Women with strong preferences about their method of childbirth are strongly driven by both fear and the desire to have control over the birthing process, according to a new analysis of 52 studies on the views and perspectives of women regarding cesarean sections and vaginal birth.

The findings, published May 5 in PLOS One, also found that women who preferred vaginal birth viewed it as a source of pride to give birth without surgery. Analyzing the complex factors motivating women to choose one birth process over another has implications for women's health because cesarean section rates are rising rapidly.

"It is important to study women's underlying preferences for cesarean sections, because there are many reasons based on fears associated with vaginal birth and wrong beliefs or misconceptions regarding potential benefits of cesarean sections," said first author Mercedes Colomar, a social scientist at the Montevideo Clinical and Epidemiological Research Unit, in Uruguay. 

These reasons, as reported in the study, include fear that vaginal birth will result in injury, as well as the perception that a cesarean section is a "more dignified birth experience" and will result in fewer risks for both mother and child. They also include a desire to control the birth experience, which has become a growing concern for mothers as technology allows a more precise estimation of variables, such as due date.

However, the reality is not so simple. While cesarean sections are lifesaving in certain circumstances, they are also major surgery and carry their own risks, which may outweigh the benefits when the procedure is not medically necessary. Due to these additional risks, the mortality rate for mothers after a cesarean section is three to four times higher than that for vaginal births.

And while maternal death rates are generally low in highly industrialized countries, in the United States, the rate is rising and is higher overall than in comparable countries. The risks of both cesarean section and childbirth in general are only further amplified in lower-income countries.

"In very low-income countries, the situation gets more complex [due to] the lack of good quality care and the lack of resources and skills to treat complications following cesarean sections," Colomar said. 

Despite the risks of cesarean sections, more women around the world are pursuing this birth method. According to a 2018 report in The Lancet, only 6% of births worldwide were done by cesarean section in 1990. By 2018, this figure had tripled to 21%, higher than the 10-15% rate considered ideal by the World Health Organization.

"Cesarean section use is a very interesting issue because it continues to grow worldwide, and because many women that don't need one are receiving it," Colomar said.

These trends drove the research team to explore why women might prefer a cesarean section versus a vaginal birth. Unlike concrete mortality rates, these motivations are multifaceted and qualitative, "including individual, health system, cultural and societal factors," according to Colomar. 

As a qualitative review, the researchers did not gather any new data. Instead, they pored over databases to find relevant studies, running them through an appraisal checklist to ensure the quality of the data. The final analysis included 52 studies from 28 countries, encompassing the views of pregnant and nonpregnant women, women who'd had cesarean sections, postpartum women, and even women's partners. 

By extracting data from all these studies and synthesizing it, the researchers were able to identify broad trends in the motivations of women when picking a particular style of birth. They found that women who preferred cesarean sections were resolute about the choice, with many claiming that they "had always known that [cesarean section] would be how they'd give birth." 

In these women, fear of pain, body changes after birth and vaginal injury were significant factors in their preference for cesarean section. They were also motivated by the notion of "taking control over the birth process due to pain and anxiety," the researchers said.

The team found that women who preferred vaginal birth were also motivated by fear. In this case, women feared the risks associated with cesarean birth. And they were also motivated by the desire to control their birth, but less as a convenience and more as "an "empowering experience" or "the natural way to give birth."

The findings suggest that while women have a wide array of motivations for choosing one method of birth, broadly speaking, the choice for many women comes down to the desire to protect mother and child and to have agency over the childbirth process. 

In the future, the researchers would like to apply a similar method to studies about the views of health care providers on cesarean sections, as they acknowledge that women's choices may also be motivated by the opinions of trusted doctors.

For now, Colomar and her team hope that the findings will encourage better education for women, as they found the "most frustrating" aspect of their findings to be the degree to which the fears of women preferring cesarean section are largely unfounded.

"This could be reverted by providing comprehensive health education and counseling," Colomar said.

The researchers also emphasized the need for women to take these educational opportunities when presented to them.

"Women should consider prenatal birth preparation classes, psychoeducation and [shared decision-making] for informed birth choice when they are willing to have a cesarean section due to fears or uncertainties," Colomar said. "They really do not need to consider [it] as the 'easy way.'"

The study, "Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences," published May 5 in PLOS One, was authored by Mercedes Colomar, Montevideo Clinical and Epidemiological Research Unit; Newton Opiyo and Ana Pilar Betran, World Health Organization; Carol Kingdon, University of Central Lancashire; Qian Long, Duke Kunshan University; Soledad Nion, Universidad de la República; and Meghan A. Bohren, World Health Organization and University of Melbourne.