Non-medical determinants of cesarean section in a medically dominated maternity system.

Objective: To assess the contribution of non-medical factors to actual mode of delivery in a setting with high cesarean rates.

Design: Follow-up survey.

Setting: University department of obstetrics and gynecology.

Sample: Women with singleton pregnancies (n = 453) where there was no awareness of medical contradictions to vaginal delivery, attending for routine mid-pregnancy ultrasound examination in November 2011 to March 2012, and delivering between March and August 2012.

Methods: Structured questionnaire completed in gestational weeks 18-22. Information on subsequent delivery was obtained from patient files and through personal contact.

Main Outcome Measures: Contribution of childbirth preference, Wijma Delivery Expectancy/Experience Questionnaire A score, socio-demographic characteristics, attitudes toward birth issues and circumstances of pregnancy/delivery to mode of delivery.

Results: The majority of respondents (410/453; 90.5%) preferred vaginal delivery; nevertheless, one-third (two-fifths of nulliparas) had a cesarean delivery. Among nulliparous respondents, a longer perceived interval from decision for pregnancy to conception, lower importance assigned to personal control, and the presence of an obstetrician with power to decide about cesarean delivery, were independent contributors to the binary logistic regression model explaining higher maternal cesarean risks. For parous respondents, corresponding factors were younger maternal age, perceived environmental influence towards cesarean section, the respondent's belief that cesarean is more beneficial than vaginal delivery and an older obstetrician attending the delivery.

Conclusions: The results of this questionnaire survey contribute to the already existing evidence that against the background of high cesarean rates, non-medical factors, as much related to the obstetricians as to pregnant women's attitudes, play an important role.