Maternal Reason for Choosing Caesarean Section at Won Request and Without Medical Indication : A Literature Review

New research from the World Health Organization (WHO) shows that the incidence of caesarean sections in childbirth continues to increase globally, accounting for more than 1 in 5 (21%) of all births. Although there is a considerable amount of literature on complications following caesarean section, the demand for caesarean section without medical indication and at maternal request is increasing. This study aimed to identify the reasons why mothers choose to have a caesarean section without a medical indication. Mothers may choose to have a caesarean section due to fear of vaginal delivery, concerns about perceived health risks, previous traumatic childbirth experiences, worries about future sexual life, positive attitudes towards the caesarean section, and the decision-making process. It can be concluded that many expectant mothers are not adequately prepared for this process. Tackling this problem requires collaboration between different stakeholders. WHO has recommended guidelines for non-clinical interventions to reduce unnecessary caesarean sections, targeting women, health professionals and health organizations, facilities, or systems.

INTRODUCTION

Pregnancy and childbirth are important stages in a woman’s life. Providing them with high-quality care allows them to have the best possible outcomes. New research from the World Health Organization (WHO) shows that incidence of caesarean sections in childbirth continues to increase globally, accounting for more than 1 in 5 (21%) of all births¹¹. Although there is evidence indicating that vaginal birth is more safe and associated with lower complications than giving birth by caesarean section²². This number is expected to increase nearly 1 in 3 (29%) by 2030³³. The World Health Organization (WHO) recommends that the average caesarean section rate in a country should be around 5-15 percent per 1000 global births. According to data from the Indonesian Demographic and Health Survey (SDKI), the incidence of caesarean section in Indonesia was 17,6%⁴⁴. This rate is significantly higher than the acceptable rate recommended by the World Health Organization (WHO).

In the past, caesarean section was only used for emergencies. Now, caesarean section is considered a safe procedure due to the improvement in health care, and caesarean section indications have increased over the years⁵⁵. However, for both mothers and babies caesarean section carries risks related to labor and anesthesia as well as short and long-term health problems when performed without medical necessity^1,6–81678.

Although there is a considerable amount of literature on complications following caesarean section, the demand for caesarean section without medical indication and at maternal request is increasing. This presents a significant challenge to the healthcare system and has sparked a global debate. The rate of elective caesarean deliveries for nonmedical reasons, such as maternal request, has been estimated to range from 4% to 18% worldwide⁹⁹. The maternal request will depend not only on her own opinion but also on the viewpoint of physicians and healthcare organizations, while a mother's request is primarily because of the psychological reason¹⁰¹⁰. The high incidence of elective caesarean section surgery at the maternal request and without medical indication, suggests a need for further evaluation of worldwide maternal and child healthcare systems. Safe delivery is a universal requirement, and the high cost and safety concerns associated with this birth method make it imperative to address this issue.

This study aimed to identify the reasons why mothers choose to have a caesarean section without a medical indication. This will hopefully lead to developing strategies to reduce unnecessary caesarean sections and thus reduce mortality and morbidity.

OVERVIEW

Caesarean section is the delivery of a fetus through an open incision in the abdomen (laparotomy) and an incision in the uterus (hysterotomy)¹¹¹¹. Caesarean section on maternal request is a caesarean section performed at the request of the mother in the absence of obstetric contraindications to vaginal delivery. There are several reasons why mothers choose caesarean section at their request and without medical indication:

Fear of vaginal birth

Many women experience fear of vaginal birth from adolescence¹²¹². They describe how they perceive based on negative live experiences of other women or social media stories¹³¹³. The concerns experienced by these women encompass anxiety regarding clinical procedures, potential complications, harm or distress to the baby, pain, and loss of control, the body's ability to give birth, physical changes in the mother during and after childbirth, and limited participation in decision-making^14,151415. A similar study also found that fear of vaginal birth was the reason for choosing caesarean section with 60% of women reporting fear of childbirth¹⁶¹⁶. However, not all women who choose to have a caesarean delivery will have a caesarean delivery. A Dutch study found that 29.3% (17 cases) of nulliparous participants who were afraid of vaginal delivery preferred a caesarean section, but only 6 delivered¹⁷¹⁷. This is an indication that the preferences for the mode of birth can still be changed. According to a study of qualitative meta-analysis, women deal with fear by coping and seeking support¹⁸¹⁸. They confronted their fear by relying on their ability to give birth naturally. The fear dissipated as they became more involved in the birth process, receiving guidance and information from midwives about what to expect¹⁸¹⁸. Therefore, it is necessary to improve obstetricians' and midwives' communication and counseling techniques to help pregnant women to reduce their fear and manage their emotions.

Safety concerns about the perception of health risks

Some women reported concerns about their health and ability to deliver their babies due to perceived safety risks. The underlying diseases such as heart disease, diabetes mellitus, and HIV, as well as biological risks associated with advanced age and obesity¹⁹¹⁹. Additionally, they noted concerns about infertility and the perception of large babies resulting from maternal diabetes mellitus. Similarly, Eide et al. (2020) reported concerns among families regarding a history of prolonged labor, emergency caesarean section, narrow pelvis, and stillbirth²⁰²⁰. Research conducted in Iran on the incidence and determinants of caesarean section indicates that mothers over the age of 30, overweight or obese, with diabetes mellitus, and mothers with LBW between 3500-4000 also prefer elective caesarean section²¹²¹. Research conducted in Chile in 2020 found that elective caesarean section was chosen by women with a family