Figure 1. International comparisons of CS rates for selected countries

* Adapted from reference 3-8.

Even considered under some necessary conditions to protect the health or survival of an infant or mother, CS has some risks, not only for mothers (postpartum hemorrhage, infection, anesthesia complications, venous thromboembolism, and psychological risks, etc.), but also for babies (respiratory and autoimmune disorders, surgical trauma, lack of breastfeeding, bonding and attachment in the first hours, etc.) [1,9, 10]. That’s why the increasing CS rate is an issue of public health concern as a “global phenomenon”.

Back in 1985, the World Health Organization recommended that there was no justification for a cesarean delivery rate higher than 10-15% in any world region [11]. Since then, in its latest 2009 publication, “Monitoring Emergency Obstetric Care: a handbook”, WHO has updated its 24-year-old recommendation, and admitting that “both very low and very high rates of caesarean section can be dangerous, but no empirical evidence for an optimum percentage” exists and an “optimum rate is unknown”. It now recommends instead that world regions make a choice. They “might want to continue to use a range of 5-15% or set their own standards.” [12].

According to data come from the ever-married women questionnaire of the 1998 and 2008 Turkish Demographic and Health Survey (TDHS). During the decade, the proportion of deliveries by CS increased from 5.7% to 37.0%. [5,13]. TDHS-2008 has also shown that CS rate increases directly with education and wealth; 60 percent or more of births in the highest education and wealth categories are delivered by CS, more than three times the rate among births in the lowest education and wealth levels in Turkey [5].

The medical profession throughout the world has been concerned for many years at the increasing rate of cesarean delivery. Many factors, medical, legal, psychological, social, and financial might be contributing to this increase [14, 15].

During the last decade, the deliveries by CS increased approximately seven-fold in Turkey. Cesarean deliveries were more common among women living in urban areas (42 %) than in rural areas (24 %); women were more than three times as likely to deliver in a public sector facility as in a private facility (70% and 20%, respectively) [5, 13]. There might be several reasons for this upsurge in rates of CS. Commonly cited reasons from literature include; previous CS and negative birth experience, fear of pain and fetal distress in labor, fear of future sexual dysfunction, aesthetic reasons, obstetricians’ willingness to patients’ request, belief that cesarean is safest for the baby, and mother’s high education level and wealth [5, 16-21]. Though many women today have come to believe that there are choices surrounding pregnancy and birth, the beliefs of individuals and the practices of their medical professionals, providers, insurers, and also hospital administrators play a major role in either influencing those choices or dictating how they will be manifested [22]. For example, doctors might be benefiting from this “epidemic of CS in Turkey” by being able to schedule cesarean surgeries ahead of time. It might allow them to attend to more patients and suffer fewer disruptions in their professional and private life. In a system in which private hospitals subject doctors to few regulations and little oversight, entrepreneurial obstetricians can order many potentially unnecessary surgical procedures [21]. In addition, physician convenience, benefits, and issues of reimbursement (social security institute pays more for CS than NVD in Turkey) may contribute to a willingness to offer CS as an elective procedure. Elective cesarean deliveries are usually performed during daylight hours, on weekdays versus weekends, and involve much less of a physician’s time than being on call or in hospital for a vaginal birth [9].

Women’s requests for CS may also be an important determinant of birth outcome, particularly in countries with growing privatization and options for patient choice [15]. A survey from eight European countries shows that 15-79% of obstetricians would comply with a women’s request for a cesarean delivery [17]. According to a study which was implemented to examine obstetrician-gynecologist’ knowledge, opinions, and practice patterns related to cesarean delivery on maternal request in an effort to better understand the factors associated with the increased rate of elective CS; of the 699 respondents, just over one half (53%) of whom reported having done CS on maternal request [16]. Besides, Allmohammadian et al. found out that 22% of the total of 824 mothers from several hospitals from Tehran was performed upon mother’s request [19]. There is a growing interest and discussion in the literature that weather the women should have the right to decide about mode of delivery or not [10, 17].

Another important factor affecting birth preference is healthcare facility where place of delivery made. From our latest study, even though the 87.2% of the participants had their last labor at a public hospital, 51.0% of them would prefer a private hospital for the next labor [23]. In recent years, because of the macro policies that encourage the private sector and the decline in the quality of services provided in the public sector, women’s perceptions might be changed in Turkey [2].

The age at first marriage has a major impact on childbearing because women who marry early will have, on average, a longer period of exposure to pregnancy, which in turn often leads to a higher number of lifetime births. The level of education has a positive association with the age at first marriage, with the differences between women who have completed at least high school and other women being especially pronounced. In Turkey, the minimum legal age at marriage with parental consent is 17 years for both males and females [5]. Information from the TDHS-2008 has shown the similar results as ours that the majority of women at childbearing age are currently married (65 percent), and one-third (31 percent) are never married, the median age at first marriage for women with a high school or higher education is 24.1 years, almost all births to women in the highest wealth quintile and to women with high school or more education are delivered with medical assistance [5]. It’s believed that women of lower socioeconomic status (SES) report lower expectations for the birth experience, and are more accepting of medical authority and obstetric technology than women of higher SES [1].

Marut et al [24] declared that women who deliver by cesarean section worry comparatively more about the baby’s condition during labor, and experience more fear during delivery. Lobel and DeLuca rewieved that women undergoing cesarean sections experience more pain after childbirth, longer and more difficult postpartum recovery, and a greater likelihood of obstetric complications and surgical delivery in subsequent pregnancies compared to women delivering vaginally [1]. Gamble et al examined the participants who wanted CS were asked if they knew of an advantage and a risk of the procedure for themselves and their baby. The 90% of them knew of an advantage to the mother and 95% of whom knew of an advantage for the baby, but only 40% of the women knew of a risk for themselves and 5% knew of a risk for their babies [25]. Some studies also support the idea that there is a higher incidence of respiratory distress syndrome and persistent pulmonary hypertension in surviving neonates after cesarean delivery [26-28].

Women delivering by cesarean evaluate their children less favorably than women delivering vaginally, both in the hospital and at home postpartum [1]. Women who deliver surgically are also less likely to breastfeed and they breastfeed for a shorter duration [29, 30]. This may occur because surgical delivery delays onset of lactation and the initiation of breastfeeding [31, 32], although the longer hospital stay following a cesarean may mitigate the impact of delivery method on breastfeeding [33].

According to Gamble et al, the main reason for most women preferring a CS (40%) related to “safest for the baby” or because it was “recommended by the doctor” (25%), and “fear of pain” (20%). Over one-half of the 170 women preferring a vaginal birth with minimal analgesia reported reasons that related to birth as “a natural event” (52%), the 28% of whom identified “safety”, and the 39% of whom identified “fear of pain” as their reason [25].

According to the study that was implemented to obstetrician-gynecologists, they were asked what their delivery choice would be if they or their spouse were pregnant. Fewer than 20% of respondents reported that they would choose or recommend a CS on maternal request, due to concerns for the mothers’ (64.8%) or neonates (19.4%) wellbeing [16]. Similarly, Tatar et al found that the majority of cesarean section mothers would not choose the same method of delivery if given the chance next time (80.3%), whereas 68.1% of the vaginal births mothers would prefer the same method [2].

Gamble et al [25] who examined the 310 pregnant women’s preferred type of birth and the reasons women give for their birth preference, most women (95.3%) reported a preference for a NVD, of whom over one-half wanted to give birth without any pharmacologic pain relief, while the remaining preferred a vaginal birth using a combination of drugs, including spinal or epidural anesthesia.

More than half of physicians in the US and the U.K. have either performed a CS on maternal request or would be willing to do so [34-36]. From 40% to 54% of physicians approve of a woman’s right to request and obtain a cesarean without medical indication, and majority believe that medical evidence and ethical issues sometimes or always support non-medically indicated cesarean delivery [9, 16].

In our previous study, we found that the most important factor of the delivery method choice was recommendation of obstetrician (40.1%) even though the most participants had a higher education [23]. Another study results from Turkey [37] also indicated that 44.4% of the public group and 21.7% of healthcare providers agreed that doctors know best and have the right to decide the mode of delivery for the woman (p<0.001). According to Arikan et al [38], of the 387 obstetricians, 206 (53.2%) stated that they would perform a patient-requested cesarean on a woman with a singleton uncomplicated pregnancy in cephalic presentation at 39 weeks or more of gestation. Physicians play a key role in promoting elective cesarean delivery to individual women. Physician convenience, benefits, and issues of the reimbursement may contribute to a willingness to offer cesarean delivery as an elective procedure [9]. The opportunity to select one’s delivery date in order to arrange employment leave and to schedule childcare might be another important factor affecting women’s childbirth preferences [1].

As a conclusion, most of the women believe that the most reliable delivery method is NVD. Although women seem to prefer NVD, their decision would be related with mostly the obstetricians’ recommendations. Because CS has a lot of risks to the mothers and babies, deciding to perform a cesarean delivery should be part of a shared decision making between pregnant and the obstetricians. Women should be encourage attending prepared childbirth classes, asking questions about the labor and delivery process, and discuss their fears and anxiety. Interventions for reducing cesarean sections by educating physicians about risk factors associated with birthing procedures should also be improved.

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