Maternal Request Is not to blame for an Increase in the Rate of Cesarean section

Background and Objective. The aim of this study was to establish whether Lithuanian women would request an elective cesarean section in a low-risk pregnancy and to compare how the women’s opinion changed during the 5-year period. Material and Methods. A study was conducted at the Hospital of Lithuanian University of Health Sciences from November 1 to December 31, 2006, and from January 1 to February 28, 2011. A total of 204 and 239 women were enrolled in 2006 and 2011, respectively. Self-administered anonymous questionnaires collected information on women’s knowledge about the advantages of the different modes of delivery and their preferred type of birth in a low-risk pregnancy. Results. Overall, 82.4% of the participants in 2006 and 74.5% in 2011 thought that women should be able to choose the mode of delivery in a low-risk pregnancy. If they had had such an opportunity, 15.2% of women in 2006 and 14.9% in 2011 would have chosen cesarean section without any medical indication. The most frequently mentioned advantage of vaginal delivery was that it is natural, while safety for the newborn and the possibility of avoiding delivery pain were the mentioned advantages of cesarean section. Conclusions. Approximately 15% of Lithuanian women would request an elective cesarean section, and this percentage did not change during the 5-year period. While the national cesarean section rate is increasing with every year, it seems that “maternal request” cannot be blamed for this phenomenon. Despite all the available information about the different modes of delivery, women still lack professional and reliable knowledge about it.


Introduction
The cesarean section (CS) rate is increasing with every year all around the world (1).In some countries, such as the United States or Australia, every third woman delivers operatively (2).In Brazil, this number is even higher: the overall CS rate was 43.6% in 2006, but in the private sector, it reached more than 80% (3).
The reasons for this may be various.In addition to medical indications, for instance dystocia, abnormal fetal position, or suspected fetal hypoxia, and more ambivalent reasons, such as previous CS or infertility, there appears a nonmedical indicationmaternal request (4,5).The data show that such operations without medical indications account for 4% to 18% of all cesarean sections (6).This reason has been reported to be one of the key factors increasing the cesarean section rate (1,4,(6)(7)(8).On the other hand, some studies show that despite the rising CS rate, women's preferences to deliver operatively or vaginally remain stable (9).
According to the National Birth Register, the CS rate in Lithuania almost doubled from 2000 to 2010, increasing from 13% to 25%.Despite the fact that CS is not performed for nonmedical reasons, nowadays obstetricians may feel women's pressure to perform such an operation.The aim of this study was to determine the mode of delivery preferred by Lithuanian women in a low-risk pregnancy, women's knowledge about the advantages of vaginal or cesarean delivery, and the most trusted sources of such information and to compare how the women's opinion changed during the 5-year period.

Material and Methods
The study was conducted at the Clinic of Obstetrics and Gynecology, Hospital of Lithuanian University of Health Sciences, from November 1 to December 31, 2006, and from January 1 to February 28, 2011.This institution provides tertiary-level care and undertakes approximately 3200 deliveries per year, accounting for half of all deliveries in Kaunas, the second largest city in the country, and 10% of all deliveries in Lithuania.The participants were women in late pregnancy or those after delivery, with a live fetus or a newborn, and who were able to complete the questionnaire in Lithuanian.
The items of the self-administered anonymous questionnaire were developed based on literature, existing questionnaires, and discussions with mid-wifes and obstetricians.The questionnaires were pretested on women during a pilot phase.The 3-part questionnaire sought to identify the demographic characteristics of the participants and to collect information on women's knowledge about the advantages of the different modes of delivery and their preferred type of birth.The first 6 questions collected information on sociodemographic characteristics and obstetric history (age, place of residence, marital status, educational level, parity, and previous deliveries).The second part of the questionnaire focused on personal knowledge and opinion about the advantages of vaginal delivery and CS and the main sources of such information.The last 4 questions revealed the women's opinion on their right to choose the mode of delivery by themselves as well as their preferences (vaginal or cesarean delivery).We also asked them if the indication "maternal request" for CS should be legalized and who or what institution should pay for such an operation without a medical indication.The questionnaire took approximately 20 minutes to complete.
The calculation of a sample size was performed using the Epi Info software, version 6.0.According to the literature data, an elective CS performed on maternal request now accounts for 4% to 18% of all CSs (6, 10).There were about 30 000 deliveries per year in Lithuania (data of the Lithuanian Hygiene Institute).Anticipating that 10%±4% of women would request CS, 202 women (α=0.05) during each study period had to be examined.Statistical analysis was performed using the SPSS (Statistical Package for Social Sciences, Microsoft Inc.) software, version 15.0.Categorical variables were analyzed by either the χ 2 test or the Fisher exact test.A P values of <0.05 was considered significant.Multiple logistic regression analysis was employed to identify the independent predictors for women's preference for cesarean delivery.The variables included in the model were age, education, place of residence, knowledge about different modes of delivery (described by women as sufficient or insufficient), and previous delivery experience.The odds ratios (OR) and their 95% confidence intervals (CI) were calculated for each individual predictor.This study was approved by the Ethics Committee for the Kaunas region (No.BC-LSMU(R)-08).Verbal consent was obtained from all participants before administering the questionnaire.

Results
A total of 204 and 239 women filled in the questionnaires in 2006 and 2011, respectively.The characteristics of the study participants are shown in Table 1.The vast majority of the respondents in 2006 thought that women should be able to choose the mode of delivery in a low-risk pregnancy by themselves (Table 2).This percentage decreased from 82.4% to 74.5% in 2011, but the difference was not significant (P=0.05).If women had had such a choice, 15.2% of them would have chosen CS in 2006 and 14.9% in 2011.Despite the fact that only a minority of women would prefer CS, 71.6% of the respondents in 2006 thought that the indication "maternal request" for an elective CS should be legalized, and 56.9% emphasized that the Health Insurance Fund should pay for such an operation.In and CS.This number has increased over the five years by almost 15%.During this period, the most trusted source of information on different modes of delivery has also changed.Earlier it was an obstetrician-gynecologist, and nowadays, it is the Internet.It is debated whether it influences the women's opinion on vaginal and operative delivery.It is well known that women tend to share their knowledge and personal experiences about their pregnancy and delivery.Some authors state that women with normal pregnancies use social networks less often than those with negative experiences (5).Consequently, a public consensus that CS is better and safer for a woman and her baby than vaginal delivery may spread in the general public.Moreover, the fact that CS is becoming somewhat fashionable and classy, especially among famous people, is in favor of CS (3,11).This undoubtedly can motivate women to request an elective CS (4).On the other hand, 5 years ago, women trusted their obstetricians-gynecologists the most.Some studies showed that 17.8% of obstetricians-gynecologists in the United States and 45% in Turkey would prefer CS for themselves or their partners (15,16).It is likely that this could also influence the increasing cesarean section rate, especially in private settings (3).Some authors claim that 40% of women who choose CS are encouraged by their doctor (17).However, our study revealed that women's preference for CS in a lowrisk pregnancy did not change.It seems that neither an obstetrician-gynecologist nor the Internet influenced the number of women who would prefer an operative delivery without a medical indication.
As the main advantage of vaginal delivery, Lithuanian women mentioned that it was natural.Moreover, this mode of delivery results in a better bond between the mother and her baby.These reasons were also important to women from other countries, who also noted that vaginal delivery was associated with faster recovery and a lower complication rate when compared with CS (4,8,11,16,18).The analysis of the advantages of CS has revealed that the most important factor for Lithuanian women and other countries' laypersons and healthcare professionals is that operative delivery may be safer for the baby (16).Some authors state that an elective CS is protective against complications such as neonatal encephalopathy, intracranial hemorrhage, and brachial plexus injury (19).Nevertheless, evidence shows that an elective CS does not improve the perinatal and maternal morbidity and mortality rates (1).The proponents of operative delivery also state that this mode of delivery gives a woman an opportunity to protect herself from the future pelvic floor dysfunction and changes in sexual functioning (4,20).However, the opponents emphasize that CS does not protect women from these possible events in general (21).Lithuanian women considered avoiding pain more important than protecting their pelvic floor from damage.Although epidural analgesia for delivery pain relief has become more popular and acceptable nowadays (22), the possibility of avoiding pain remains the most popular reason for choosing an elective CS in some countries (11,18).

Conclusions
Our results show that despite the increasing national cesarean section rate, the number of women who would prefer operative delivery is not growing, and the reasons for this phenomenon should be investigated further.

statement of Conflict of Interest
The authors state no conflict of interest.

Table 1 .
The Characteristics of the Study Population NSValues are number (percentage).NS, not significant.*Question only for parous women.

Table 3 .
Variables Predicting Women's Preference for Cesarean Delivery Maternal Request for Cesarean Section