Why do pregnant women prefer cesarean delivery?: a qualitative study in a tertiary care center in Southern Thailand


 Background

The increasing worldwide rate of cesarean sections is of global concern, and in recent years, cesarean deliveries upon maternal request have become both an interesting and debated issue. Hence, this study aimed to explore the maternal reasons for cesarean preference without medical indications.
Methods

A descriptive qualitative study was conducted, using an in-depth interview, with 27 pregnant women, attending antenatal care at Songklanagarind Hospital from September, 2018 to June, 2019, who preferred cesarean delivery. Data were analyzed using content analysis.
Results

Maternal reasons for cesarean preference were classified into 6 main categories including: fear of childbirth, safety concerns related to health risk perception, negative birth experience, a positive attitude toward cesarean delivery, access to biased information resources and superstitious belief in auspicious birth dates. Most women had more than one reason for choosing cesarean delivery.
Conclusion

Several reasons for cesarean delivery preference emerging from pregnant women have been elucidated. One striking reason was a superstitious belief in auspicious birth dates, which was challengeable for an obstetrician to approach. Obstetricians should explore the exact reasons why women request cesarean delivery, so as to prevent or diminish unnecessary cesarean sections.

4 of delivery. They were invited to participate in this qualitative study, and were assured in regards to confidentiality and anonymity. The inclusion criteria of the main project were: 1) singleton pregnancy; 2) gestational age ≥ 20 weeks; and 3) no maternal or fetal indications for cesarean section. Exclusion criteria were women who could not read/write or understand the Thai language or having an obvious fetal anomaly.
A qualitative study was performed using an in-depth interview to explore the reasons why pregnant women preferred having a cesarean delivery. The pregnant women were individually interviewed by the third author (PM) at the antenatal clinic in the private room, in a narrative style. The conversation was opened with, "Could you please tell me the reasons why you choose to have a cesarean delivery?" If the concept was not clear, the participants were asked to explain in more detail, until the reason was clarified. Each interview lasted for 20-30 minutes. All conversations were audio-recorded, and then transcribed verbatim by the interviewer. The material was evaluated by the first (CS) and second authors (SC), as being saturated with sufficient confidence to answer the research question.

Data analysis
Data were analyzed by the first (CS) and second authors (SC) independently, using content analysis including 4 stages, which were: 1) decontextualization, 2) recontextualization, 3) categorization, and 4) compilation [14]. Each author read through the transcripts and identified meaning units in the text, condensed meaning units and then labeled each meaning unit with a code; the codes were inductively generated. Then, themes and categories were identified. Each stage was performed and revised several times in order to verify the information. The results were then discussed to obtain a consensus. The transcripts were discussed using an editing analysis style and drafting categories based upon the empirical data. Finally, synthesis of the condensates into re-conceptualized description was performed, and approved by all authors.

Results
A total of 27 pregnant women underwent an in-depth interview. The ages ranged from 24 to 45 years, with 14 cases being nulliparous. There were 6 categories and 14 themes emerging from the analysis (Table 1). From the in-depth interviews, most women had more than one reason that had convinced 5 them of their decision. "I am afraid that I could not push the baby, and the baby might be in danger." Category II: Safety concern related to health risk perception Some women perceived that they had significant risk factors potentially leading to an unsafe delivery as well as fetal jeopardy. These included their underlying medical diseases (such as heart disease, diabetes mellitus, etc.), biological risks (advanced age, obesity), infertility and even the perception of a big baby as a consequence of maternal diabetes mellitus. They believed that they were not healthy, and might not have enough power to push the baby out, thus resulting in injury to the baby.
"I have an underlying heart disease, I am experiencing dyspnea sometimes, so I am afraid that I

Category III: Previous negative birth experience
Previous negative birth experience also had a strong impact on some women. Traumatic birth leads to fear of giving birth in later pregnancies, as they perceived that delivery was harmful to themselves as well as their babies. Inadequate analgesia during labor is also a problem, resulting in fear of pain during the birth process.

Category VI: Superstitious belief in auspicious birth dates
Some people believe in destiny, in that they believe that if their babies are born on an auspicious date and time, they will be prosperous. This is a strong ideology in some families; hence, cesarean delivery has an advantage due to this issue.

Discussion
There were several reasons emerging from women who preferred cesarean delivery. Fear of childbirth, safety concern related to health risk perception, previous negative birth experience, a positive attitude toward cesarean delivery, access to biased information resources, and superstitious belief in auspicious birth dates, were found in this study.
Almost all aspects were in accordance with previous studies [10][11][12][13]15], except for the personal superstitious belief in auspicious birth dates, which has been found only in some Asian countries.
Furthermore, in each category, some different details have been noted. For example, in the category of fear of childbirth, some participants mentioned about the risks of two painful events (labor pain and cesarean section), if they failed vaginal delivery. In regards to a positive attitude toward cesarean section, having fibroids removed during a cesarean section as an advantage of having a cesarean delivery was mentioned by some participants, this however was a misunderstanding, because this 9 procedure may cause profound or uncontrolled hemorrhage, thus the requirement for a hysterectomy.
In this study, fear of childbirth was the most common reason for cesarean delivery preference, which was similar to previous studies [10-13, 15, 16]. In this study, women described their fear of childbirth in 3 aspects, fear of labor pain, fear of taking the risk of two painful events (failure of vaginal delivery and cesarean section) and fear of harming the baby. Fear classified in this category was the primary fear, just anxiety of women, not related to previous experiences. Providing proper recommendations for women with fear of childbirth, such as analgesia for pain relief, risks and benefits of vaginal and cesarean delivery, during antepartum care is essential.
Safety concerns related to health risk perceptions were also common in this study. Since our institution is a referral center in the South of Thailand, there have been a high proportion of complicated pregnancies in our center. Women with underlying medical diseases, advanced age, or a history of infertility, perceived that they were high risk and felt it was unsafe for both themselves and their babies. They did not want to take any risks during the birth process. They believed that cesarean delivery was safer than vaginal delivery. Due to this issue, obstetricians should clarify any misunderstandings and the exact risks and benefits in regards to modes of delivery, as there are some serious consequences of cesarean delivery; especially placental adherence in future pregnancies. Safety concerns based on health risk perception has also been mentioned in previous studies [10,13].
Previous studies reported that negative birth experiences have been recognized as a strong factor for cesarean preference [10][11][12]17]. History of traumatic deliveries made women fear birth, and hence the request for a planned cesarean section, in order to avoid such a bad event. In our study, women expressed their feelings on how they suffered from birth experiences in three aspects, including pain control, dystocia and baby injury. Inadequate pain control during labor made women fear birth in subsequent pregnancies. This reflects quality of care during labor, as modality of pain control should be offered as well as mental support. Dystocia is associated with severe pain [18]. Traumatic birthing makes women stressful, frustrated and depressed [19]. As no one want her baby to be injured, these events can have a strong impact on cesarean preference.
One important factor is related to a positive attitude toward cesarean delivery, which might be related to a lack of health literacy. They appreciated the advantages of cesarean delivery in terms of its convenience, short delivery time, less pain, and some women believe that it is a safe procedure.
They lacked the knowledge in regards to some of the serious consequences for future pregnancies; placental adherence. From our point of view, obstetrician should take the opportunity during antenatal care to counsel about both the risks and benefits of cesarean vs. vaginal deliveries.
Knowledge has an influence on attitudes [20], so if they have the correct knowledge, their attitude might change. Thus, there is a need to educate pregnant women and their spouses, partners, caregivers, and family members or influential relatives about the advantages and disadvantages of different modes of delivery. To the contrary, a previous study found that most women who had a positive attitude toward normal delivery would prefer normal delivery in their present pregnancies [21]. To reduce the incidence of cesarean sections, health care providers should promote positive childbirth experiences for first time women in labor, by giving physical and emotional support during the intrapartum period.
In the era of knowledge explosion and digital disruption, people can access information very easily, so it is no wonder that pregnant women addressed clearly that the information acquired from various sources had a strong impact on their decision making. In our study, information resources were from personal advice and mass media. Words or experiences from their relatives or close friends had a strong influence on some participants' decision. Information from mass media such as television, the internet, or any kind of social media could dictate one's ideas or beliefs [15]. Perception and interpretation of the information were different among people based on their experiences, belief, critical thinking and reasoning. As it is a one-way communication, misleading information can occur.
Obstetricians should therefore clarify some misbeliefs or misunderstandings for pregnant women. If women could get informative, professional and correct information, they may change their attitudes toward mode of delivery; leading to the rate of cesarean delivery on demand decreasing.
Finally, a striking reason found in our study was a superstitious belief in auspicious birth dates. To our 11 knowledge, this cultural preference is not found in most western populations, although superstitious belief in auspicious dates and times of delivery is quite common in Thai society, as well as Chinese families. A previous study conducted in California found a large number of Chinese births on the auspicious dates of the; 8th, 18th, and 28th day of the month, but no corresponding increase among the Whites [22]. Some people have a strong belief in destiny; wherein, they believe that birth time determines the course of their life. If they were born during an unlucky period, they would have bad luck throughout their life, this is also coupled with the belief in astrology. Parents desire to provide the best opportunity for their children, so if they can choose an auspicious time to give birth, they would do so. In concerns to this issue, it is very difficult to deal with personal beliefs and ideology, besides providing information about adverse consequences for mothers and babies for elective cesarean delivery without medical indications, one course of the action for the obstetricians is to simply decline to do cesarean delivery on maternal request due to this reason. However, it must be noted that this may lead to conflict, and/or the mother/family changing their obstetrician.
Our qualitative study contributed to additional data from pregnant Thai women, reflecting the cultural preference of our country, where either cultures or beliefs are different from that of most western populations. It is challengeable for obstetricians to approach, since such ideas and belief systems are difficult to change. Such beliefs might not relate to education level, whereas family backgrounds seem to be more influential.
The strength of this study was that we used two investigators to perform the content analysis independently, and then discussed the results to obtain consensus. This increases the research validity, because there is a risk that different researchers have disparate conclusions from the same data. Another point is that the two investigators are from different careers (obstetrician and nurse), so we were able to approach and discuss the findings from different angles to ensure the consistency in the analysis.
Previous reports have mentioned some reasons which were not found in our study, such as fear of pelvic floor injury and urinary problems [15] or encouragement from health personnel [13]. Since cesarean section on maternal request is not allowed in our institution, some women who preferred cesarean delivery and were aware of our hospital policy, might have gone to the private sector instead. Obstetricians' preference and hospital policies might have more influences on women's decisions. Some doctors prefer cesarean delivery to vaginal birth because it is faster, more convenient, and probably more profitable [8]. The limitation of our study was that it did not represent pregnant women in private sectors where cesarean delivery on demand is permitted.

Conclusion
There were many reasons for cesarean delivery preference emerging from pregnant Thai women. One striking reason was a superstitious belief in auspicious birth dates, which was challengeable for obstetricians to approach. Obstetricians should explore in detail why women request cesarean delivery, and provide effective counseling in order to decrease cesarean delivery on demand. Declarations