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Table 3 Summary of qualitative review findings

From: Prevalence of and reasons for women’s, family members’, and health professionals’ preferences for cesarean section in Iran: a mixed-methods systematic review

Summary of review findings Studies contributing to the review finding CERQual assessment of confidence in the evidence Explanation of CERQual assessment
Theme 1:Women’s and health professionals’ beliefs
Deep rooted fear of labour pain and vaginal birth: “Fear” was reported frequently by most of the women as one of the most important influencing factor on choosing mode of delivery; and fear from pain was the most common cause of fear [109, 110,111,112,113,114,115,116,117,118,119,120, 122,123,124,125, 127, 129, 131, 132] Moderate confidence Due to minor concerns about methodological limitation and coherence
Irreversible damage to body and sexual function: Women believed that vaginal delivery would damage their genitalia and caused vaginal relaxation that led them to undergo genital cosmetic/medical surgeries. They believed that CS was an ideal method to maintain their figure and sexual satisfaction. Women believed that these kinds of damages would hurt their sexual function [109,110,111, 113, 114, 120,122,123, 125, 129, 131,132,133] Moderate confidence Due to minor concerns about methodological limitations; No or very minor concerns about coherence and adequacy; and moderate concern about relevance
Safety (mother/ baby) and comfort: Many women believed that safety of the baby was guaranteed during CS; and CS is less traumatic for baby. Some women believed that children born by CS are more intelligent. The safety issues were more prominent if the baby was boy [109,110,111, 113, 114, 116, 118, 119, 121,122,123, 125,126,127, 129, 130, 132] Moderate confidence Due to moderate concern about methodological limitations and minor concern about coherence
Social convenience of birthing to time (time scheduling): Some women preferred CS because they preferred to know the exact time of delivery. Some obstetricians also believed that women prefer to have a scheduled delivery [109, 110, 112, 113, 117, 119, 120, 123, 125, 128] Low confidence Due to minor concerns about methodological limitations, and moderate concerns about relevance and adequacy
Religious beliefs: Although most women stated that vaginal delivery had severe pain, some indicated advantages of tolerating pain during childbirth that was a reflection of religious beliefs. Some women believed that vaginal delivery was a natural way of childbearing and considered it as God’s will. Also they believed that vaginal delivery was part of being a mother [109, 112, 118,119,120,121,122, 128, 130] Moderate confidence Due to moderate concerns about methodological limitations; no or very minor concerns about relevance, coherence, and adequacy
Cultural beliefs (having role models; modernity, capability to do vaginal birth): CS was considered to be a higher class method of birth that people with a higher socio-cultural class and higher education preferred to choose it and it was a social norm. This cultural belief was stated by doctors as well. Having role models also play important role in women’s decision-making. Wealthy women or doctors and midwives behaviors were important [111, 119, 121, 122, 124, 125, 128, 130, 131] Moderate confidence Due to minor concerns about methodological limitations and relevance
Influence of information about birth from family, friends, doctors, and media: Women, especially nulliparous ones, were eager to hear about the experience of their relatives and friends about different types of delivery. Some women mentioned that their fear was caused by negative experience of relatives and friends with regard to vaginal delivery. Some women reported recommendations from their mothers or husbands to undergo CS. Healthcare providers believed that non-standard birth facilities make unpleasant experience to women and they transfer these negative experiences to other women. Some women also reported stories of relatives or friends who had experienced inappropriate, unfriendly or even impolite behavior of labour and delivery ward staff. Some participants explained that their clinicians had a significant role in decision-making for choosing CS [109,110,111,112, 114,115,116, 117, 119,120,121,122,123,124,125,126,127,128,129, 131, 132] Moderate confidence Due to moderate concerns about methodological limitations and relevance; minor concerns about coherence
Women’s previous birth experience: Previous undesirable experience had caused some women decide to have CS. Some women, who had been hospitalized during pregnancy due to complications such as hypertension, stated that the ward’s atmosphere (practicing students, lack of privacy, frequent vaginal examinations, etc.) frightened them and made them to choose CS for delivery. Some women reported that watching movies in which women were in pain due to vaginal delivery provide them a bad experience and they have decided to undergo CS. However, some women with previous childbirth were more likely to be in favor of vaginal delivery [109, 112, 115, 118, 123, 124, 126, 127, 131] Moderate confidence Due to minor concerns about methodological limitations and moderate concerns about coherence
Women’s preferences informed by availability (i.e. what they or insurance can pay): Supplemental insurance plans in private hospitals support elective CS by providing high-quality facilities for women, Women who were not covered by these supplemental insurance plans could not pay for CS had not received insurance and they “had to” go vaginal delivery. Some women stated that after the “Health revolution program” and freeing vaginal deliveries, families were more eager to have vaginal delivery [112, 119] Moderate confidence Due to minor concerns about methodological limitations and relevance; and moderate concerns about adequacy
Theme2: Healthcare professional factors
CS is now safe/r option for birth: Some obstetricians deeply believed that CS was the better choice for both women and their babies. Unpredictable status of vaginal delivery and safety of baby were frequently stated reasons by doctors [111, 117, 121, 124, 131] Moderate confidence Due to minor concerns about methodological limitation and adequacy
Convenience of birthing to time (work scheduling): Some doctors stated that the process of vaginal delivery is time consuming and unpredictable and disturbs night sleeps. They believed that they are too busy to pay time for vaginal delivery [109, 111, 114, 117] Moderate confidence Due to moderate concern about methodological limitation and minor concern about adequacy
Patient pushes doctor to do CS: Doctors believed that reduced number of pregnancies as well as the increased age of marriage and pregnancy was leading to the families’ higher tendencies towards undergoing CS. Some doctors stated that one of the factors affecting the rise in CS is that the women and their families asked for a CS and pushed the doctor to do CS [111, 117, 124] Moderate confidence Due to minor concern about methodological limitation and moderate concern about adequacy
Legal issues: Some of the proclamations made by the doctors showed the importance of legal issues in increasing rate of CS. Doctors stated that there were no guidelines or scientific basis which would guarantee the judging process. They believed that the policies and laws affect the behavior of healthcare providers [111, 117, 121, 132] Moderate confidence Due to moderate concerns about methodological limitation and adequacy
Vaginal delivery fees not worth the time paid for it: A financial incentive in terms of higher fees for doctors in doing CS in private hospitals was considered to be a factor increasing the CS rate. Some Obstetricians also claimed that the fee paid for vaginal delivery is not worth the time consumed and stress endured during such a procedure. Changing the tariff imposed on vaginal delivery may be one of the strategies adopted by the policymakers to reduce CS rate [111, 117, 121, 124, 132] Low confidence Due to minor concerns about methodological concern and coherence; moderate concerns about adequacy and no or minor concern about relevance
Lack of respectful, dignified, and supportive communication with women: Women stated that disrespect, poor communication between them, their families and healthcare providers and mistreatment could result in deciding not to go for vaginal delivery. Some women had bad experiences about mistreatment in labor that inhibited them from going back to labour ward for the next delivery [27, 111, 112, 114, 115, 118,119,120, 123,124,125, 127, 128, 131, 132] Moderate confidence Due to moderate concerns about methodological limitation and minor concerns about coherence
Lack of adequate information support: Maternal unawareness regarding labor along with women’s imprecise knowledge about different delivery methods, their complications, and their hospitalization period has reduced their tendency toward undergoing a vaginal delivery. Both women and healthcare providers believed that providing maternity preparation classes and hotlines could help women to make proper decisions and made them ready for a vaginal delivery and reduce their stress [27, 110, 111, 112, 114, 121, 122] Moderate confidence Due to moderate concerns about methodological limitation
Mistrust: Some women described the level of trust in their doctor as a factor in choosing their method of childbirth. Some stated that they did not trust the recommendations made by their doctors. Some doctors also stated that the patients did not trust them; and in case of complications, patients saw it as doctors’ fault, [27, 111, 119, 124, 125, 132] Moderate confidence Due to minor concern about methodological limitation and relevance; and moderate concern about adequacy
Lack of skilled and experienced doctors/midwives during labor and vaginal birth: Many healthcare providers believed that the skills and experience of obstetricians and residents in conducting a vaginal delivery has been reduced in recent years due to poor quality of education. They believed that because of reduced number of birth rate in recent years, residents had rare opportunities to do vaginal deliveries [27, 111, 114] Moderate confidence Due to minor concern about methodological limitation; moderate concerns about adequacy; no or minor concerns about coherence and relevance
Theme3: Health organization, facility, or system factors
Physical condition of birth facility (comfortable, calming, clean birth environment): Poor quality care for women and their children during labor was the most commonly cited external barrier for vaginal delivery. Low environmental facilities, lack of proper equipment, and crowdedness were cited as low quality physical condition of birth facilities. Doctors and midwives also believed that the physical environment of labor rooms was far from standard. This unsuitable condition would negatively affect the women’s perspective and subsequently her decision regarding type of delivery [27, 109, 111, 114, 115, 118, 119, 120, 121, 124125, 129, 131] Moderate confidence Due to moderate concerns about methodological limitation
Physical examination and procedures (asking permission, privacy, painful vaginal examination, unnecessary vaginal examinations/interventions): Some healthcare providers considered the early admission of women as a reason of unnecessary interventions, and consequently CS. Some of the midwives added that induction in patients with no evidence-based indication may also increase the C-section rate. Most doctors claimed that medicalizing the process of labor and adding interventions (such as hospitalizing, maintaining an IV-line and injecting solutions, elective induction and frequent vaginal examination) are among the factors turning physiologic labor into a non-physiologic process and consequently increasing the CS rate [27, 109, 110, 111, 118, 119121, 123, 125, 129, 131] Moderate confidence Due to moderate concerns about methodological limitation
Continuous, organized, timely care: Fear of being alone during birth encompassed feelings of loneliness, being ignored by care providers, and feelings of helplessness were common fears expressed by women. Doctors also believed that the absence of an on call physician as an obstacle in the way of performing vaginal. Having a continuous midwifery care was proposed by some midwives [27, 111, 114, 121,122,123,124] High confidence  
Limited availability of pain relief procedures: Both doctors and women believed that providing a comfortable condition might hasten the tendency of vaginal delivery [27, 112, 114, 118, 120, 124, 129] Moderate confidence Due to moderate concern about methodological limitations
Lack of partner/family companion during labour/delivery: Midwives or other healthcare providers are the women's only source of support during labour and childbirth because pregnant women are not allowed to have family companion during labor and birth in Iran. Having companions in labor that accompanied women during birth were mentioned by both women and healthcare providers as a supportive factor for parturient women [27, 111, 120, 124, 128, 132] Moderate confidence Due to minor concern about methodological limitation and relevance
Lack of practical birth guidelines and collaborative midwife-obstetrician models of care: The absence of a scientific and accurate hospital protocol has also contributed to the addition of unnecessary and often non-scientific interventions to the labor process [27, 111] Very low confidence Due to serious concerns about adequacy
Too little value placed on midwifery care: There have been changes in professional roles of midwives and obstetricians during childbirth. Midwives, who used to manage normal delivery and play a critical role in promoting physiologic labor, have lost their authority; and have faced challenges in realizing their role during birth. Midwives, who used to provide prenatal care at public healthcare centers, can no longer be actively involved in child delivery. Midwives and midwifery students account for less active involvement in vaginal delivery and subsequently a decline in the quality of their education has been occurred. Moreover, setting tariffs for labor affects the relation between physicians and midwives [27, 111, 119, 124] Moderate confidence Due to minor concerns about methodological limitation and adequacy
Financial and legal conflicts: Many midwives claim that physicians receive all the money so why should a midwife spend long hours in the labor room; physicians, on the other hand, claim they should receive more money as they are in charge of any possible legal problems linked to labor [111, 121] Very low confidence Due to serious concern about adequacy