Multicentre study on stress coping strategies and vaginal/caesarean birth opinions among medical students

Abstract

Background.

Polish perinatal care is facing a high and increasing caesarean birth (CB) rate, which is at 43%. Stress coping strategies among professionals can be important factors in the decision-making for CB. Study aimed to identify opinions associated with a birth route and stress coping strategies.

Methods.

This cross-sectional, exploratory study included 748 Polish medical students and aimed to identify opinions associated with a birth route and stress coping strategies among medical students. A descriptive questionnaire was distributed online. Group comparisons were performed using Welch’s t-test for continuous data or the χ² test for categorical data. Spearman’s ρ coefficient was used.

Results.

Statistically, first- and second-year students thought that every woman can choose vaginal birth (VB) or CB. Students in their final years of study considered that VB is more beneficial for women at low risk of VB-related complications. The respondents who reported that VB is safer, women recover faster after it, and women should not be able to choose VB/CB on their own exhibited statistically significantly lower helplessness levels and greater use of religion as a stress coping strategy. Those who were more helpless and less religious were also less convinced of the safety of VB, believed in faster recovery after CB and expressed that the woman herself should decide how to give birth.

Conclusion.

Stress coping strategies seem to be related to the understanding of the childbirth process and the set of attitudes connected with it. Helplessness and religiosity turned out to be the most important factors in this area. The connection between helplessness (stress coping strategy) and estimation of greater pain during VB than CB obtained in our research, is a phenomenon that may lead students with these characteristics to prefer and recommend CB in their future practice.

Introduction

Standardised education of medical students in the perinatal care area is both founded on recommendations and shaped by the system that functions in the particular region or country. Polish perinatal care is facing a high and still increasing caesarean birth (CB) rate.[1] Currently, in Poland, the CB rate is 43%,[1] much higher than the European average of 27%.[2, 3] An increase in the number of CB cases represents one of the most frequently discussed topics in perinatal care worldwide, especially as it applies to pregnant women from groups at low risk for vaginal birth (VB)-related complications.[4, 5] Poland is a European Union Member State with a population of nearly 38 million, representing the largest population among Central and Eastern European countries.[6] The gradual increase in preference for CB over VB is particularly worrisome because it does not reflect current recommendations and it ignores retrospective reports that have described the serious consequences of high CB rates for both individuals and populations.[3, 5, 7, 8] The most recent Polish reports have shown that the rate of medical interventions (birth induction, augmentation, episiotomy, amniocentesis, non-spontaneous pushing techniques, overuse of intrapartum cardiotocographic foetal monitoring) is also great.[9, 10]

The conclusion from the above concerns is that the practical education of Polish medical students in the area of perinatal care is based on a medicalised and interventional system. They observe intervention during the birth often then it’s physiological course. What students see and experience during their practical training will shape their future practice, including in pregnancy- and birth-related topics. Moreover, there is a direct connection between the knowledge, experience and attitudes of medical professionals and the perinatal care system.[5, 11, 12, 13] For people working in medical professions, including medical students, coping strategies for stress and other emotions are particularly needed. Crucially, reports have revealed that the attitudes, experiences and skills of clinicians, especially obstetricians, directly contribute to the elevated CB rate.[14, 15] We can also hypothesise that strategies for coping with stress among medical professionals, as a part of their personal characteristics, can be important factors in the decision-making process for CB.

The objective of this study is to identify opinions and attitudes associated with birth routes and stress coping strategies among medical students. In our view, this such attitudes reflect theoretical and practical education on perinatal care and can help identify areas for modification.

Material And Methods

Study design and research group

This exploratory cross-sectional study was conducted within a group of Polish medical students between January and May 2021. All respondents were informed of the study aims and the planned manner of publication for the results; all provided their voluntary consent to participate. A descriptive online questionnaire, which allowed for the collection of quantitative data, was administered. The questionnaire was piloted in a group of 10 students to verify that the questions were easy for the respondents to understand. We decided to distribute the research tool via email sent to the academic email addresses of the medical students. A Google Forms questionnaire, together with a description of the study, was sent to the medical students with their universities’ consent, and students were included on a nationwide scale. We focused on the diversity of the respondents in the field of the study area.

Eligibility screening was an integral part of the questionnaire. The inclusion criteria for the study included current medical student status (the field of study needed to include educational effects based on perinatal care) and completed survey returned from a university email address. To determine the size of the representative group of the finite population of medical students (total number of medical students at the universities in the 2021/22 academic year is 6196) [6], a commonly available sample size calculator was used. With an assumed confidence level (95%) and a maximum error of 5%, the minimum sample size was set at 362 respondents. From 765 attempts to fill out the survey, 17 were excluded, resulting in a total sample size of N = 748.

Research tools

The final version of the survey included 40 questions divided into the following sections:

Section A: Demographic characteristics (age, gender, habitation city/village, field of study, year of education);
Section B: Medical students’ opinions about CB and VB, including knowledge about the Polish VB/CB proportions, the World Health Organization (WHO) recommendations on this topic, views about which method of birth is safer for low-risk pregnant woman, and views on whether every woman should have a right to choose VB versus CB. We also investigated the knowledge about the birth and postpartum period course, for example, factors that can intensify the pain experience (lack of information, temperature in the room, too many people in the room, light intensity).

We elicited medical students’ opinions using the following standardised tools:

A 5-point Likert-type scale was used with the following responses: 1 = ‘Definitely no’, 2 = ‘No’, 3 = ‘I don’t know’, 4 = ‘Yes’ and 5 = ‘Definitely yes’.
To assess the subjectively assessed pain experienced by women during VB and CB, we used the most frequently recommended pain intensity assessment tool, the numerical rating scale (NRS), in which 0 means no pain and 10 means the strongest pain. The NRS was combined with a visual analogue scale (VAS) in the form of a 100 mm segment, with the left end indicating no pain and the right end indicating the strongest pain. The VAS is one of the most frequently used tools in Poland to describe pain subjectively experienced by a patient.[16] Both scales are used in daily practice to assess birth pain.[17]
The Brief COPE (Carver, 1997) is a self-report tool designed for scientific purposes that measures how people respond to stressors and how they cope with situational and dispositional stress. In our study, we decided to use the shortened version of 28 questions that constitute 14 scales. After the Polish adaptation, a different factor structure was obtained, suggesting the use of the seven following subscales in Polish conditions:

- Active coping (planning, positive reframing)

- Helplessness (substance use, behavioural disengagement, self-blame)

- Seeking support (using emotional support, using instrumental support)

- Avoidance behaviours (self-distracting, denial, venting)

- Turning to religion

- Acceptance

- Humour.

The tool is characterised by appropriate reliability and validity.[18, 19]

Statistical analysis of the results was carried out with the IBM SPSS 23 software package using R (R Core Team, 2018). Group comparisons were performed using Welch’s t-test for continuous data or the χ² test for categorical data. We have also used Spearman’s ρ coefficient. The protocol of the study was approved by the Independent Bioethics Committee for Scientific Research at the Medical University of Gdansk.

Results

Demographic characteristics of the medical students

The study group consisted of 748 medical students, aged 18–46 years (mean 22.22), studying in different medical fields. For all of them, the scope of practice will include (on different levels) pregnant women and women of reproductive age. The biggest group of respondents comprised Medicine Faculty students (31.6%). Detailed demographic characteristics are presented in Table 1.

Table 1

Characteristics of the group/General information about the respondents
	N	%
Age; mean ± SD (standard deviation) 22.22 M ± SD 2.61	748
Place of residence
Rural	176	23.5
Urban	572	76.4
Sex
Female	646	86.4
Male	102	13.6
Field of study
Midwifery	131	17.5
Nursing	82	11
Medicine Faculty	236	31.6
Clinical Nutrition	43	5.7
Physiotherapy	61	8.2
Pharmacy	88	1.8
Emergency Medicine	13	1.7
Medical Analytics	46	6.1
Health Psychology	14	1.9
Electroradiology	25	3.3
Public Health	5	0.7
Dentistry	4	0.5
Year of study
I	213	28.5
II	183	24.5
III	141	18.9
IV	78	10.4
V	96	12.8
VI	37	4.9

Overall knowledge about Polish perinatal care practice and opinions about vaginal birth (VB) and caesarean birth (CB) (Table 2)

Table 2

Overall opinions and knowledge concerning vaginal/cesarean birth.
Statements	N	%
Most births in Poland
VB	617	82.5
CB	131	17.5
The current proportion of VB in Poland
0–20%	4	0.5
21–40%	114	15.2
41–60%	414	55.3
More than 60%	216	28.9
The current proportion of CB in Poland
0–20%	62	8.3
21–40%	460	61.5
41–60%	188	25.1
More than 60%	38	5.1
The Polish CB rate follows WHO recommendations
Yes	85	11.4
No	350	46.8
I don’t know	313	41.8
Type of birth recommended for pregnant women from groups at low risk for vaginal birth (VB)-related complications
VB	716	95.7
CB	32	4.3
VB is safer and more beneficial for the mother and baby compared with CB
Yes	515	68.9
No	233	31.1
Every woman should have the right to opt for CB in any situation, independent of existing medical indications
Yes	625	83.6
No	123	16.4
Stress influence the birth pain experience
Definitely yes	519	69.4
Yes	209	27.9
I don’t know	17	2.3
Definitely no	2	0.3
No	1	0.1
Factors that are independent of the childbearing woman but can intensify the birth pain experience (lack of information, temperature in the room, too many people in the room, light intensity)
Definitely yes	332	44.4
Yes	349	46.7
I don’t know	57	7.6
Definitely no	10	1.3
No	0	0

The total group results revealed that Polish medical students have appropriate knowledge about basic Polish perinatal care rates. However, it should be noted that most medical students (61.5%) are not aware that the CB rate already exceeds 40%. In addition, most Polish medical students (62.2%) have the opinion that every woman should have the choice to undergo CB, regardless of medical indications. Students in Health Psychology (92.9%) and Electroradiology (88%) were convinced that every woman should have free choice within the birth route. The χ² tests showed a statistically significant difference between the results of these two groups and the other groups. The group most opposed to women choosing between VB and CB in every situation was that of Midwifery students (68%): In their view, medical indications are crucial in decision making for CB [χ²₍₉₎ = 93.77; p = 0.000]. In addition, I- and II-year students were statistically likely to express that every woman should be able to choose the birth route [χ²₍₅₎ = 24.60; p = 0.000; Fig. 1]. In addition, students living in urban areas were more often supportive of VB/CB choice possibility [χ²₍₅₎ = 8.17; p = 0.043]. We did not find that sex and age were statistically significant in this issue.

Midwifery students (96.2%) definitely thought that VB is safer and more beneficial for the mother (pregnant women from groups at low risk for VB-related complications) and newborns compared with CB [χ²₍₉₎ = 78.89; p = 0.000]. Students from the III, IV, V and VI years of study were statistically significant different then I and II years students in their view that VB is safer and more beneficial, especially for women at low risk for VB-related complications [χ²₍₅₎ = 16.85; p = 0.005].

Medical students were aware that stress level and factors external to the childbearing woman (lack of information, temperature in the room, too many people in the room, light intensity) correlate with birth pain level experience. Respondents stated that the pain level is greater during VB than CB, but 24 hours after the procedure, women experience greater pain after CB (Table 3).

Table 3

Opinions about birth pain level experience (VAS scale)
VAS Score for Birth Pain Intensity	N	Min	Max	M	SD
VAS score for VB pain level	748	4	10	9.03	1.04
VAS score for CS pain level	748	0	10	4.11	2.65
VAS score for pain level 24 h after VB	748	0	10	5.41	2.19
VAS score for pain level 24 h after CS	748	0	10	5.76	2.23

We were also interested in whether there would be any connections between medical students’ stress coping strategies and their general attitudes towards VB and CB. We found differences between the groups giving different answers to the questions about CB and VB, especially in the context of two stress coping strategies—helplessness and turning to religion (Table 4). The respondents who thought that VB is safer, women recover faster after it and women should not be able to choose the mode of delivery independently were statistically significantly lower in their helplessness level and higher in religiosity. Those who were more helpless and less religious were also less convinced of the safety of VB, believed in faster recovery after CB and expressed that the woman herself (not medical factors) should determine how to give birth.

Table 4

Comparison of groups giving different answers to questions about VB and CB in terms of helplessness and turning to religion as stress coping strategies
Stress coping strategy	Statement	Group 1	Group 2	Z	p
Helplessness	VB safer and more beneficial for the woman and newborn^a compared with CB	Yes	No	3.01	0.003
		N 515 M 1.64 SD 0.94	N 233 M 1.90 SD = 1.06	3.01	0.003
	Recovery is faster after VB or CB	VB	CB	2.04	0.041
	Recovery is faster after VB or CB	N 625 M 1.69 SD 0.99	N 123 M 1.87 SD 0.99	2.04	0.041
	Every woman^a should have a right to choose between VB and CB in every situation, independently from existing medical indications	Yes	No	2.48	0.013
		N 465 M 1.80 SD 1.01	N 283 M 1.60 SD 0.94	2.48	0.013
Turn to religion	VB safer and more beneficial for the woman and newborn^a compared with CB	Yes	No	2.22	0.026
		N 515 M 1.73 SD 1.98	N 233 M 1.33 SD 1.70	2.22	0.026
	Recovery is faster after VB or CB	SN	CC	3.17	0.002
	Recovery is faster after VB or CB	N 625 M 1.70 SD 1.95	N 123 M 1.12 SD 1.64	3.17	0.002
	Every woman^a should have a right to choose between VB and CB in every situation, independently from existing medical indications	Yes	No	2.76	0.006
		N 465 M 1.46 SD 1.85	N 283 M 1.85 SD 1.99	2.76	0.006
^a Pregnant women from groups at low risk for VB-related complications

Table 5 lists the Spearman’s ρ correlations between the estimation of the intensity of pain experienced during VB and CB (VAS and NRS scales) and stress coping strategies. A correlation was again found between helplessness and the assessment of the intensity of pain during VB, as well as 24 hours later (the greater the helplessness, the greater the anticipated pain during VB). The turn to religion correlated only with the assessment of pain intensity 24 hours after CB.

Table 5

Spearman’s ρ correlations between stress coping strategies and the assessment of the intensity of pain during VB and CB (VAS and NRS scales)
Assessment of the intensity of pain during VB and CB	Helplessness	Turn to religion
Score for VB pain level	0.11^a	-0.04
Score for CB pain level	0.06	-0.009
Score for pain level 24 hours after VB	0.08^a	-0.03
Score for pain level 24 hours after CB	-0.04	0.1^a
^ap < 0.05

Discussion

Currently, almost half of all children born in Poland are born through CB, although the underlying cause of this unusually high CB rate remains unknown. Reports from other countries indicate several factors that contribute to elevated CB rates, including cultural and social factors, the medicalisation of pregnancy and births, and the attitudes of clinicians (including stress coping strategies).[14, 15, 20] We hypothesise that medical students’ attitudes and knowledge about the VB and CB is the effect of all mentioned factors but mainly of standardised theoretical and practical education as a foundation for their future practice. Therefore, describing factors that can contribute to unusually high CB rates in Poland, we decided to ask medical students for their attitudes about VB and CB and investigate their stress coping strategies. Students entering the practice are confronted with a certain paradox: In the curriculum, they are told that optimising the number of CBs performed among the population of healthy pregnant women is one of the greatest challenges facing modern obstetric practice; however, they then become a part of a highly interventional system where the CB rate remains one of the highest in Europe.[1] Lack of a unified guideline was also identified as a factor contributing to the rise in CB preference among clinicians. This trend is often based on the belief that the controlled and planned course of CB is safer relative to the uncontrollable nature of VB.[21] The recommended rate of CB presented in the resent statement of World Health Organisation (WHO) states: every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate.[22] The approach shows that medical justification should underly decision-making processes surrounding CB, as opposed to population-level recommendations. In Poland, perinatal care has been observed to trend in two conflicting directions: the medicalization of childbirth, often promoted by physicians, and demedicalization, which is often supported by service users and midwives. This tension may contribute to confusing messaging and a lack of a consistency in approaches to childbirth that together may complicate decision making for women about preferred birth route. In addition, epidural availability in Poland is currently insufficient (only 35%-40% of laboring women having access to this procedure). Interestingly, the highest CB rates are reported in the regions of Poland where epidural access is the most limited.[23]

In our study, we were interested in medical students’ opinions, and at the same time, we wondered whether emotions were related to attitudes towards CB and VB. As our study showed, stress coping strategies seem to be related to the understanding of the childbirth process and the set of attitudes connected with it. Helplessness and religiosity turned out to be the most important strategies for coping with stress. Greater helplessness declared as a stress coping strategy was associated with a stronger connection with an opinion about lower safety of VB compared with CB and slower recovery after VB. This was also related to the opinion that it is the woman who should decide about the type of delivery (independently of medical indications). This set of attitudes about childbirth, accompanied with helplessness as a stress coping strategy, can dangerously support so-called CB on demand in both medical students’ private lives and recommendations for future patients.

In the literature, we can find data confirming the link between religiosity and the preference for VB.[24, 25] These results are in line with those obtained in our study. The turn to religion as a stress coping strategy was associated with a conviction that there is greater safety (and faster recovery) in VB compared with CB.

Conclusion

Our research also showed connections between helplessness and a greater intensity of pain estimation, both during VB and the day after. Based on research, fear of pain during VB is linked to asking for a CB.[22, 23] The connection between helplessness (stress coping strategy) and estimation of greater pain during VB than CB obtained in our research, is a phenomenon that may lead students with these characteristics to prefer and recommend CB in their future practice.

One of the promoted strategies to reduce the trend of performing unnecessary CB includes the promotion of VB, preparing women for pregnancy and birth and constant support during the birth.[15] It seems equally important to support students in their personal development, including learning appropriate and effective stress coping strategies. The important factor at the individual clinician level is having leadership and executive support.[27] For medical students, we can interpret this as a support from their trainers and supervisors. A disconnect between theoretical recommendations and practical observation in hospital settings can result in lower confidence, elevated stress levels and decisional conflict among medical students. These factors seem to correspond to elevated CB rates.

Abbreviations

CB: caesarean birth

NRS: numerical rating scale

VAS: visual analogue scale

VB: vaginal birth

WHO: World Health Organization

Declarations

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of Medical University of Gdańsk (protocol code NKBBN/286/2021 and date of approval: 2021/03/24).

Informed consent was obtained from all subjects and/or their legal guardian(s).

Consent for publication

Not applicable as this is a qualitative evidence synthesis.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

All authors declare that they have no competing interests.

Funding

Departmental financial sources

Authors' contributions

AM, AZR, MP Contributions to the conception

AM, AZR, MP design of the work;

AM, AZR, MP the acquisition, analysis,

AM, AZR interpretation of data

AM, AZR, MP, JP have drafted the work and substantively revised it

Acknowledgements

Not applicable

References

Wielgos M, Bomba-Opon D, Breborowicz GH, Czajkowski K, Debski R, Leszczynska-Gorzelak B, et al. Recommendations of the Polish Society of Gynecologists and Obstetricians regarding caesarean sections. Ginekol Pol. 2018;89(11):644–57.
Zeitlin J, Alexander S, Barros H, Blondel B, Delnord M, Durox M, et al. REPORT, EUROPEAN PERINATAL HEALTH 2015, Core indicators of the health and care of pregnant women and babies in Europe.
Macfarlane AJ, Blondel B, Mohangoo AD, Cuttini M, Nijhuis J, Novak Z, et al. Wide differences in mode of delivery within Europe: Risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG An Int J Obstet Gynaecol. 2016;123(4):559–68.
Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341–8.
Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018;392(10155):1358–68.
Demographical Atlas of Poland [Internet]. Warsaw: Central Statistical Office of Poland [Internet]; 2021.
Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, et al. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol. 2015;213(3):384.e1-384.e11.
Magne F, Puchi Silva A, Carvajal B, Gotteland M. The Elevated Rate of Cesarean Section and Its Contribution to Non-Communicable Chronic Diseases in Latin America: The Growing Involvement of the Microbiota. Frontiers in Pediatrics. 2017;(5):192.
Adamska-Sala I., Baranowska B., Doroszewska A., Piekarek M. PJ. Raport z monitoringu oddziałów położniczych. Opieka okołoporodowa w Polsce w świetle doświadczeń kobiet, Fundacja Rodzić po ludzku. 2018.
Kopeć-Godlewska K, Pac A, Różańska A, Wójkowska-Mach J. Is vaginal birth without an episiotomy a rarity in the 21st century? Cross-sectional studies in southern Poland. Int J Environ Res Public Health. 2018;15(11):1–11.
Coates D, Thirukumar P, Henry A. Women’s experiences and satisfaction with having a cesarean birth: An integrative review. Birth. 2020;47(2):169–82.
Dominiek C, Natasha D, Foureur M, Spear V, Amanda H. Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section. Women and Birth. 2021;34(4):352–61.
Dweik D, Girasek E, Töreki A, Mészáros G, Pál A. Women’s antenatal preferences for delivery route in a setting with high cesarean section rates and a medically dominated maternity system. Acta Obstet Gynecol Scand. 2014;93(4):408–15.
Potter JE, Hopkins K, Faúndes A, Perpétuo I. Women’s autonomy and scheduled cesarean sections in Brazil: A cautionary tale. Birth. 2008;35(1):33–40.
Panda S, Begley C, Daly D. Clinicians’ views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. Boatin A, editor. PLoS One. 2018;13(7):e0200941.
Leppert W.; Majkowicz M. Ból przewlekły. Ujęcie kliniczne i psychologiczne. [Chronic pain. Clinical and psychological approach]. Warszawa (Warsaw): PZWL; 2018.
Jones LE, Whitburn LY, Davey MA, Small R. Assessment of pain associated with childbirth: Women׳s perspectives, preferences and solutions. Midwifery. 2015 Jul 1;31(7):708–12.
Carver CS. You Want to Measure Coping But Your Protocol’s Too Long: Consider the Brief COPE. Vol. 4, INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE. Lawrence Erlbaum Assoeiate.~, Inc; 1997.
Juczyński, Z., Ogińska-Bulik N. Narzędzia pomiaru stresu i radzenia sobie ze stresem. Pracownia Testów Psychologicznych Polskiego Towarzystw Psychologicznego. 2012.
Mulchandani R, Power HS, Cavallaro FL. The influence of individual provider characteristics and attitudes on caesarean section decision-making: a global review. Journal of Obstetrics and Gynaecology. 2020;(40):1–9.
Litorp H, Mgaya A, Kidanto HL, Johnsdotter S, Essén B. ‘What about the mother?’ Women׳s and caregivers׳ perspectives on caesarean birth in a low-resource setting with rising caesarean section rates. Midwifery. 2015 Jul 1;31(7):713–20.
Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM. WHO statement on caesarean section rates. BJOG: An International Journal of Obstetrics and Gynaecology. 2016:(123):667–70.
Michalik A, Wojcicka L, Czerwińska-Osipiak A, Zdun-Ryżewska A, Jakitowicz K, Olszewska J, et al. Preferences of women with low obstetric risk for cesarean or vaginal birth in Poland: Areas for intervention. Birth. 2021;48(2):265–73.
Ryding EL, Lukasse M, Parys AS Van, Wangel AM, Karro H, Kristjansdottir H, et al. Fear of childbirth and risk of cesarean delivery: A cohort study in six European countries. Birth. 2015;42(1):48–55.
Pomeranz M, Arbib N, Haddif L, Reissner H, Romem Y, Biron T. “In God we trust” and other factors influencing trial of labor versus Repeat cesarean section. J Matern Neonatal Med. 2018;31(13):1777–81.
Jenabi E, Khazaei S, Bashirian S, Aghababaei S, Matinnia N. Reasons for elective cesarean section on maternal request: a systematic review. Journal of Maternal-Fetal and Neonatal Medicine. 2020;(30):3867–72.
Marshall JL, Spiby H, McCormick F. Evaluating the ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’: A mixed method study in England. Midwifery. 2015 Feb 1;31(2):332–40.