A total of 27 pregnant women underwent in-depth interviews. Age ranged from 24 to 45 years (median 34), with 14 women being nulliparous. Six categories and 14 themes emerged from the analysis (Table 1). From the in-depth interviews, most women had more than one reason that convinced them of their decision.
Category 1: Fear of childbirth
Fear of childbirth was the main concern, even though seven women never had experienced childbirth before. They had fears for labor pain and facing two painful events: 1. failing 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.”
Category II: Safety concerns related to health risk perceptions
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)
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 vaginal delivery.”
Category III: Previous negative birth experiences
Previous negative birth experiences also had a strong impact on pregnant women. Traumatic birth leads to fear of giving birth in subsequent pregnancies, as they perceived childbirth harmful for themselves and their babies. Inadequate analgesia during labor is also a problem, resulting in fear of pain during birth.
“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 drugs to enhance uterine contractions for such a long period with terrible pain, though ended up with successful vaginal delivery.”
Category IV: Positive attitudes toward cesarean birth
Many women had positive attitudes toward cesarean birth, appreciating advantages over vaginal birth in terms of convenience, 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 with less blood loss. Four women thought that it was worth to choose cesarean birth for tubal ligation. Women with fibroids, sometimes also wished to 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.”
Category V: Access to biased information
Women have obtained information from either personal advice or mass media. Personal resources including words, experiences or advice from people, such as friends or relatives about their negative or positive birth experiences, may have had an influence on their decisions.
“My relative struggled 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 women’s decisions. Information from television, newspapers or movies may also present some information leading to misunderstanding about the real concepts and factors with regard 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 believed in destiny. If their babies could be 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.”