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 them of their decision.
Main categories and themes of maternal reasons for cesarean section
I. Fear of birth
- Fear of labor pain
- Fear of facing two painful events (failure of vaginal delivery and cesarean section)
- Fear of harming the baby
II. Safety concern related to health risk perception
- Underlying medical diseases (diabetes mellitus, heart diseases, HIV infection, etc.)
- Biological risks (advanced maternal age and obesity)
- Reproductive health problem (infertility)
III. Negative birth experiences
- Inadequate pain control
- Baby injury
IV. Positive attitude toward cesarean delivery
- Advantages of cesarean delivery
- Disadvantages of vaginal delivery
V. Access to biased information resources
- Personal advice
- Mass media
VI. Superstitious belief in auspicious birth dates
- Good fortune
Category 1: Fear of childbirth
Most women expressed that fear of childbirth was their main concern, even though some of them had never had the experience of childbirth before. They had a fear of labor pain, a fear of facing two painful events; firstly from failure vaginal delivery and then having to undergo a cesarean section as well as a fear of harming the baby.
“I have a fear of pain during labor and delivery. I have heard that it is the most severe pain in one’s life.”
“I have a fear of labor pain, even though I had two spontaneous vaginal deliveries, and this was my third time.”
“If I try vaginal delivery, but fail, I have to undergo an emergency cesarean section, so I have to face two painful events. If I choose cesarean delivery, I will have pain from only one procedure.”
“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 cannot push the baby, or may have worsening dyspnea during pushing, and my baby will be obstructed for a long period and be unsafe.”
I am getting older, and have diabetes mellitus with a history of preeclampsia from a previous pregnancy. I am afraid that I have not enough power to push.”
“I have an HIV infection. I am afraid that my baby might have contact with blood or mucous in my vagina during delivery. I prefer cesarean delivery because I have heard that it reduces the risk of infection to my baby.” (She had received standard antiretroviral drugs.)
“I am obese and getting older, I fear that I could not push effectively, and will have difficulty in delivery, so my baby will be in danger.”
“I got married 9 years ago and just got pregnant by GIFT. I have paid a lot. I don’t want to have any problem. I believe that cesarean delivery is safe for my baby.”
Some women had multiple risk factors: medical diseases, advanced age, infertility, maternal perception of a big baby, and infertility, leading to the preference of a cesarean delivery.
“I have been married for 6 years, and never got pregnant. Now, I am having my first pregnancy by IVF, after 3 attempts. I am now 45 years old, and also have diabetes mellitus arising during pregnancy, furthermore I am on diet control as well as insulin injections to control blood sugar. I fear that my baby is big at the time of delivery, so I am afraid that my baby will not be safe during a vaginal delivery.”
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.
“My first baby was delivered by vacuum extraction with much difficulty. His head was swelling, though it recovered a few days later. I don’t want to have this problem again.”
“I have had a bad experience of my previous pregnancy. I delivered with much difficulty, having labor pain for 2 days and was referred to the provincial hospital for cesarean section. However, cesarean section was not performed as expected. I was given drug to enhance uterine contraction for such a long period with terrible pain, though ended up with successful vaginal delivery.”
“I had severe labor pain in my first pregnancy for more than 10 hours. I requested for an analgesic drug, but the doctor did not give it to me.”
Category IV: Positive attitude toward cesarean delivery
Many women had a positive attitude toward cesarean delivery, stating that they appreciated the advantages of cesarean delivery over vaginal delivery in terms of its convenience, a short delivery time without labor pain, and so forth. Some women thought that a cesarean section was a safe procedure, without terrible pain as compared to vaginal delivery as well as less blood loss. As tubal resection can be conducted at the time of cesarean section, some women thought that it was worth to choose a cesarean delivery. Women being concerned with their fibroids, wished to also have these removed during cesarean section. On the contrary, they held the belief that vaginal delivery was an unpredictable process.
“I feel that cesarean delivery is safe for both mother and baby. Blood loss is less than vaginal delivery.”
“Cesarean delivery is faster than vaginal delivery.”
“Planned cesarean sections are convenient, the date and time can be selected, and there is no need to wait for spontaneous labor.
“I have a tumor in the womb, and I would like to have it removed at the time of cesarean section.”
“I prefer cesarean delivery because I want to have tubal resection at the same time. I do not want to have pain twice from two procedures; vaginal delivery and postpartum tubal resection.”
Category V: Access to biased information resources
Women have obtained information from either personal advice or mass media resources. Personal resources including; words, experience or advice of people, such as friends or relatives about their negative or positive experiences of delivery, may have had an influence on their decisions.
“My relative struggles with shoulder dystocia. I am afraid that I may have the same problem, so I would like to have a cesarean delivery.”
“My friend told me that she had a cesarean section with a spinal block, and it was not painful.”
Currently, people can access various sources of information very easily, including social media, such as Facebook, wherein anybody can share their experiences, ideas, or comments, and this may have an influence on the mothers’ decision. Information from television, newspapers or movies may also present some information leading to misunderstanding about the real concepts and factors in regards to route of delivery.
“I have read comments shared on Facebook and the internet, saying that vaginal delivery is very painful.”
“I have searched for information about cesarean sections, it is an alternative route of delivery with a short, painful period.”
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.
“I prefer cesarean delivery because I can set an auspicious time for my baby.”