Abstract

Background: Caesarean section has become an emerging issue and catching attention worldwide. Shared decision-making among families and individuals has become a fashion and the main reason for women's preference for caesarean section. There are many societal factors that play an important role in unnecessary caesarean sections. Objective: To evaluate the driving factors influencing the women's preference and decision-making for caesarean section at the mother's request. Material and method: Qualitative research design used in this study via face-to-face in-depth interviews in a public-sector Faisalabad. IDI was conducted at the convenient time of the participant at the time of their antenatal visits. The interview's time was 30 to 40 minutes. The study's participants were pregnant women. A purposive sampling method was used. Data analysis was done on Nviovo software. Results: After transcribing the data, codes were made which leads to the basic themes with their sub-themes. The themes which were the influencing factors in women's preference and shared decision-making towards caesarean section were: child and maternal health, peer pressure (husband/mother-in-law/society influence), financial influence and hospital management (shortage of staff). Conclusion: The percentage of non-indicated caesarean sections has drastically increased day by day in the last ten years. There should be introduced some strategies for the education of women about pro cons and indications or non-indication for caesarean section. Patients' and peer preferences should be deliberated with healthcare practitioners. Healthcare staff should explain the indications of caesarean section at the time of antenatal.

Key Words

Caesarean Section, Shared Decision-making, Maternal Preference, Non-medical Indication

Introduction

The decision to choose the optimal way of birth is very important and in some situations, it becomes very challenging. There is a hard-wearing trend in our society which increase peer and societal involvement in taking a decision which allows the patients to take a part in this decision-making process (Kalish et al., 2022). Though mother's preference is not always an ideal choice for the child's health as well mother's health. An incongruity to adopting a caesarean section of vaginal delivery leads to postpartum depression which leads to PTSD (post-traumatic stress disorder) manifestations (Garthus-Niegel et al., 2019). Therefore, mother preference is very necessary to involve in the decision-making process to choose their mode of birth. Even practitioners also play an important role to take the patients' decisions in the right direction. Caesarean section is a surgical procedure with negative consequences for both mother and child (Loke et al., 2019).

Like other surgeries, Caesarean Section induces the complications like a wound and pelvic infection, respiratory problems, urinary infection, blood transfuse infection, lung emboli, thrombosis and many other complications of anaesthesia. Caesarean Section only should be conducted when there is a danger to the mother or infant's health and there is no chance of normal birth (Guo et al., 2021).

There are many factors which are influencing the mother's preference to choose the caesarean section unnecessarily. These factors are age, educational factors, relative and friend's suggestions, financial strong background, cultural factors, religion and nationality (Hatamleh et al., 2019). Nevertheless, frequently occurring reasons for the preference for caesarean section are fear of prolonged labour pain, concern about child health, fear of pelvic floor damage and future sex life complications(O'Donovan & O'Donovan, 2019).

Many other factors like late approach in the provision of health care facilities, unavailability of the emergency operation room, prolonged labour pain, illiteracy rate, multi number of cases with vaginal and uterine scars and tears, bad management of keeping the record about previous caesarean section has been comprising in low-income countries (Thapsamuthdechakorn et al., 2019).

It is the utmost need of the time that trustworthy knowledge about the advantages and disadvantages of a different mode of birth and probabilities of pharmacological and non-pharmacological methods used to relieve the pains during labour pain, is provided by the health care providers during antenatal visits. 

Decision?making is an intellectual procedure through which all individuals go through in their lives. Moreover, efficient decision?making required a huge bundle of knowledge, actually, knowledge is considered a mean and strategic tool for decision?making. Indeed, decisions made by quaky must be contingent on the truthfulness of knowledge and information at the time of decision-making. During the process of decision-making, the attitude of the decision-maker plays a significant role in the assessment and evaluation of knowledge (Panda et al., 2020).

There are different people who have different opinions nationwide about caesarean sections on mother preference. Some practitioner accepts the cesarean delivery on the mother's request (CDMR) final decision. The level of acknowledgement of CDMR between healthcare providers is different in different countries. American College of Obstetrician and Gynaecologists' acceptance range of CDMR is 84.5%, Australia's Obstetrician acceptance range of CDMR is 77.3%, 10% in Canada, 15% in Spain and 14.3% acceptance range of CDMR in China (Sun et al., 2020). Preference for the mode of birth among women is also different in different countries that give preference for Caesarean section, 3.1% in the US and 34.1% in Iran (Kjerulff et al., 2019).

Today, the caesarean section on mother preference without medical indication has not only become a social problem but has emerged as one of the biggest organizational challenges to deal with it. Hence, the principal objective of this study was to evaluate the driving factors influencing women's preference for the caesarean section at the mother's request. 

Methodology

The qualitative exploratory research design was used to evaluate the driving factors influencing the women’s preference and decision-making for non-medically indicated caesarean section at the mother's request.




Data Collection Procedure

Actual data collection procedure was started after getting permission from the Research Ethical Committee at the University of Lahore. To evaluate the driving factors influencing the women's preference and decision-making for caesarean section at the mother's request, IDI (in depth-interview) technique was used. The study participant was a pregnant woman in their third trimester visiting the study setting, a public sector of Faisalabad, Punjab. An open-ended semi-structured interview instrument was used to collect the data. There were two main questions which supported the study questions. The interview session was 30 to 40 minutes. Data was collected at the time of saturation started. A diary, pencil and recorder was the instrument of data collection.







Data Analysis Process

Interview recorded data was transcribed into the English language. The textual format was made after the transcription of data. Codes were made from the transcribed data after content analysis. Coding was done after reading the content lines several times. Themes were generated after the codes and word tree was made to see the relationship between the thematic text. Data analysis was done on Nivio-20 software.

Data trustworthiness was checked by creditability, transferability, confirmability and dependability. 




Ethical Consideration

This study was conducted according to the standard of the Declaration of Helsinki in 1964. It remained anonymous. Rules and regulations followed by the ethical committee of the University of Lahore. Participant rights were being respected. The consent form was used to take permission. They assured that their identity and name were kept confidential. Confidentiality and anonymity were retained. They also had the choice that they were free to withdraw or quit the study whenever they wanted.

Results

A relevant portion of the interview was used for the

 coding, which was related to the research objectives at the time of data analysis. 

Table 1

Themes Compared with References.

Name	Description	Files	References
Child and maternal health		6	9
Financial influence		2	2
Hospital management		0	0
shortage of staff		2	2
Peer pressure		2	3
husband's and mother-in-law's pressure		4	5
society influence		2	2

Child and Maternal Health

When talking to the participants during the interview, many misconceptions come across. Mother considered caesarean section safe for mother and baby. They find it safe as there did not remain any dysfunction regarding sexual life. They thought their baby was not stuck in the birth canal like vaginal delivery and got no injury or harm in caesarean section. This theme coverage was 16.03% in all data analysis processes. Participant no 1 stated that

“Advantage of caesarean section is that as the baby gets stuck in the normal delivery and becomes serious but in caesarean section, the baby has been delivered by making a cut on the abdomen. It is heard that if you take a decision timely, then it has no harm. Don't keep thinking that you are going to get normal delivery. Therefore, the caesarean section should be done on time". Reference 1 - 11.64% Coverage

Participants thought that the baby will be healthier and safe during a caesarean section. There was no harm to the baby and its brain during a prolonged labour trial.

A participant stated that:

"Baby is at low risk is the advantage of caesarean section. Children often did not survive in normal delivery. I thought you get a safe and healthy child. Secondly, it is the easiest way to give birth to a child. I did not see any type of harm in caesarean section till this time." Reference 1 - 7.36% Coverage

The second participant's perception was:

"My cousin had a normal delivery. Everyone was curious about her. Actually, she had a very bad experience with normal delivery and I saw her. Her baby did not survive. She said perhaps her baby head was stuck and inhaled the meconium in your terminology. In short, her baby did not survive. My three sisters and one sister-in-law experienced a caesarean section. They all go good and all the kids are healthy and alive". Reference 2 - 11.34% Coverage

Peer Pressure (Husband/Mother-In-Law, Society, Cultural)

Women are not fully autonomous in taking a decision regarding their mode of birth. They have to choose the delivery mode according to their family decisions. The decision-making process is one of the most complex mechanisms of human thought and is influenced by several factors like husband/mother-in-law pressure, societal influence, and cultural influence.

"Frankly speaking my mother-in-law and mother wanted that I will be a normal delivery but my husband forced me that it should be a caesarean section. That's why I decided on the caesarean section. Older mothers whom we said them senior citizens like our grandmothers, mothers-in-law and mothers forced the normal delivery till the end. But I think we people are in such a competition, every guy does a job nowadays, so caesarean section is much suitable itself" Reference 2 - 12.56% Coverage

"My husband also asked me for the caesarean section. Firstly, he asked what the doctor said as we are common people and fully depended on the doctor now it is the doctor's duty how sincere he is with us and his profession and how well he guides us. After consultation with one doctor then another and a third doctor, we think about the caesarean section because if I was going through the pain, he was also going through the same standing outside. He also told the doctor that we should not take any risk and let it be done" Reference 1 - 7.66% Coverage

"I guess out of 100, only 10 lucky women could deliver normally. I wanted to deliver normally this time after having one 'big operation' (caesarean section) five years back, but none of my family members were willing to take the risk. My husband and mother-in-law asked me to conduct a cesarean section on their suitable days meaning weekends. Since there was no option other than caesarean, I came to this hospital 15 days prior to my given date of delivery and being delivered through C-section." Reference 1 - 70.57% Coverage




Society Influence

Society plays an important role in our lives in taking decisions. People even think according to the trends of the society where they lived. As one of my participants verbalized:

“In a normal delivery, a woman gives birth in a normal way. I thought it happened in the old times. I see, nowadays everyone has gone through a caesarean section. My all family members had a history of caesarean section that's why I have no knowledge about normal delivery" Reference 1 - 7.36% Coverage




Cultural Influence

Culture has a meaningful impact on people's opinions and attitudes towards caesarean section and associated behaviours. The attitude towards caesarean section can be an element or factor in women's decisions about the mode of delivery.

One participant choose caesarean section as there was a cultural trend to deliver by traditional birth attendants. After the complication by the birth attendant, they were referred to the hospital. Then they have no choice except caesarean section.

"You have educated yourself and you know that caesarean sections are taking place everywhere and a normal delivery is rare. Madam first reason is that you can give birth to only two or three children and secondly, it's become a trend"  Reference 1 - 7.42% Coverage 

Hospital Management (Shortage of Staff)

Non-supportive behaviours of healthcare staff have negative impacts on organisational outcomes, patient safety and staff well-being. Patients during their antenatal time perceived staff behaviour as very rude and insulting in the labour room. Fear of this behaviour changes their thoughts from normal delivery to caesarean section. One of my participants verbalized that:

 “I am a staff nurse and performed my duties in this hospital as a charge nurse in my last pregnancy. It was the first week of my eight-month pregnancy. Suddenly there was lower abdomen pain when I was on my duty. The pain intensity was so high that I could not bear it. But my seniors thought that I was functional and acting to gain the benefit from the job. After two hours in this hustle and bustle, bleeding started. I went into the labour room where my vaginal examination was done. It was 7.30 pm in the evening. Everyone come and did a vaginal examination which was very painful. The doctor said that there was a need to expel my child as he was no more. No one was available for CTG there as the shifting time going to be changed. No one was bothered even though I am the staff of this hospital. There was a lot of pain that I could not bear. At least I could call an anaesthesia doctor and request for caesarean section. Finally, my caesarean section was done at 10 pm but my baby did not survive" – Reference 1 - 64.33% Coverage




Shortage of Staff

Up to 22 per cent of hospitals nationwide continued to suffer staffing shortages. Staffing shortages have led to challenges around the ability of staff to respond to incidents, and to untrained staff being asked to take on responsibilities they may not be able to carry out safely. These factors can increase the trend to move into a private set-up. There is a shortage of health facilities in the labour room and bed availability as well. These are the main reasons for the increasing trend of caesarean sections.

"During the hospital stay, they checked the child's heartbeat repeatedly. Doctors only prescribed but when you go ahead, there is only one machine and ten patients are sitting there. Written to check the heartbeat in my nine months of pregnancy. After two hours, it was my turn to go and they said that your child's heartbeat is not stable, come back after drinking the juice. After the juice, wait in line for two hours again. That time I had no pain, I was brave enough to stand there and wait for my turn. Trust me there was only one staff and a lot of patients. That is the reason for the problem there. There were so many women around but they had no bed. Eight to ten women were sitting only on one bed. Three to four women sitting on one bed and were in so much pain. If someone asked the staff to check their patient, she would rebuke them. Seeing these all things, I was so afraid. That's why I planned for the caesarean section" Reference 1 - 13.64% Coverage

Discussion

The purpose of this study was to explore the factors influencing maternal choice for caesarean section without medical indication. This study was conducted in the public health sector, in Faisalabad. Child and maternal health, peer pressure (husband/ mother-in-law/society/culture), fear of prolonged labour pain, hospital management (non-supportive behaviour of staff/ shortage of staff) and financial influence were the factors explored in the current study. 

In the current study, fear of prolonged labour pain was one factor which provoke the women to make the decision for a caesarean section. Interviewed women had witnessed the bad experience of vaginal birth in their family or their community. Fear about normal vaginal delivery was self-generated which made them think about NVD is a very painful and difficult procedure with an unpleasant procedure. This perception and fear of labour pain led them to prefer a caesarean section. 

This finding is supported by the study conducted by Wigert et al. (2020). Fear of labour pain was the major factor for the participants who choose the caesarean section. This shows a link between the lack of open discussion with the doctors during the time of antenatal care. There is a need for time to courage better communication among doctors, midwives and pregnant women to improve their emotional condition and helps to reduce the fear of labour pain (Wigert et al., 2020).

Responses of the pregnant women in the current study show that there is no medical information about the benefits of vaginal birth. Mostly, they perceived NVD as the way child and maternal complications. Therefore, caesarean section is the most easier and safe for the child and maternal health. This finding is supported by the study conducted by Mulchandani et al. (2020). The main theme of this study was that child and maternal injuries during NVD led women to think about caesarean section. Participants thought that caesarean section is a more controlled and secure birth option than normal vaginal delivery (Mulchandani et al., 2020). This specifies that healthcare providers should give evidence base information to the women to make them fully understand the advantages and disadvantages of the mode of delivery. It will help them to take the best decision to choose the mode of birth which is best for the mother and babies. 

Non-supportive behaviour of staff verbalized by some participants was the main reason to make a decision for a caesarean section. A participant expressed that scolds, bad words and humiliations from the hospital staff provoked them to think about the caesarean section. these things make them low confident and hesitant in the labour room and they make a decision of caesarean section. This finding of the current study is contradicted by the study in Jordan by Maya et al. (2019) in which care during pregnancy and childbirth procedures was done by obstetricians based on the medical model guidelines. According to this model, births are managed and supported by the use of advanced technology. There is no birth is managed by induction or augmentation, no 2hourly vaginal examination, no need for episiotomy for every primigravida and electro foetal monitoring (Maya et al., 2019). Women in this study were treated with respect and dignity which is like all women in the world. In the present study, this model is not used anywhere by anyone. 

A Chinese study by Lengua et al. (2022) found the strongest factors for preferring CS were choosing a lucky day for baby birth, age of 40 years old and above, ethnic minority, difficulties in getting pregnant, and the husband's preference for CS. The main reasons for women's preference for CS were the belief in the higher safety of CS than VD for both mother and baby and the belief that CS was associated with a lower level of pain (Lengua et al., 2022).

This study also supported our study as peer pressure and giving birth on a convenient day and lucky day and no harm to the baby and mother was the main factors of the study findings.

A study by Preis et al. (2020) in a cohort of 832 prim parous women in Israel indicated that being religious, and therefore having a preference for a higher number of children, was the main factor including the preference for VD in the study group. Women who had a history of VD, and those who believed that birth is a medical process, were more likely to have chosen CD (cesarean delivery). Factors influencing preference for VD were being more religious, higher education, spontaneous conception, a history of CD, and perception of better treatment from the medical staff (Preis et al., 2020).

This study opposed our study as the current study included the women with any gravida not specifically primigravida as in this study. Furthermore, religion was not the variable in our study.

Similar to this study, another study conducted by Khan et al. (2019) supported the current study. Mothers make the decision of caesarean section after experiencing painful sexual intercourse after episiotomy among women in Nigeria and Turkey (Khan et al., 2019). Some women also stated the bad attitude of staff in the labour room and lack of kind behaviour during labour was also the reason for caesarean section. As every individual has his/her own pain tolerance capacity, every health care worker should be supportive and kind-hearted towards the patients in labour pain. It gives courage to women to support vaginal birth (Khan et al., 2019). It is necessary to make a disciplinary committee for the improvement of healthcare provider behaviour and working strength in the labour room. From the finding of the current study and other studies that is a dire need to introduce professional and ethical communication way which will be helpful to decrease the ratio of caesarean sections.

One contra-indicatory study conducted in Hong Kong among nulliparous showed that most women who preferred caesarean section at 20 weeks of gestation changed to normal delivery at the time of gestation 37 weeks and vice versa. In our study, only participants with gestation at 37 weeks or the third trimester were involved in the study. Due to this conflict, more studies are needed to be carried out to know the relationship between the preference for caesarean section and 

gestational age (Verma & Baniya, 2022).

In our study, only public hospital was included and the participants were only pregnant women. We did not involve the practitioner. There is a need for further studies which involve both women and practitioners. In our study, a history of difficult delivery was not a statistically significant factor for choosing either CS or VD but increased the preference for CDMR.

Limitations of the Study

A possible limitation of our study was recalled bias and the subjectivity of patients' opinions. Another limitation was that the interviews were conducted mostly among women who were able to complete them by means of their interest and knowledge, equal chances to participate all the women were not done among pregnant women. This study was conducted in only one public health, so the findings of this study were no international representative.

Conclusions

The proportion of women who prefer the caesarean section has been dramatically amplified in the last ten years. Some of the main factors which are influencing women's preference to choose caesarean section without medical indication such as fear of childbirth, worried about maternal or child health, mismanagement of the hospital, and cultural and social influences are explored in this study. All these factors are modifiable with the help of educational programmes and psychological preparations that would help to decrease this alarming trend of cesarean section. In the last some years, it has been observed that the increasing ratio of caesarean sections among women who preferred their decision about caesarean section should be discussed with their health practitioners and medical indications should be explained to them. This alarming trend reveals that there is a need to emphasize the significance of educating women related to the pro and cons of caesarean section and normal vaginal delivery. Healthcare facilitators like professors, lady health workers, midwives and the staff who are involved in pregnancy care to the delivery time should provide relevant education and knowledge to the women about the mode of delivery, they have to choose according to their situation. In this way, they will be aware of the indications or non-indication of caesarean section and its complications for the mother and the child. 

Recommendations

Pregnant women should be monitored with great concern during their antenatal. Hospital staff should give all the relevant information about mother and child complications and benefits from the mode of delivery, knowledge about the painless normal delivery and the long-term effect of unnecessary caesarean section on both mothers and child. Policymakers should introduce strategies for the better behaviour of hospital staff and education programs for peer involvement during antenatal visits. These programs should be laid on ethics and improving methods of vaginal birth. Additionally, these strategies should include knowledge based on social and cultural factors about normal vaginal delivery and caesarean section. There is a need for health administration to check in balance of professional practices and Gynae unit outcomes for evaluation. Some interventional studies to reduce the burden of unnecessary caesarean section in Pakistan recommended considering the research question about the behaviour of healthcare facilitators and exploring the perceptions of midwives and practitioners in rural areas about caesarean section and their preference for the mode of delivery.  

References

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