Abstract

Objective

The World Health Organization recommends vaginal delivery while aiming for a cesarean delivery rate of 15% or lower. Factors influencing birth method preference include previous birth experiences and experiences during and after childbirth. Our study aimed to examine the past birth experiences of women who had previously given birth and to identify factors influencing birth method preferences.

Method

A descriptive cross-sectional study, designed as a questionnaire survey, was conducted with 434 participants at the Bahçelievler Memorial Hospital Obstetrics and Gynecology Polyclinic. Socio-demographic characteristics, past birth experiences, and questions related to maternal and infant health were administered face-to-face to voluntary participants. Data analysis was performed using SPSS 25 software. A p-value of <0.05 was considered statistically significant.

Results

As of the date of the study, the average number of vaginal deliveries was 2.48±1.13 (min: 1.0, max: 5.0), while the average number of cesarean deliveries was 1.87±0.79 (min: 1.0, max: 4.0). Reasons for cesarean delivery included stalled labor in 38.0% (n=113) and a history of previous cesarean delivery in 29.3% (n=87). When asked, “If you were to become pregnant again, which delivery method would you prefer?” 73.1% (n=321) answered vaginal delivery, while 26.9% (n=118) answered cesarean delivery. Having had a vaginal delivery in the first birth [odds ratio (OR) =6.54; 95% confidence interval (CI): 3.94-10.85; p<0.001] and the absence of a history of chronic illness (OR =3.68; 95% CI: 1.86-7.28; p<0.001) were significant factors influencing the preference for vaginal delivery.

Conclusion

The previous mode of delivery influences the decision-making process regarding birth method. Women with a history of cesarean delivery prefer vaginal delivery. Experiences during and after previous deliveries are influential in deciding the method of childbirth.

Introduction

Childbirth is a multifaceted event that encompasses physical, cultural, and medical dimensions. Vaginal delivery, as one of the physiological modes of birth, generally results in favorable outcomes when the mother is both physically and emotionally prepared. The alternative mode of delivery, cesarean section, is typically preferred in cases of cephalopelvic disproportion, fetal malpresentation, fetal distress, dystocia, macrosomia, or a history of cesarean delivery. Maternal morbidity and mortality rates associated with cesarean sections are reported to be 2 to 7 times higher than those associated with vaginal deliveries (1, 2).

In our country, cesarean section—although frequently performed—is often perceived as a substitute for vaginal birth. However, cesarean delivery is associated with several disadvantages, including delayed initiation of breastfeeding, disrupted maternal-infant bonding, and increased risks in subsequent pregnancies. Moreover, the high cost of cesarean births places a considerable economic burden on national healthcare systems (3, 4).

The childbirth process poses numerous risks to women during both the intrapartum and postpartum periods (5). Performing cesarean sections without valid medical indications can lead to significant adverse outcomes, including increased maternal and neonatal morbidity and mortality (1). Therefore, determining the mode of delivery is one of the critical decisions to be made during pregnancy.

Various factors influence a woman’s choice regarding the mode of delivery. These may include previous birth experiences, recommendations from family and friends, concerns about neonatal health, preferences for specialized healthcare facilities, and participation in prenatal care visits (6). Women’s perceptions of delivery methods are often shaped by their prior birth experiences.

The present study aims to explore the birth experiences of women with prior deliveries and to identify factors influencing their current preferences for mode of delivery when presenting at the clinic.

Materials and Methods

This descriptive cross-sectional survey was conducted at the Bahçelievler Memorial Hospital Obstetrics and Gynecology Outpatient Clinic between April 20, 2019 and January 20, 2020. Based on data from the first nine months of the previous year, the estimated number of women aged 15-49 years was approximately 960. Using Epi Info software and assuming a 95% confidence level, the minimum required sample size was calculated as 361 participants.

Two independent researchers informed eligible women (aged 15-49 years with a history of childbirth) about the study. Participants were asked about their previous modes of delivery, place of delivery, reasons for their delivery preferences, the decision-maker regarding the mode of birth, and experiences related to childbirth and to postpartum maternal and neonatal health. Socio-demographic information was also collected through a structured 31-item questionnaire.

Women who voluntarily agreed to participate and signed the informed consent form were interviewed face-to-face using the questionnaire during the study period. A total of 434 women completed the survey.

Ethical approval for the study was obtained from the Local Ethics Committee of Bezmialem Vakıf University on March 19, 2019 (approval no: 06/97).

Statistical Analysis

All statistical analyses were performed using IBM SPSS Statistics version 25.0. Continuous variables are presented as mean ± standard deviation, and categorical variables are expressed as frequencies (n) and percentages (%). The chi-square test was used to compare categorical variables.

To identify predictors of the preferred mode of delivery in a future pregnancy, a multivariable logistic regression analysis was performed. A p-value <0.05 was considered statistically significant.

Results

The mean age of the participants was 32.87±6.76 years (range: 19-49), and 64.7% (n=281) had completed only primary education. While 363 (82.7%) of the participants were housewives, 21 (4.8%) were healthcare professionals. The frequency analysis of participants’ demographic data is presented in Table 1.

At the time of the study, the mean number of vaginal births was 2.48±1.13 (range: 1-5), while the mean number of cesarean deliveries was 1.87±0.79 (range: 1-4). Frequency analysis of obstetric data is shown in Table 2. The most commonly reported reason for cesarean section was arrested labor (38.0%, n=113), followed by previous cesarean delivery (29.3%, n=87). Admission to the neonatal intensive care unit after delivery was higher among cesarean births (26.6%, n=50) than among vaginal births (16.7%, n=50).

Table 3 presents the association between responses to the question “If you were to become pregnant again, what delivery method would you prefer?” and various demographic and obstetric variables. Statistically significant associations were found between this question and the following variables: Current occupational sector (p=0.012), method of first delivery (p<0.001), method of most recent delivery (p<0.001), who made the decision regarding the first delivery (p<0.001), who made the decision regarding the most recent delivery (p=0.006), place of the first delivery (p<0.001), and, among those whose first delivery was vaginal, who decided on the delivery method (p=0.044).

To determine the factors influencing the preference for vaginal delivery in a future pregnancy, univariate and multivariate logistic regression analyses were performed (Table 4). In the initial step, each independent variable was analyzed separately, and those found to be significant were included in the multivariate model. The backward likelihood-ratio method was used for variable selection in the multivariate model, producing a simpler, more reliable model by retaining only significant predictors with strong effects.

Only variables related to the first delivery were included in the model, as this experience was common to all participants and a defining event. The literature supports the notion that the first childbirth experience significantly shapes attitudes toward future delivery preferences and provides a more homogeneous foundation for analysis. Therefore, focusing solely on the first delivery improved the model’s predictive power and validity.

In the univariate analyses, several variables were found to be significantly associated with a preference for vaginal birth in a future pregnancy, including vaginal birth in the first delivery [odds ratio (OR) =7.11; 95% confidence interval (CI): 4.46-11.35; p<0.001]; place of delivery (OR =2.52; 95% CI: 1.62-3.93; p<0.001); person deciding the delivery method (OR =2.84; 95% CI: 1.63-4.94; p<0.001); presence of chronic illness (OR =2.79; 95% CI: 1.56-4.99; p<0.001); regular use of medication (OR =2.35; 95% CI: 1.28-4.31; p=0.005); and employment sector (OR =2.96; 95% CI: 1.08-8.07; p=0.034). Occupation was also found to be significant (p=0.005); notably, healthcare professionals were less likely to prefer vaginal delivery (OR =0.21; p=0.001).

In the multivariate model, only three variables remained statistically significant predictors of a preference for vaginal delivery in a future pregnancy. Having a vaginal first delivery (OR =6.54; 95% CI: 3.94-10.85; p<0.001) and absence of chronic illness (OR =3.68; 95% CI: 1.86-7.28; p<0.001) were significantly associated with the outcome; giving birth in a public hospital (OR =1.61; 95% CI: 0.97-2.65; p=0.061) approached significance.

The overall model fit was acceptable (-2LL =401.74), and its explanatory power (Nagelkerke R²) was 0.277.

Discussion

In our study, we explored women’s perspectives on delivery methods by asking, “If you were to experience pregnancy again, which birthing method would you prefer?” The majority of participants expressed a preference for vaginal delivery. The most significant predictor of this preference was the mode of the first birth, with maternal health status also playing an influential role. However, the proportion of women preferring cesarean section was still higher than the rate recommended by the World Health Organization (WHO).

Over the past two decades, studies have documented increases, both globally and nationally (Turkey), in women’s preference for cesarean section, even in the absence of medical indications (7). According to the WHO, the optimal cesarean delivery rate should be 10-15% (8). As of 2014, WHO reported cesarean section rates of 46% in Mexico, 32% in Germany, 33% in the United States, and 37% in Turkey (9). In our study, the vaginal delivery rate was 73.1%, contrasting with a study in China that reported 45.1% of births were vaginal and 54.9% were cesarean deliveries (10). Our cesarean delivery rates align with broader national trends.

Our analysis found that the mode of the first delivery significantly influenced preferences for the mode of subsequent deliveries. Notably, some women who had a cesarean for their first birth expressed a preference for vaginal delivery in a subsequent pregnancy. In line with our findings, Karabulutlu (11) reported that women with a previous vaginal birth were more likely to choose vaginal delivery again, whereas those with a previous cesarean were less likely to do so; this difference was statistically significant.

While cesarean delivery can be life-saving for both the mother and the infant when medically indicated, no evidence supports its benefits in the absence of such indications (12). Increased risks of allergies and childhood asthma among children born via cesarean section may influence the decision to opt for vaginal birth in subsequent pregnancies. Roman et al. (13) found that women with pre-existing illnesses or health issues during pregnancy were more likely to deliver via cesarean section. However, in our study, women with chronic conditions were more likely to prefer vaginal birth, possibly because of associated benefits, such as higher breastfeeding rates, fewer neonatal intensive care unit admissions, and a lower risk of allergic conditions in infants.

A careful evaluation of delivery indications can help mitigate risks and guide women toward appropriate delivery choices. In a study by Mutlu and Yurtçu (14) lower cesarean rates were associated with higher vaginal delivery rates. In our study, most women delivered vaginally, and most reported that their physician made the decision regarding the delivery method. We believe this may reflect the impact of appropriate clinical indications and of national health policies favoring vaginal delivery.

Numerous studies have also shown that educational level, socio-economic status, and environmental factors play roles in determining delivery preferences (3, 11, 15, 16). While Torloni et al. (17) reported higher cesarean rates among women with lower education levels, Gözükara and Eroğlu (3) found no significant association between education level and delivery method (18). In our study, we observed that women with lower education levels more frequently preferred vaginal delivery, whereas more educated women more often preferred cesarean section. A possible explanation is that a considerable proportion of the educated women in our sample were healthcare professionals.

Supporting this, studies in Turkey have shown that approximately half of obstetricians and 56% of healthcare workers consider cesarean delivery safer for the baby (19, 20). Thus, the preference for cesarean delivery among educated women in our study may reflect a perception that it is safer.

Common medical indications for cesarean delivery in current practice include prior cesarean delivery, fetal distress, cephalopelvic disproportion, and malpresentation (especially breech) (2). In our study, the most frequently cited reason for cesarean was prolonged labor, followed by a previous cesarean, which is consistent with the literature.

Özkan et al. (15) showed that delivering in the private sector and a lack of information about delivery methods increased cesarean rates. Similarly, in our study, most women who underwent cesarean section did so based on physician-determined indications. Vaginal delivery was more common in public hospitals, while cesarean delivery rates were higher in the private sector. According to Turkey’s 2015 health statistics, 70.5% of deliveries occurred in private hospitals, and the institutional cesarean rate was 53.1% (21). In contrast, in our study, more than half of the births took place in public hospitals, which may explain the higher vaginal delivery rate observed.

However, not all studies agree. Karabulutlu (11) found no significant relationship between delivery preference and place of birth.

Study Limitations

This study has several limitations. It is based on self-reported data, making it susceptible to recall bias. Moreover, no objective measurement tools were employed, and the study was conducted within a culturally and socio-economically homogeneous population, which may limit the generalizability of the findings.

Conclusion

The mode of previous a birth significantly influences women’s preferences for the subsequent mode of delivery. Our findings indicate that women with a history of cesarean section often express a preference for vaginal delivery in future pregnancies. Experiences during and after prior births appear to influence this decision-making process. Additionally, women whose delivery mode was determined by their physician were more likely to undergo vaginal delivery.

It is essential that medical indications be carefully evaluated for each pregnancy, as the chosen delivery method can have a lasting impact on preferences for future births. Educating expectant mothers about delivery options during prenatal care is crucial. Developing evidence-based health policies that promote vaginal birth, while clearly communicating the risks associated with elective cesarean delivery, is equally important.

When planning the mode of delivery, women should receive balanced and individualized counseling on the potential risks and benefits of both vaginal birth and cesarean section. This approach helps prepare them for a variety of outcomes and strengthens their involvement in the decision-making process. Prenatal education programs and the active engagement of family physicians play a critical role in empowering pregnant women and providing the necessary guidance and support throughout the prenatal period.