School                Not Planned pregnancy and happy pregnancy
Diploma                          Not Planned pregnancy and Not
                                        happy pregnancy
University                          Planning to Breast feed
mother's occupation                           Yes
with house                                     No
work outside the home                       Not sure
Spouse occupation                    Baby number programmed
Labour                                  1 or 2 children
Employee                            At least three children
free                                      No decision
Adequacy of income                      Prenatal care *
Completely                                Obstetrician
Somewhat                                    Midwife
Not at all                                    Both

Variable                    N       NVD        C/S

                                   n(%)        n(%)
Age group *
<20                        182   94(51.6)    88(48.4)
20-25                      26    17(65.4)    9(34.6)
Mother's education level    8    94(61.6)    88(48.4)
High School                 4    17(65.4)    9(34.6)
University                 186   102(54.8)   84(45.2)
Spouse Education level     22     9(40.9)    13(59.1)
Primary school
Secondary school           159   81(50.9)    78(49.1)
High School                45    28(62.2)    17(37.8)
Diploma                     4      2(50)      2(50)

mother's occupation        204   110(53.9)   94(46.1)
with house                  2      0(0)       2(100)
work outside the home       2      1(50)      1(50)
Spouse occupation
Labour                     151   76(50.3)    75(49.7)
Employee                   14    11(78.6)    3(21.4)
free                       43    24(55.8)    19(44.2)
Adequacy of income
Completely                 54    16(29.6)    38(70.4)
Somewhat                   93    64(68.8)    29(31.2)
Not at all                 60     30(50)     26(63.4)

P < 0.05 *

Table 2: The Relationship between acceptance of maternal role and
choice of delivery based bivariate tests.

Variable           NVD          C/S          P

                Mean (sd)    Mean (sd)

acceptance of   31.7 (6.7)   31.7 (6.7)   0.532 *
maternal role

* T-Test

Table 3: The relationship between perceived anxiety and choice of
delivery based bivariate tests.

Variable                NVD         C/S          P

perceived anxiety      n(%)        n(%)
Extremely nervous    10 (9.0)    22 (22.7)
Very nervous         10 (9.0)    16 (16.5)
Moderately nervous   31 (27.9)   29 (29.9)   < 0.001 *
Somewhat nervous     35 (31.5)   23 (23.7)
Not at all nervous   25 (22.5)    7 (7.2)

* Mann-Whitney Test

Table 4: The relationship Predictors of choice of scesarean delivery
based on multivariate logistic regression.

Variable                        OR (CI 95%) *     P

Age (years)
<20 (reference)                       1           --
20-25                           0.3(0.1-0.8)    0.023
>25                             0.2(0.1-0.6)    0.002
Perceived anxiety
Not at all nervous(reference)         1           --
Extremely nervous               7.8(2.5-24.1)   <0.001
Very nervous                    5.7(1.8-18.0)   0.003
Moderately nervous              3.3(1.2-8.8)    0.016
Somewhat nervous                2.3(0.8-6.3)    0.091

Variable                             Variable        OR (CI 95%) *

Age (years)                      Prenatal care *
<20 (reference)                 Midwife(reference)         1
20-25                              obstetrician      7.1(3.03-16.9)
>25                                    Both           2.5(1.2-5.3)
Perceived anxiety
Not at all nervous(reference)
Extremely nervous
Very nervous
Moderately nervous
Somewhat nervous

Variable                          P

Age (years)
<20 (reference)                   --
20-25                           <0.001
>25                             0.013
Perceived anxiety
Not at all nervous(reference)
Extremely nervous
Very nervous
Moderately nervous
Somewhat nervous

OR (95% CI) = Odds Ratio (95% Confidence Interval)
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Article Details
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Author:Fathollahi, Zahra; Hasanpour, Shirin; Mirghafourvand, Mozhgan; Bani, Soheila
Publication:Advances in Environmental Biology
Article Type:Report
Geographic Code:7IRAN
Date:Nov 15, 2014
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