A total of 27 pregnant women underwent an in-depth interview. Age ranged from 24 to 45 years (median 34), with 14 women being nulliparous. There were six 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.
Table 1 Main categories and themes of maternal reasons for cesarean 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, and HIV infection)
- 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
Category 1: Fear of childbirth
Most women expressed that fear of childbirth was the main concern, even though seven of them had never had experienced childbirth before. They had a fear of labor pain, a fear of facing two painful events: 1. failure vaginal birth and then; 2. having to undergo emergency cesarean section as well as 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.”
Category II: Safety concern related to health risk perception
Seven women perceived that they had significant risk factors potentially leading to unsafe vaginal birth as well as fetal jeopardy. These included underlying medical diseases (such as heart disease, diabetes mellitus and HIV), biological risks (advanced age and 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.”
Two women had multiple risk factors: medical diseases, advanced age, infertility and maternal perception of a big baby, leading to the preference of cesarean birth.
“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 pregnant women. Traumatic birth leads to fear of giving birth in later pregnancies, as they perceived that childbirth 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 birth
Many women had a positive attitude toward cesarean birth, stating that they appreciated the advantages over vaginal birth in terms of its convenience, a short delivery time without labor pain, and so forth. Four women thought that cesarean section was a safe procedure, without terrible pain as compared to vaginal birth as well as less blood loss. As tubal ligation can be conducted at the time of cesarean section, four women thought that it was worth to choose cesarean birth for that reason. Women being concerned with their fibroids, wished to also have these removed during cesarean section.
“I feel that cesarean birth is safe for both mother and baby. Blood loss is less than vaginal birth.”
“Cesarean birth is faster than vaginal birth.”
“Planned cesarean sections are convenient, 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 birth because I want to have tubal ligation at the same time. I do not want to have pain twice from two procedures; vaginal birth and postpartum tubal ligation.”
Category V: Access to biased information
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 birth experiences, 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 cesarean birth.”
“My friend told me that she had 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 experiences, ideas or comments, and this may have an influence on the women’s decision. Information from television, newspapers or movies may also present some information leading to misunderstanding about the real concepts and factors in regards to mode of birth.
“I have read comments shared on Facebook and the internet, saying that vaginal birth is very painful.”
“I have searched for information about cesarean section, it is an alternative route of delivery with a short, painful period.”
Category VI: Superstitious belief in auspicious birth dates
Three women believe in destiny. 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 and cesarean birth has an advantage due to this issue.
“I prefer cesarean birth because I can set an auspicious time for my baby.”