International Journal of Clinical Medicine, 2013, 4, 395-399 Published Online September 2013 (
Psychosocial Factors for Women Reques ting Cesarean
Yajuan Zhao1, Shuangyun Chen2*
1Department of Obstetric and Gynecology, Taihe Hospital, Hubei Medical College, Shiyan, China; 2Department of Obstetric and
Gynecology, Taihe Hospital, Yunyang Medical College, Shiyan, China.
Email:, *
Received June 26th, 2013; revised July 31st, 2013; accepted August 10th, 2013
Copyright © 2013 Yajuan Zhao, Shuangyun Chen. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Rates of caesarean section are progressively increasing in many parts of the world. As a result of psy-
chosocial factors, there has been an increasing tendency for pregnant women without justifiable medical indications for
caesarean section to ask for this procedure in China. The psychosocial factors for requesting cesarean section were ana-
lyzed in our study. Methods: A self-made questionnaire and the State-Trait Anxiety Inventory (STAI) and Self-rating
Depression Scale (SDS) were administered to evaluate lying-in women’s psychosocial state. Results: The proportion of
lying-on women’s age and education degree was different significantly between the two groups (p < 0.01). In the study
groups, the proportion of lying-on women who were in lower economic degree and in her first para was markerly higher
than control (88.62% vs. 63.24%; 13.32 vs. 3.42%, p < 0.01). In the study groups, the proportion of women who felt
fearful, anxious, depressed and lacking confidence was higher than control. The ratio of women with university educa-
tion in the CS group was higher than vaginal delivery group. The proportion of lying-on women without correct deliv-
ery knowledge was higher than control, but the difference was not significant (p > 0.05). By logistic regression, we
found that for primipara, higher education degree, anxiety and lacking confidence were the dangerous factors for cesar-
ean, while lower economic degree was a defendant factor. Conclusion: There were five main psychosocial factors such
as education degree and economic state, parity, anxiety and confidence of lying-on women affecting the choice of the
delivery way. The nulliparous women who feel anxious without confidence in nice economic state, with better educa-
tion have higher risk to choose cesarean.
Keywords: Cesarean Section; Psychosocial Factor; Delivery Mode; Anxiety; Depression
1. Background
Caesarean section (CS) is needed to prevent or treat life-
threatening maternal or foetal complications in an esti-
mated 5 - 15 percent of pregnancies [1,2]. During the
past few decades, CS rates are progressively increasing
in many countries, particularly among developing coun-
tries such as China [3-5]. The World Health Organization
(WHO) Global Survey on Maternal and Perinatal Health
reported that in 2007-2008 the overall facility-based CS
rate was estimated to be 27.3 percent in Asia with the
highest estimate for China at 46.2 percent [6]. During the
last 30 years, the cesarean rate in China has risen from
6% in to 30% in 2005 [7-11]. In many Chinese hospitals,
the caesarean section rate was more than 40%, while in
some cases, it was up to 80%, which was much higher
than the acceptable caesarean rate (5% - 15%) in WHO’s
guidelines [12].
In recent years, there has been an increasing tendency
for pregnant women without obstetric indications for
caesarean section to ask for this procedure because they
perceive it to be safer and more convenient than vaginal
delivery [4,6]. This situation has become a significant
factor leading to the increased rate of caesarean section
in China [13,14]. Caesarean section on maternal request
(CSMR) has been added to this list of indications and
considered an important contributing factor in the CS
rising rate [15-17]. The latter occurs when a woman asks
to schedule a purely planned caesarean section on a date
mutually convenient for her and her doctor, before the
onset of labour, without any medical rationale, and in the
absence of any clinical indication.
Women’s preference can be affected by tokophobia
*Corresponding autho
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Psychosocial Factors for Women Requesting Cesarean Section
(fear of childbirth), the risk of out-of-hour delivery, the
belief that caesareans are safest for the baby, or because
vaginal delivery has become stigmatised as archaic and
disfiguring [18]. Known reason for requesting CS is aged
above 35, a history of CS, a previous negative birth ex-
perience or a complicated pregnancy, fear of giving birth,
prenatal anxiety and depression. A relationship had also
been found between women’s personality and mode of
delivery [19-23]. A growing number of women achieve
their first pregnancy late in life [24-26]. In China the
proportion of primiparous women being 35 years or older
increased to 9.6%. Fertility decreases with age. Conse-
quently, older women will make more use of assisted
reproductive technologies (ART). Babies, conceived af-
ter ART, of older primiparous women may therefore be
considered as “Precious Babies”.
Preparation for motherhood has previously been stud-
ied intensely and the studies have focused on psycho-
logical factors. For many women, pregnancy is a com-
plex experience, and becoming a mother for the first time
is seen as a developmental milestone. A number of fac-
tors, including the woman’s past experience, her present
life situation, and the hospital setting may influence the
first contact between the two.
The aim of this study was to compare psychosocial
factors of women who demanded CS with those who had
a vaginal delivery, and to find the main psychosocial
factors contributing to the request.
2. Methods
This study was an case-control study, comparing women
who had CSMR (as study group, n = 413) with a compa-
rable low risk group of women who had vaginal delivery
(as control group, n = 321). In this subjects 569 Primi-
para, 165 plurigravidas. It involved pregnant women with-
out obstetric indications or with relative medical indica-
tions for caesarean section, in other words low risk preg-
nant women. Women with absolute medical indications
for caesarean section were excluded (n = 430).
2.1. Patient Selection
This study was undertaken in Taihe Hospital in Shiyan.
This study was a was carried out between December
2004 and December 2005.
The inclusion criteria were: 1) geststional week 37 - 40;
2) no history of induced abortion (including medical
abortion and surgical abortion); 3) no history of heart,
liver, lung, kidney, endocrine or psychiatric diseases re-
sulting in hospitalization; 4) planning to have the deliv-
ery at Taihe hospital and planning to live in Shiyan after
The exclusion criteria were: 1) unmarried, divorced or
widowed; 2) a history of spontaneous abortion; 3) multi-
ple foetus; 4) more than 42 weeks gestation at delivery; 5)
low birth weight (less than 2500 g); 6) the presence of
absolute indications for caesarean section.
The research team took no part in the clinical care of
the women and did not participate in the decision to have
a caesarean section.
The women in the caesarean section group were
matched with those who delivered vaginally.
2.2. Data Collection
1) Assessment Tools. a) Self-made questionnaire was
used to survey the general social conditions of the ma-
ternal, including: age, educational level, economic status,
prenatal preparation, family and social support, knowl-
edge of the delivery of medical services, such as the level
of satisfaction; b) Anxiety Characteristics Questionnaire:
State-Trait Anxiety Inventory (STAI) and Depression
Scale: Self-rating Depression Scale (SDS) (11) was used
to assess maternal mental state.
2) Evaluation Methods. The pregnant women filled the
questionnaires, individually without interference, before
they delivery. For the few illiteracy, whose statement
were asked by the medical staff and completed the ques-
3) Evaluation criteria. Subjects in a normal adult norm
median of 95% over the value of standards that abnor-
malities (total score of 55 properties, State-57), total
crude by SDS-exceed the norm for the sector worth 41
Seven hundred and sixty-one questionnaires had been
send out to the expectant women, seven thirty-four were
completed, Response rate was 96.45%. Twelve Of these
did not fill the questionnaires due to lack of time before
birth, fifteen were abandoned for incomplete.
2.3. Statistical Methods
U-test and logistic regression were used for multivariate
3. Results
A significant difference in age was found between the
study group and the control group (mean age 27.36 ver-
sus 25.14 years, p < 0.05). Thirty-point-one percent of
the study group was older than 35 years as compared to
23.7% in the vaginal group (Table 1). Significantly more
women in the CS group fear to give birth (31.96% versus
8.2%, p < 0.005) and anxiety (24.46% versus 6.54%, p <
0.005) and depression (36.80% versus 18.07%, p <
0.005). Significantly more women in the CS group in
poor economic conditions (13.32% versus 3.42%, p <
0.005). The ratio of women with university education in
the CS group was higher than control group (41.20% ver-
sus 18.40%, p < 0.005), significantly. The ratio of
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Psychosocial Factors for Women Requesting Cesarean Section
Copyright © 2013 SciRes. IJCM
Table 1. Maternal psychosocial factors compared between the two groups.
study group (413) control group (321) χ2 P-value
Related Factors
n % n %
University education 170 41.20 59 18.40 33.86 <0.005
Age > 35 23 5.60 40 5.60 8.48 <0.005
Primiparae 366 88.62 203 63.24 51.76 <0.005
Fear of giving birth 132 31.96 68 21.18 8.20 <0.005
Poor economic conditions 55 13.32 11 3.42 16.74 <0.005
Erroneous understanding of childbirth 224 54.24 156 48.60 1.78 >0.10
Lack of confidence 136 32.93 24 7.48 53.21 <0.005
Depression 152 36.8 58 18.07 24.06 <0.005
Anxiety 101 24.46 21 6.54 32.42 <0.005
primiparae in the study group was significantly more
than the control (88.62% versus 63.24, p < 0.005). The
women with erroneous understanding of childbirth in the
study group was more than the vaginal group (54.24%
versus than 48.60% p > 0.1), but not significant.
Psychosocial factors for unnecessary cesarean The
single factor analysis had shown some psychosocial fac-
tors including: maternal age, education level, family
economic status, lack of confidence in childbirth, depres-
sion and anxiety, was associated with delivery mode.
Logistic regression analysis on psychosocial factors
for cesarean section Took the mode of delivery as the
dependent variable, with maternal age, education level,
parity, economic status, fear, anxiety, depression, lack of
self-confidence as independent variables. Logistic-re-
gression analysis was performed; the variables entered
the equation shown in Table 2.
4. Discussion
Some studies had shown that the rate of selective cesar-
ean section without medical indications were growing,
psycho-social factors have become the main reason for it
[6,7]. In our study some psycho-social factors such as
women’s economic status, education level, parity, the
lack of confidence in childbirth, anxiety had associated
with cesarean section.
A maternal demographic factors The single factor
analysis showed that CS had a correlation with the ma-
ternal’, education level, economic status, and parity. The
women with higher education level more likely request
CS. The ratio of women who had university education
was higher in the study group than that of the control,
while who had primary school education was less than
that of the control, significantly. Logistic regression
analysis suggested that high qualifications were a risk
factors for unnecessary CS. Other study discovered that
the younger women with a stable income and higher
education level, prefer to give birth with CS; The older
with relatively low income and low education prefer to
give birth with vaginal delivery [14]. This is consistent
with our study results. The reason for this phenomenon
was that women with higher education feared to give
birth, because the older primiparae age, on the contrary,
the women with lower education are often regarded rais-
ing children as perfectly justified.
The proportion of low economic status women in the
CS group was significantly lower than the control group
(52.8% vs 83.33%), Logistic regression analysis of com-
bined results suggest that low economic status was a
protective factors from CS. Worrying about the high cost
of CS, the parturient at lower economic status preferred
to natural childbirth, in addition, the success rate of trial
of labor in this group was higher, because of their physi-
cal activity and better tolerance. Primiparous age above
35 years was a known reason for requesting CS [7]. Be-
cause women aged between 25 - 35 in this study ac-
counted for the majority part, it couldn’t shown statistical
significance correlation between women’s age between
cesarean section.
Maternal psychological factors As one of the four
main factors affect the delivery, the impact of maternal
psychological factors on childbirth can not be ignored, it
affects not only the labor progress but also the choice of
delivery mode [14-16]. Severe anxiety of childbirth has
been demonstrated in 5% - 10% of pregnancy woman
[17]. Maternity is a major physical and psychological
stress, the majority of women have varying degrees of
mental pressure, severe anxiety and depression occurred,
which led to bad feelings increased obstetric complica-
tions and cesarean section rates are rising [16,17]. The
results had shown that fear of childbirth, lack of confi-
dence in childbirth, feelings of depression and anxiety
had associated with CS. Logistic regression analysis
showed that maternal anxiety and lack of confidence in
childbirth must be the main risk factors for CS. Other
studies found that maternal erroneous understanding for
delivery mode was correlated with increasing rate of CS
Psychosocial Factors for Women Requesting Cesarean Section
Table 2. The variables entered the equation and the estimated value of parameters.
Variables Regression coefficient Standard error Wald P OR
education level 0.386 0.186 4.308 0.038 1.471
Parity 1.892 0.637 8.830 0.003 6.631
Poor economic conditions 1.210 0.471 6.599 0.010 0.298
Fear of giving birth 1.955 0.495 15.586 0.000 0.142
Lack of confidence 2.306 0.641 12.930 0.000 10.038
anxiety 3.551 1.113 10.179 0.001 34.832
Constant 1.367 0.714 3.667 0.055 0.255
[14]. Our study did not support that view. Nevertheless,
the investigation did found that some of maternal request
CS without any medical indication because the wrong
knowledge for delivery, such as, the child delivered by
CS are more smart, fear the quality of sexual life decline
for relaxation of vaginal after delivery. A small group of
people asked optional CS, because they believed that
born chrono decided fate. Moreover, for the tense doc-
tor-patient relationship, some doctors accommodate there
patients in order to avoid risks, it might be another risk
for unnecessary CS rate increased. This factor has not
been incorporated into the analysis, due to low response
5. Limitation
In this study, data concerning women’s health are based
on self-report and not clinically confirmed. We did not
get enough information about personality, family rela-
tionship and the physician-patient relationship.
6. Conclusion
Women requesting a CS without a specific medical indi-
cation were anxious, lack of confidence, fear of giving
birth, primiparity, in higher education level and better
economic condition. This finding suggested psychologi-
cal counseling and support for women requesting CS, as
it may reduce the unnecessary CS.
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