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Cesarean delivery (CD) is a life-saving procedure with specific medical indications. CD without medical indications has become a main issue of concern among health professionals. Appropriate rate of cesarean delivery is 10-15% based on the World Health Organization, which is associated with the lowest rate of perinatal and maternal complications. However, CD without any medical indication has increased dramatically worldwide (1). Several studies confirmed higher rate of maternal and neonatal mortality rate and morbidities including placental abnormalities, neonatal respiratory complications, and postpartum depression in cesarean delivery compared to vaginal delivery (2-4).  The rate of cesarean section in Iran has increased by six fold over the past three decades (5). Results of a study in southwest of Iran in 2010, showed a rising trend of cesarean section rate as high as 50% (6).  There is controversy about elective cesarean section due to maternal request. Result of a cross-sectional study showed that maternal request was the main cause of cesarean section. Physicians' tendency to CD is another reason for higher rate of this procedure (6). Hantoushzadeh et al. in Tehran assessed factors affecting physicians' responses to patients consulting the delivery type. Findings of this study demonstrated that physicians generally suggest to mothers as the safe delivery type what they prefer for themselves (7). Results of a qualitative study about mothers’ choice of delivery methods showed that sociocultural, religious and economical norms in Iranian women were important factors in their selection of delivery mode (8). Women with negative experiences in their previous vaginal delivery have higher risk for cesarean section. Preference of cesarean delivery by women is related to lack of awareness regarding cesarean section complications, inadequate information about vaginal delivery, fear of child’s birth, anxiety and pain. A qualitative study was performed in Kashan by Bagheri et al. to determine effective factors on choosing the delivery method by pregnant women. Results of this study showed that fear and pain were the most important reasons to select cesarean section, while having a good experience of preceding delivery was one of the most important reasons for choosing normal vaginal delivery (9).  Another study in Zahedan assessed the reasons of elective cesarean delivery in pregnant women. Mothers’ opinion was assessed through focus groups discussion; results revealed four major categories for preference of CD. Most women mentioned emotional causes, low perceived behavioral control, inappropriate subjective norms, and incorrect attitudes about normal delivery as their reasons to prefer CD (10). Ghotbi et al. in their study in six private and public hospitals in Tehran showed that mothers with higher marital age, and level of education, and better insurance and socioeconomic situation condition, had higher tendency to undergo cesarean delivery (11).  Intention to elective cesarean section based on the theory of planned behavior in pregnant women was evaluated by Shahraki et al. Results showed that in the areas of subjective norms and obedience motivation, women were influenced mainly by their physicians and then their husbands, mothers and friends (12).  It seems that the high rate of CD in Iran is a complex and multidimensional phenomenon. Therefore, programs and interventions to decrease the rate of CD including painless vaginal delivery, educational and emotional interventions, improved quality of normal vaginal delivery services, and change in maternal and professionals attitudes to the mode of delivery are essential.

Reasons for Elective Cesarean Section in Iranian Women