Preferences of pregnant women regarding mode of delivery: a questionnaire based study

INTRODUCTION

The childbirth experience has always represented as a very important event in women’s lives, a unique and special moment, marked by the transformation of the woman in her new role, that of being a mother.¹ In developed countries, women often opt for caesarean delivery because of their improved understanding of its role and safety and increasing importance given to the right to self-decision making, regarding mode of delivery.² However in developing countries like India, women are reluctant to accept caesarean delivery because of their traditional beliefs and socio-cultural norms, hence they even try to avoid hospital delivery and engage in the services of untrained and unskilled care providers. These women usually report to hospital with life threatening complications and in such situations most of the caesareans are performed as an emergency procedure under suboptimal circumstances.² Main reason of choosing caesarean section by pregnant women is the fear and lack of sufficient knowledge about normal vaginal delivery. Although in specific situations caesarean section can prevent serious morbidity and mortality of the fetus and mother, but data indicates that in many cases the procedure is not indicated and vaginal delivery could have been achieved safely.³ An increasing rate of births by caesarean section is an issue of concern in many countries. Despite the recommendations by WHO that no region in the world is justified to have a caesarean section rate greater than 10-15%, it is the most common obstetrical operation worldwide.^4,5 A rising trend of caesarean sections has been noted with the advent of electronic fetal monitoring, better operative techniques and availability of tertiary care neonatal facilities. When medically justified, a caesarean section (CS) can effectively prevent maternal and perinatal mortality and morbidity.⁶ A cohort study showed that women are increasingly inclined to opt for delivery by caesarean for non-medical reasons such as fear of labour pain, concerns about date or time of birth that are traditionally believed to be auspicious and the belief that delivery by caesarean ensures protection of the baby’s brain.⁷

Aims and objectives

This survey on knowledge, attitude and preferences of women about vaginal versus cesarean delivery may help to define strategies for reducing cesarean birth rates. This survey will also tell us about the preferences of women about mode of delivery and co-relating this with rising trend of caesarean section.

METHODS

This was a questionnaire based; prospective study conducted on 100 antenatal women in third trimester who attended the antenatal clinic in SLBSGMC, Mandi at Nerchowk, Himachal Pradesh from 1 June, 2017 to 1^st September, 2017. The information regarding socio-demographics, age, educational status, occupation, obstetric history, previous mode of delivery, knowledge, attitude and preferences towards vaginal versus caesarean delivery has been collected.

A questionnaire was designed for this study contained the information of demographic data and questions for evaluating knowledge, attitude and preferences of women about vaginal versus caesarean delivery. We approached the 100 pregnant women among those who attended the antenatal clinic in Dept. of Obstetrics & Gynaecology at SLBSGMC, Mandi at Nerchowk from 1^st June to 1^st September, 2017.

The questionnaires filled by the pregnant women at the antenatal clinic. For illiterate women the researcher read the questions to the patients and selected the answers based on their opinion.

Inclusion criteria

All pregnant women in third trimester attending the antenatal clinic of our institute.

Exclusion criteria

Not fulfilling the inclusion criteria and not willing to participate in our study.

Data of various demographic parameters and questionnaire data based on knowledge, attitude and preferences towards mode of delivery was collected, master chart was framed and statistical analysis by descriptive statistics was done.

RESULTS

Majority of women in the present study were in the age group of 26-35 years (51%). 91% were house wives. 85% had received education up to High school and above. Relatives and friends were the main sources of information regarding mode of delivery (98%). Majority of them (62%) were multigravidas (Table 1).

Majority of women (90%) in our study believed that the vaginal delivery is natural and acceptable mode of delivery only 7% of the women have biased for caesarean delivery.85% believed that vaginal delivery is less costly and 93% of women considered vaginal delivery better in long term outcome. Vaginal delivery favoured by 80% of women due to fear of operation and by 68% of women due to fear of anaesthesia. 88% of women considered it pleasure for mother to see the baby immediately after vaginal delivery, according to 74% women vaginal delivery culminates in affectionate relationship with baby and 87% of women believed that in term of outcome vaginal delivery is more pleasant. 53% women did not agree that the infants born by caesarean section are healthier than those born by vaginal delivery. 50% women did not consider that vaginal delivery leads to sexual dysfunction. Attitude of majority of women showed that vaginal delivery is the natural mode of birth (90%), health recovery is fast (93%) and involves less risk (90%). The attitude towards caesarean section shows that this mode of delivery is associated with more complications (89%), 87% believed that prolonged bed rest is required after caesarean section, 89% believed that caesarean section is associated with more infection rate. Almost half of women disagreed with the opinion that caesarean section is preferred due to unpleasant pain of vaginal delivery (47%) or economic problems (54%). Higher percentage of women (43%) did not consider that caesarean section is option of high class society (Table 2).

DISCUSSION

The present study showed that the majority of the women visiting our hospital were undergraduate and gained knowledge about mode of delivery from their relatives and friends. According to the traditional view of our society they consider vaginal delivery as a natural method of childbirth and caesarean section is considered as a deviation from normal way of giving birth because it is associated with higher rate of complications, prolonged bed rest, bleeding risks and costly as well. Similar results were seen by Aali et al.⁸

Women who preferred vaginal delivery generally felt that caesarean sections were associated with more complications and were more costly while the women who preferred caesarean delivery felt that caesarean section was safe, comfortable and less painful. Similar findings were reported in a study by Adageba et al.⁹

In developing nations the lower education level is responsible for poorer knowledge of human reproduction than women in developed countries.¹⁰ These findings suggest that the missing link is counselling and informed discussions with the pregnant women and their partners by health professionals about the need and true picture of risks and benefits that are associated with either mode of delivery. Though majority of patients considered this fact, that if caesarean section is necessary for betterment of fetus and mother then this mode of delivery is justified and acceptable beside their preferences. The majority of women also responded that there is no correlation between the financial status and caesarean delivery if they are justified. In our set up, with increasing use of medical technologies during childbirth and increasing numbers of institutional births, the trend of CS delivery is also sharply rising, especially in private sector where the cost for caesarean delivery is much more compared with normal delivery.¹¹

In our study majority (90%) of the women preferred vaginal delivery as natural and acceptable mode of delivery. Our results are comparable with study done by Ajeet et al.¹² This also concludes that in our setup patient’s preference is not a contributing factor for the increasing trend of caesarean section.

CONCLUSION

Majority of pregnant women interviewed in our institution believed that the vaginal delivery is the natural and acceptable mode of delivery, while many were indecisive due to lack of accurate knowledge and phobia of labor pains during vaginal delivery. The rising caesarean birth rate in developing countries is an important issue; to decline this trend health professional should provide the true information to the pregnant women and their partners about the modes of delivery, their indications, advantages and adverse consequences during antenatal period. This knowledge will change their outlook and make them a better judge while choosing their preferences.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Tedesco RP, Maia NL Filho, Mathias L, Benez AL, Castro VCL, Bourroul GM, et al. Fatores determinantes para as expectativas de primigestas acerca da via de parto. Rev Bras Ginecol Obstet. 2004;26(10):791-8.
2. 2. Najmi RS. An audit of caesarean section carried out in tertiary care maternity unit. J Coll Physicians Surg Pak. 1999;9:20-3.
3. 3. Alimohamadian M. The effect of pregnant women’s request on elective cesarean section rate. Payesh. 2003;2(2):133-9.
4. 4. World Health Organisation. Appropriate technology for birth. Lancet. 1985;2(8452):436-7.
5. 5. Cunningham FG, MacDonald PG, Gant NF, Leveno KJ, Gilstrap LC, Hankins GDV, et al. Caesarean delivery and caesarean hysterectomy. In: Cunningham et al editors. Williams Obstetrics. 20th ed. Stamford, CT: Appleton & Lange; 1997: 509-531.
6. 6. WHO Statement on caesarean section rates; 2015, WHO reference number: WHO/RHR/15.02. Available at http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/. Accessed on 15 July 2016.
7. 7. Lei H, Wen SW, Walker M. Determinants of caesarean delivery among women hospitalized for childbirth in a remote population in China. J Obstet Gynaecol Can. 2003;25:937-43.
8. 8. Aali BS, Motamedi B. Women’s knowledge and attitude towards modes of delivery in Kerman, Islamic Republic of Iran. Eastern Mediterran Health J. 2005;11(4):663-72.
9. 9. Adageba RK, Danso KA, Adusu A, Ankobea F. Awareness and Perceptions of and Attitudes towards Caesarean Delivery among Antenatal. Ghana Med J. 2008;42(4):137–40.
10. 10. Naithani U, Prerna B, Chauhan SS, Kumar D, Gupta S, Kirti. Knowledge, attitude and acceptance of antenatal women towards labor analgesia and cesarean section in a medical college hospital in India. J Obstet Anaesthesia Critical Care. 2011;1(1):13-20.
11. 11. International Institute for Population Sciences and ORC Macro, Report of the National Family Health Survey (NFHS-III).2006; Mumbai: IIPS.
12. 12. Ajeet S, Jaydeep N, Nandkishore K, Nisha R. Women’s knowledge, perceptions, and potential demand towards caesarean section. National J Community Med. 2011;2(2):244-8.