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Introduction
Cesarean delivery is defined as the birth of a fetus through
incisions in abdominal and uterine walls (laparotomy and
hysterotomy) when the natural vaginal delivery (NVD) is
not simply possible, and the life of the mother or baby may
be at risk without a cesarean section (CS). The invention of
this surgical technique is one of the human achievements
in reducing maternal and fetal mortality and morbidity
(1). Currently, CS has dramatically increased in the world
and the rate of CS without medical indication is rising (2),
which is globally carried out as one of the most common
surgical procedures every year, namely, nearly around 18
million cases annually which is 6 million more than the
recommended rate by the World Health Organization (3).
The number of CS in developed countries increased in
the second half of the 20th century, as in the United States
where the rate of 4.5% of all births in 1970 rose to 25%
and 38% in 1988 and 2007, respectively (4). The steady
increase in the rate of CS in the United States was due to
reduced fertility rates and, consequently, an increase in the
number of nulliparous women, an increase in the average
age of mothers during childbirth, and the increasing use
of continuous electronic fetal monitoring during labor.
Further, the other reasons included planned CS in breech
presentation, reduced operative NVD using a vacuum
extractor or forceps, increased use of labor induction, the
high prevalence of obesity, increased rate of CS in women
with preeclampsia, limited number of vaginal birth after
CSs, and litigation for medical malpractice relating to
labor and NVD (1).
The ratio of CS to total birth is one of the important
health indicators. A ratio of less than 5% of CSs shows
that a significant number of women have no access to
surgical facilities for pregnancy. On the other hand, the
ratio above 15% represents the use of CS for reasons other
than saving the lives of the mother and the fetus (3). CS
posing extraordinary challenges to the health system
imposes extra charges of more than 2 million dollars on
the US health system (5). Despite the ideal rate for CS,
which has been between 10% and 15% from 1985 until
Abstract
Objectives: Cesarean delivery without medical indication has regularly increased among Iranian women in the last three decades,
and Iran has one of the highest rates of cesarean in the world. The present study aimed at reviewing the studies regarding the increase
of cesarean in Iran and discussing the root causes for such an increase.
Methods: This literature review focused on the existing quantitative and qualitative studies conducted from January 1990 to January
2019 regarding the reasons for an increase in the cesarean section in Iran. The combination of keywords including “cesarean section”,
“C-section”, “cesarean delivery”, and “Iran” was searched in several databases such as MEDLINE/PubMed, Embase, ISI Web of
Science and Scopus, along with national databases (e.g., SID, MagIran, Iran Medex, and IranDoc).
Results: A dramatic rise in cesarean birth stems from a number of factors including the role of health care professionals, insurance
companies, socio-cultural factors, and the health policies, all of which have their roots in the medicalization of birth.
Conclusions: In general, reducing the cesarean on maternal request necessitates the de-medicalization of birth, cultural awareness
through the mass media, informing women of the long-term complications of cesarean, and physical and mental preparation of
the mother. In addition, other contributing factors include encouraging inter-professional teamwork and collaboration between
midwives and obstetrician-gynecologists, transforming the current curriculum of the midwifery and residency education, applying
the midwifery-led care models, and decreasing the fear of litigation in midwifery and obstetrics-gynecology. Otherwise, maternal
and fetal mortality will rise in the near future due to increased complications in subsequent pregnancies.
Keywords: Cesarean section, Natural childbirth, Delivery, Medicalization, Iran
Dramatic Rise in Cesarean Birth in Iran: A Coalition of
Private Medical Practices and Women’s Choices
Zohreh Behjati Ardakani1, Mehrdad Navabakhsh2*, Fahimeh Ranjbar3, Soraya Tremayne4, Mohammad
Mehdi Akhondi5, Alireza Mohseni Tabrizi6
Open Access Review Article
International Journal of Women’s Health and Reproduction Sciences
Vol. 8, No. 3, July 2020, 245–258
http://www.ijwhr.net doi 10.15296/ijwhr.2020.41
ISSN 2330- 4456
Received 9 July 2019, Accepted 18 January 2020, Available online 15 February 2020
1Department of Sociology, Central Tehran Branch, Islamic Azad University, Tehran, Iran. 2Faculty of Humanistic and Social Sciences, Science
and Research Branch, Islamic Azad University, Tehran, Iran. 3Nursing Care Research Center, School of Nursing and Midwifery, Iran University
of Medical Sciences, Tehran, Iran. 4Fertility and Reproductive Studies Group (FRSG), Institute of Social and Cultural Anthropology, Oxford, UK.
5Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran. 6Department of Sociology, University of Tehran,
Tehran, Iran.
*Corresponding Author: Mehrdad Navabakhsh, Email: navabakhsh@srbiau.ac.ir
Behjati Ardakani et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
246
now, world organizations and medical associations’ efforts
are to provide CS to women who need the technique
instead of attempting to reach a specific rate. If CS is
used in essential cases, it effectively prevents maternal
mortality during pregnancy and childbirth. However,
research does not list more than 10% of essential CS cases
with reduced maternal and fetal mortality rates, and there
are no indications on the benefits of CS for women and
infants who do not need this procedure (6). According to
a Cochrane systematic review, no clinical trial has been
conducted to assess the risks and benefits of CS without
medical indications so that, based on the results, no
clinical recommendations can be made for the planned
CS for non-medical reasons (7).
Doing CS without medical indication and based on
the physician
’
s suggestion or the mother
’
s preference
has normally significant negative consequences in health
equity within and among the countries (3). Unequal
access to CS in each country can be an indicator of the
lack of access to emergency care in areas with a lower
socioeconomic level, and consequently, the high range of
CS without medical indications in the richest sub-groups
of the country, especially in countries with an average
income level (8). Although CS has recently become
safer because of anesthetic and surgical techniques (7),
this technique, like any other surgery, has short-term
and long-term complications that can last for years after
delivery and affect the health of the women, children, and
later pregnancies (6). According to previous evidence,
the mortality and morbidity of CS, especially the risk
of bleeding, sepsis, thromboembolism, and amniotic
fluid embolism are approximately 5 times higher than
normal delivery. Furthermore, technical problems due
to adhesions increase the risk of injury to the bladder
and bowel in future pregnancies. Although CS can save
the fetus
’
s life in jeopardy, rising neonatal morbidity
and mortality such as iatrogenic preterm delivery and
respiratory morbidity has raised in countries in which
there is an increase in the CS rate. For example, neonatal
adaptation, body temperature maintenance, glycemia,
and abdominal respiration are delayed and immune
system development is also affected in infants born with
CS. Therefore, it is recommended that CS takes place
only with medical indications (9). Moreover, although
CS decreases the risk of urinary incontinence and pelvic
organ prolapse, it increases the risk of obesity in children.
The short-term complications of CS are well-described in
the literature, but women are less aware of the long-term
benefits and risks of CS on themselves, their children, and
their future pregnancies. CS is associated with subfertility
and some risks in future pregnancies, including placenta
previa, uterine rupture, and the need for hysterectomy
and stillbirth (10). The short-term potential benefits of
CS, in comparison with planned NVD (women with
natural childbirth or the ones who will require CS during
labor), include the lower risk of bleeding and blood
transfusions, fewer surgical complications, and reduced
incontinence in the first year after delivery. Regardless
of attention to the balance between the benefits and
disadvantages, the American College of Obstetricians and
Gynecologists suggests that planning for natural delivery
is safer and more suitable in the absence of maternal and
fetal indications. Additionally, CS by maternal request is
undesirable for mothers who seek to have several children
because the risk of placental adhesion disorders, placenta
previa, and hysterectomy increases with each CS (11,12).
According to statistics, Turkey (47.9%) and Iran (47.5%)
have the highest rates of CS in Asia, respectively (13). The
prevalence of CS among Iranian women has permanently
increased in the last three decades. The statistical analysis
of the Demographic and Health Survey showed that 35%
of Iranian babies were delivered by CS (14) and this rate
increased significantly and reached 48% in 2009 (15). In
two recent systematic review and meta-analysis studies in
Iran, the prevalence of CS has been reported to be 48%
(16,17).
In a recent study (18), the ratio of CS has been reported
72% in Tehran and 91.7% in private hospitals, which is
significantly more than public hospitals (62.6%). The
prevalence of CS in multiparous women has been reported
by 71.8% in Tehran (19). Although the government has
attempted to reduce the average of CS in the health reform
plan, it seems that, contrary to the original goals of the
plan, CS has moved from public to private hospitals (20).
Recent studies in other cities and provinces of Iran (i.e.,
Mazandaran, Fars, Hamedan, and Shiraz) have confirmed
the increased prevalence of CS as well (21,22).
It seems that scientific advancements, socio-cultural
changes, and medical and legal considerat ions are the main
reasons for increasing the CS rate among the countries
(23) to the extent that both mothers and obstetricians
consider CS as the safest method of childbirth (24). The
policies of the Iranian Ministry of Health and Medical
Education, including implementing mother-friendly
hospitals, providing standard protocols for pain relief in
labor, holding workshops for midwives and gynecologists
have not been highly successful (25), and new policies have
encountered a long difficult path. The ratio of nearly 50%
of CS is extremely alarming and can seriously jeopardize
the health of mothers and their children in the near future
highlighting the need for in-depth explorations of this
area. Therefore, the present study aimed to summarize the
literature regarding the increase of CS in recent years in
Iran.
Methods
This research is a literature review regarding the reasons
for increased CS in Iran. Different related quantitative
and qualitative studies (from 1990 to January 2019) from
reliable Persian language databases including Magiran and
Scientific Information Database (SID) of Academic Center
for Education, Culture and Research, and information
Behjati Ardakani et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020 247
database of Iranian medical articles (IranMedex), as well
as English databases such as MEDLINE/PubMed, Embase,
ISI Web of Science and Scopus and Google Scholar were
searched in English and Persian using keywords such as
“
cesarean section”,
“
C-section”,
“
cesarean deliveries”,
and
“
Iran”. Research on CS and the reasons for its increase in
Iran published in national and international journals was
the main focus of the study. Articles related to the causes
of a decrease in normal delivery were included in the
research as well. Finally, the findings were classified into
four areas including the role of health care professionals,
insurance companies, social-cultural factors, and health
policies (Figure 1).
Results
Factors Contributing to the Rapid Rise of CS in Iran
In a recent study in Iran (26), the most common causes
of CS were repeated CSs (52.9%), CS on maternal request
(7.5%), meconium staining (6.1%), fetal distress (5.0%),
and breech presentation (4.5%), respectively. In addition,
statistically significant associations were observed
between CS reasons, and age (P < 0.001), the number
of previous pregnancies (P < 0.001), and the previous
delivery method (P = 0.010). In a systematic review,
women’s educational level, multiparity, previous CS, fear
of childbirth, and doctor’s recommendation were the most
important reasons for performing CS in Iran (16). Socio-
demographic factors such as delays in the age of marriage
and childbearing rise among women at the educational
level, mothers’ employment, low economic status, living
in urban areas, ethnicity, access to health insurance,
housing situation, and family size were associated with CS
as well. Furthermore, maternal and obstetrical risk factors
such as lower parity, previous delivery history, body
mass index, weight, head circumference of the newborn,
history of abortion, infertility, and assisted conception
were also associated with CS (14,17,19,27-29). Further,
provincial differences in the rate of CS have a significant
relationship with socio-economic development indicators
(14). However, the good social-economic situation was
not the only reason for the prevalence of elective CS in
nulliparous women in Iran, and elective CS was also
increasing among mothers with low socio-economic
status. Furthermore, decreasing the fertility rate in Iran,
having health insurance, and increasing access to health
services have been reported as important factors in
increasing elective CS (30).
The woman’s preference for CS has also affected the
childbirth method (31). Psychological factors such as self-
esteem, self-efficiency, and perceived stress influenced
the method of delivery while social support and quality
of the marital relationship were not correlated with the
delivery method (32). Among individual and social
factors affecting CS, the educational level, employment,
and maternal age had the greatest impact (17). The
perceived picture that CS babies are more intelligent than
NVD babies, lower maternal and neonatal morbidity and
mortality after elective CS, scheduled delivery, charges
for CS supported by supplemental medical insurance,
socio-cultural perceptions around prestige, and the
mistreatment of women during labor were the factors
that persuaded them to select CS in Iran (33, 34). In a
qualitative study, the maternal request for CS was related
to the fear of NVD (labor pain and damage to mother or
fetus), postpartum complications (i.e., vaginal prolapse,
urinary incontinence, and sexual dysfunction), trust to
the gynecologist, and the lack of trust in the midwife (35).
Health Care Professionals and Their Contribution to the
Increasing Cesarean Delivery Rate
Obstetricians-Gynecologists
In studies regarding the main factors of doctors’
tendency and their recommendations toward CS in
Iran, several factors were mentioned, including belief
in painfulness and long-lasting process of NVD, respect
for women’s rights in choosing the mode of delivery, and
the possibility of scheduling delivery for saving time for
physicians. Further, other factors included less stress
and financial incentives, fear of malpractice, heavy costs
of blood money and insufficient support of physicians’
Figure 1. Factors Influencing Cesarean Birth in Iran. Note. *MOHME: Ministry of Health and Medical Education; **PNC: Promotion of natural childbirth.
Factors influencing cesarean birth in Iran
Health care professionals
Midwives
Obstetricians/
Gynecologists
Medicalization of childbirth
Insurance
companies
Social-cultural
factors
Subjective norms
and body image
Cultural beliefs and
traditions
Child birth Fear Current social
norms
Health policies
National
protocols
published by the
MOHME*, 2008
The PNC**
package, 2014
Behjati Ardakani et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
248
professional liability insurance, requests for not doing a
CS in challenging cases, and lower tariffs and payments
for NVD (36). Furthermore, the reasons for prioritizing
CS by most doctors were heavy costs of blood money
and inappropriate punishment of doctors for medical
malpractice, unfair judgments in the court due to the lack
of individuals’ medical skills to detect medical errors, the
lack of liability insurance support from doctors, support
of the court from the patient, and doctors’ condemnation
in most cases of complaints (37). Iranian gynecologists
mostly comprising female doctors did not take the risk of
managing ambiguous or complicated deliveries apparently
due to the fear of legal issues and forensic positions. When
encountering ambiguous or complicated cases, they
specifically prefer their own security and use alternative
methods. In a study by Samadi et al, more than 50% of
Iranian gynecologists did not take risks and preferred CS
in ambiguous situations (38).
Since women’s preference for CS is also related to
the mode of delivery, it is known that gynecologists
are more likely to recommend CS because of women’s
requests (31). In a qualitative study by Bagheri et al in
Kashan, gynecologists believed that NVD is a painful
and prolonged process while CS is a shorter process with
less waiting time and higher incomes and less stress for
gynecologists. Some gynecologists also indicated that
CS is the best way of delivery and women have the right
of choice in this case. In this qualitative study, most
gynecologists preferred or experienced CS for themselves,
and the predictable nature of delivery on elective CS was
an advantage for physicians (36).
Gynecologists also believed that low tariffs of the NVD
do not worth the tolerated time and stress during NVD and
some gynecologists mentioned that natural delivery tariff
should be two, three, or five times more than CS. In most
hospitals, gynecologists are responsible for NVD and the
defined tariff is allocated to them. Gynecologists further
claimed that they should receive more than midwives
due to their professional and legal responsibilities (37). In
public sections, the implementation of more procedures
leads to more incomes for doctors, and CS results in
more incomes with less spent time. Given that economic
issues are one of the important barriers in reducing CS,
the Iranian Ministry of Health and Medical Education
(MOHME) in the health reform plan increased the tariffs
of NVD against CS in the book of the updated relative
value units of health services, and the tariff increased
from 15k in 2014 to 50k in 2015 (39). The special internal
rules of Iran in prohibiting the entry of male doctors
in the medical specialties associated with women and
limiting the gynecology field merely to female doctors
have considerably changed and decreased the situation of
risk-taking (38). Given the willingness of gynecologists
affiliated to the university (faculty members) to perform
CS, the training of gynecologist assistants has also
changed, and they have less experience in complicated
NVD (39). Increasing the number of female obstetrics-
gynecology (OB/GYN) residents in recent years in
addition to reducing the quality of residency education
and OB/GYN residents’ skills in managing NVD and
financial incentives have led to an increase in CS (37).
The physician’s efforts to accelerate labor with
unnecessary medical interventions due to handover or
passing of few patients to another doctor at the end of
a shift, incentive, and punitive policies of promotion of
natural childbirth package (PNC) and bed shortage have
been declared as the barriers of physiologic birth that can
increase CS rates. Disregarding the role of doctors and
the necessity of their beliefs in physiologic birth to have
effective inter-professional collaboration with midwives is
also another barrier in this regard (40).
Midwives
The main factors regarding the tendency of midwives
and their recommendations to perform CS in Iran can
be related to cases such as the allocation of normal labor
costs to physicians, the lack of professional autonomy
for midwives and the marginalization of midwifery
expertise in childbirth-related decisions. In addition,
other cases included a change in people’s understanding
of the professional skills of midwives, the lack of the
cooperation of insurance companies with midwives in
insurance contracts, and the lack of having insurance
coverage for midwives services. Moreover, a reduction
in the professional skill of midwives with regard to NVD
management and failure in the midwifery education
system and training medicalized models of delivery to
midwifery students were the other contributing factors.
In the job description of midwives approved by MOHME,
managing normal pregnancy, labor, delivery, and postnatal
care is the main duty of midwives, and they should be
trained to prepare patients for delivery and manage
NVD (29). Nonetheless, gynecologists know themselves
responsible for all deliveries whether NVD or CS and
the tariff is allocated to them prior to implementing
the PNC package. Therefore, in the situation, when
midwives have no responsibility and receive insufficient
salaries in accordance with their professional duties, they
have no motivation to do their defined educational and
professional duties for performing natural delivery and
do not try to choose the best delivery method for the
patient (37, 41). Accordingly, midwives are marginalized
in decision-making for the patient and have no role in
making decisions about delivery (36). Medicalization of
delivery in Iran has changed people’s understanding of
the professional skills of midwives and thus gynecologists
have been replaced by midwives in NVD (42). Limiting
the role of midwives and increasing the authority of
gynecologists in Iran are the significant incentives to the
increase of CS in the 3 last decades. Using midwives as
doctors’ assistants and not having professional autonomy
had left doctors to have the prime control of pregnancy
Behjati Ardakani et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020 249
and childbirth care (43). The lack of covering midwifery
services by insurance providers in Iran is also one of the
other important reasons for referring pregnant women to
gynecologists and increasing medical interventions like
CS (37, 41).
Some unnecessary CSs take place in ambiguous cases
and the presence of capable and experienced midwives in
this situation can decrease the rate of CS without negative
consequences. Thus, training a skilled and professional
midwife is of paramount importance. In recent years, the
skill of midwives in NVD has decreased due to an increase
in CS. The lack of midwives with enough experience in
managing women with complicated labor and delivery is
an issue that makes the gynecologists prefer CS (29). In
a qualitative study on the challenges of physiologic birth,
midwives
’
low motivation for implementing physiologic
birth was due to the unfair payment system and the lack of
support from gynecologists when encountering problems.
Midwives considered the physiologic birth as a costly
service and reported that no payment was defined for
the attempts of the midwives. Moreover, health insurance
providers had no commitment in this regard. Midwives
indicated that NVD tariffs do not worth the time and
stress. Insufficient numbers of midwifery staff and
imbalance between the labor statistics and the number of
midwives in addition to inadequate access to physiologic
birth retraining courses are the typical challenges of the
physiologic birth schedule (40).
Additionally, increasing the rate of midwifery students in
recent years while reducing the quality of student training
and using midwives as nurses or secretaries in hospitals
have reduced the motivation of midwifery students (37).
On the other hand, inadequate training of midwifery
workforce, the lack of training in midwifery care models,
and physiologic birth in midwifery schools are the reasons
for the lack of the ability and disbelief of midwives in
NVD. Only medicalized models of delivery are now taught
to midwifery students in Iran and midwifery training
is based on Williams’ medical book which does not
consider childbirth as a normal physiological process. In
this condition, midwives do not regard NVD as a normal
process and prefer to consider it as medical experience.
Therefore, in this condition, it is not uncommon for
midwives to shorten labor, clamping umbilical cords
immediately after delivery, pulling the cord to remove the
placenta faster and separate care for the new mother and
infant during the first hours after delivery although none
of these actions are now recommended in midwifery care
models (43).
The Interaction of Insurance Companies With Doctors
and Midwives
The lack of supervision in controlling unnecessary CS,
along with the lack of insurance coverage for midwifery
services and supplemental insurance support for elective
CS in Iran are among the effective factors contributing
to an increase in CS by insurance companies. Following
the announcement of CS indications by the MOHME in
2004 (issued 2 years later, starting from 2006 by insurance
companies), the expenses of elective CS should not be
paid by insurance companies (44). However, studies
have shown that private health insurance companies
(supplemental insurance) covering the elective CS and
the limitations posed on insurance companies regarding
hindering them from paying the CS surgery costs have
not reduced the number of procedures. The financial
relationship between the patient and doctor that forces
the doctor to receive their wage from the patient instead
of the insurance company is one of the main reasons for
not impacting the reduction of CS. Many doctors also
believe that indications that are acceptable to insurance
companies are limited and impedes the recording of the
real indication, which leads to CS, in patient
’
s records.
The issue further causes difficulty in identifying accurate
data on the indications for CS and unreal increases in the
mortality report in pregnant women (37).
Assigning more tariffs and effective roles for midwives
in NVD and doing frequently exact monitoring by
insurance companies can be partly related to preventing
unnecessary CS. NVD tariff must be paid to the services
instead of people, and insurance companies should pay to
the person who does the service whether a gynecologist
or midwife. A gynecologist who does not have the
opportunity to monitor the labor process should not take
advantage of tariffs which is assigned to midwives
’
duties.
In the current situation, the lack of insurance coverage
for midwifery services is considered to be a factor in
increasing CS (29).
The Role of Socio-cultural Factors in the Tendency of
Women to CS
The Medicalization of Childbirth
In recent decades, the MOHME in Iran has been
managed only by physicians (clinicians). Health policy-
making by physicians has changed the management of
health services and thus has led to medicalization. This
type of management has also affected the birth culture.
These health policies were fundamentally invested in
training medical specialists while neglecting the role of
other health care professionals including midwives in
maternity care with inappropriate distributions of staff
(30 gynecologists compared to 15 midwives for every
1000 births). The gynecologists have autonomy for
making decisions in the entire process of pregnancy and
childbirth. Andrea Robertson (2006) in her memories
indicated that all physicians dictate powerful management
in every birth and neglect the evidence on care, midwifery
skills, mothers’ wishes, or anything else that may affect
their practices. These changes in maternal care policies
have led to fears of normal delivery among women and
increased the rates of CS, which is a high-income source
for gynecologists (24).
Behjati Ardakani et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
250
Child Birth Fear
Fear of normal delivery and labor pain in women is one
of the most important non-medical reasons for CS (17).
Contrary to claims in the medical field, pain is a physical
phenomenon and has socio-cultural aspects, and social,
cultural, and environmental factors can influence this
experience. More precisely, fear increases the perception
of pain and, therefore, pain is a learned and controllable
experience. In spite of the general fear of surgery, the fear of
normal delivery is magnified in a way that Iranian women
are concerned about normal labor rather than the fear of
CS and awareness of its complications (29). Accordingly,
fear of childbirth or labor pain, concerns about neonatal
safety, urogenital injuries, a history of one prior difficult
NVD, and advice from relatives, friends, and health care
professionals including the genealogists affect women
’
s
decisions for selecting the mode of birth (45,46). Women
’
s
fear of normal NVD is constructed by the community and
it is partially due to the negligence of medical personnel
because they have not done proper physical and mental
preparations of women before childbirth. In addition,
cultural, social, and religious beliefs can determine how a
woman understands and interprets the pain of labor and
chooses how to manage it. A phenomenological study in
Iran about the experiences of women who had normal
delivery showed that the woman
’
s choice of the delivery
method was not based on scientific evidence and accurate
information. In other words, women did not attend
educational sessions, did not have the necessary physical
fitness, and were not ready to encounter it and even were
not aware of its process. Further, most of these women
did not evaluate the setting of public hospitals for natural
delivery (47).
Subjective Norms and Body Image
Subjective norms on body image also play an important
role in choosing the mode of delivery. More precisely,
women who have more concerns about their body image
are more likely to have a CS in their pregnancies. This
factor is related to this belief that after natural delivery,
bladder and uterine prolapse will occur but CS prevents
the deformation of pelvic floor muscles. Probably, the
most important underlying issue is the quality of a sexual
relationship after childbirth because there is a fear for
couples that the quality of their sexual intercourse will
change following genital tract trauma (34,48). Another
study also showed that common beliefs about the negative
effects of NVD on postpartum sexual functioning play an
important role in choosing CS by pregnant women (49).
Social Norms
Social norms also led NVD to be regarded as a traditional
and low-social class mode of delivery that relates to the
income and socioeconomic position and social prestige.
When the mainstream of society ranks this method
of delivery as the mode of birth in wealthy people, this
may slowly encourage women to be reluctant to have a
normal delivery, and individuals voluntarily choose the
CS by attention to the social waves which are formed in
the community (47). The prevailing belief of the society
occasionally suggests that women are not physically able
to have NVD (34, 50). It has pretended that CS is the safest
way to deliver a baby and is often very comfortable and
predictable and has no pain. The health care professionals
do not provide enough information about the potential
short-term and long-term consequences of CS. Therefore,
social learning plays a role in choosing the mode of
delivery, and observing and modelling the behavior of
others leads to new learning in every person. Abbaspoor
et al also reported that the socio-economical value of
society is one of the main factors that influences women
’
s
decision making for childbirth. In this qualitative study,
participants considered CS as a high prestige, modern,
and common way of childbirth, and in fact, a high rate
of CS in society was mentioned as a justification for
choosing it by women and their partners. Participants
also emphasized that their socioeconomic status and the
higher charge for CS did not affect their decision-making
process for childbirth since, in the Iranian culture and
society, it is socially accepted that if someone pays more
for something, it is probably more valuable (51).
Although CS is related to the socioeconomic status of
women, its increase in recent years has caused it to be
known as a custom and gradually be valued as a custom
in lower classes of the society. Therefore, NVD should
change from a low social class process of giving birth to
a process that women experience a sense of control and
empowerment in childbirth. This culture is prevalent
in some Iranian ethnicities such as Kurdi and Luri. The
debate over the adverse effect of CS, especially in general
belief, has become very complex. Thus, it is needed to
change the negative attitudes toward the NVD among
women. More serious supervision on organizations and
medical centers is needed, some of which push women to
CS because of financial incentives. Public campaigns are
also useful for increasing the knowledge of people because
the social outlook is occasionally distorted, and they claim
that CS is safer than a normal birth. Culture-making can
be extremely helpful by introducing popular celebrities
who have given birth through NVD.
Currently, the negative attitude of physicians and
midwives toward NVD is even more worrying, and
changing their behavior is more complicated compared to
pregnant women (37). The CS is generally the preferred
method of delivery in women with higher social and
educational levels including health care professionals
(i.e., midwives, nurses, and physicians) in Iran (51).
Many midwives and gynecologists do not believe in
NVD as the safest and best option of childbirth (36). In
a study in Ahvaz, only 22.5% of midwives experienced a
natural delivery (52). This negative attitude shows that
the education system of midwifery and residency needs
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fundamental reviewing and revising the existing courses.
It is certain that when doctors or midwives themselves
do not believe in the advantages of NVD, they cannot
encourage pregnant women to have a natural delivery.
Cultural Beliefs, Values, and Traditions
Cultural beliefs, values, and traditions affect people
’
s
attitudes toward delivery, their interpretations from
various methods, and their decision-making. In fact,
natural delivery has not been a pleasant process for
mothers in last decades and part of this dissatisfaction
is due to the lack of the privacy of mothers in normal
delivery and partly because of the inability to carry out CS
in emergencies which, ultimately, causes fetal-maternal
mortality and morbidity. Insufficient support for women
during labor and NVD by medical staff including doctors
and midwives, and the limitation of the presence of labor
support (a close female relative or husband) are also the
other factors that influence the mode of delivery among
women. The participants believed that health care
professionals usually support women who choose CS (51).
The Role of Health Policies in Controlling and Reducing
the CS
The MOHME has adopted several policies in order to
reduce the rate of CS. The first five-year plan for reducing
CS with the plan to reduce the rate to 25% from 2009
to 2014 was not successful. Designing mother-friendly
hospitals, setting up a standard protocol for pain relief
in labor, holding workshops for mothers, midwives and
gynecologists, changing from pro-natalist to anti-natalist
policies, and experiencing free of charge delivery in public
hospitals were some of the policies that were implemented
with the goal of reducing CS by the MOHME but were
unsuccessful (25).
Iranian population policies have shifted from population
control to the pro-natalist policies of population increase
since 2012 (53). The main objective of new pro-natalist
policies in Iran was to increase fertility rates. Given that
CS was an anti-natalist procedure, increasing the rate
of CS on maternal request by limiting the number of
women’s deliveries was a significant barrier to population
growth (54). The government, in accordance with pro-
natalist policies, has taken steps to encourage normal
delivery in which, free of charge normal delivery in public
hospitals since 2014 can be mentioned (37). In line with
the health sector evolution policy, the package for the
PNC was introduced in 2014 which was one of the most
important supportive packages of the health system. This
package included experiencing a free-of-charge natural
delivery in public hospitals, holding prenatal childbirth
classes, equipping hospitals with labor-delivery-recovery
rooms, providing some maternity services such as water
birth for pain relief, and improving the patient privacy
and financial support of public hospitals which provide
natural delivery (25). The instruction of PNC was also
announced in 2018, the specific goals of which were to
reduce the rate of CS in accordance with the 2018 target
table, considering the dignity and respect of pregnant
women, to increase the mother’s satisfaction, and to
support the mother mentally and spiritually to choose the
mode of delivery. Other policies considered in PNC were
to reduce the cost of childbirth, to increase the satisfaction
of the providers of childbirth services and to provide
medical and non-medical pain relief options, to promote
prenatal childbirth classes and their free availability, to
review the instructions for holding these classes, and to
arrange obstetric emergency triage cover round-the-clock
(2018). However, there are no birth centers in Iran, and
home birth is illegal due to the lack of the referral system.
Postpartum care is usually done in public or private clinics
and home care is not prevalent (41).
The encouragement policies considered in the PNC
(2018) for hospitals providing vaginal birth after CS
(VBAC) were not very well appreciated by Iranian
gynecologists due to the potential risk of the uterine
rupture in such deliveries. Although CS repetition is the
most frequent indication of CS in Iran (16,26), women’s
access to VBAC is limited and gynecologists are concerned
about the litigation risk (36).
Discussion
In recent studies in Iran, CS on maternal request has been
related to a variety of factors such as the fear of labor pain,
lack of knowledge about the long-term complications
of CS, exaggerations regarding the postpartum
complications of NVD, and the belief in the lower risk of
injury and neonatal death during CS. Furthermore, the
other factors included the perceived superiority of CS, the
shorter process of CS, concerns about sexual satisfactions
following NVD, inadequate support during labor, better
management and timing of birth in CS, and the possibility
of predicting and scheduling CS, a higher social class of
CS, and private supplemental health insurance.
According to Williams and McShane, these factors act
as a driving force that promotes the disruptive measures
and comfort of the stakeholders and reduce their
commitment to the standards announced by the Wor l d
Health Organization regarding monitoring the desirable
level of CS (up to a maximum of 15%) to the point where
doctors introduce CS delivery as the best option for
childbirth. Since abnormity is a theory at a macro-level,
the appropriate form of politics may appear to be the goal
of a social transformation (55). For example, eliminating
the structure of the physician’s community in unnecessary
CS is a factor for limiting the opportunities for CS.
From this point of view, providing greater educational
opportunities can be considered as a desirable approach
to stress and provides easy access for all mothers during
pregnancy through an educational plan. Therefore,
increasing the levels of education across the country and
providing information to pregnant mothers can reduce
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International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
252
the CS. Accordingly, the doctor’s recommendation is one
of the important non-medical reasons for CS rather than a
fear of natural delivery (17).
Coordinating the turbulent state of childbirth requires
corrective measures that will be implemented through
a proper educational system and the re-experiencing
of socialization. In other words, the deviation from the
normal path of delivery is associated with the absence
of a social process and full socialization and will partly
be compensated by the use of educational systems and
social media. Previous research shows that organizing and
monitoring are relevant to a low rate of deviation and can
well prevent further damage (55).
Changing Women’s Attitude Toward Vaginal Delivery
Pregnancy, delivery, and the postpartum period are like
a physical and psychological chain and none of them
are considered separate and distinct states. Anxiety
about delivery is also the heritage of human evolution.
Most women naturally seek a positive birth experience.
Historically, women have often had the support of their
close family members during delivery. This support
includes continuous support and ongoing and reassuring
presence by providing full information and collaboration
on the process of delivery. Scientific, emotional, and
planned support can increase the sense of perceived
control over their conditions, reduce fear of labor pain,
and improve the women
’
s childbirth satisfaction (56).
Unfortunately, there is currently no continuous emotional
support during labor in most hospitals in Iran. Continuous
support can help relieve the fear of labor, reduce elective
CS, and promote the health of mothers and babies around
the world (57). In the absence of family support, the
first step should be to plan for the continuous support
of women during pregnancy and delivery and reassure
them about the safety of a normal delivery. According to a
systematic review study, maternal and neonatal outcomes
improved by the continuous support of women during
childbirth. Moreover, continuous support decreased the
duration of labor, CS, and operative NVD, the use of any
analgesia, the use of regional anesthesia, low five-minute
Apgar score, and negative emotional experiences about
childbirth (58).
Ensuring the Management of Labor Pain
The sense of having no control over the NVD can lead some
women to opt for CS. With correct and proper planning,
women’s fear of childbirth and anxiety can be managed
in order to help them not to choose CS because of the
unavailability of effective pain relief methods. Emotional
support in labor and the use of pharmacological and
non-pharmacological labor pain management can ensure
pregnant women of care in delivery (12). Fortunately,
new guidelines for the promotion of normal delivery
(PNC) have emphasized the increasing use of various
pharmacological and non-pharmacological methods
and training mothers in childbirth classes. However,
a few midwives participated in 60-hour courses for
childbirth preparation and pain management methods
in Iran. Additionally, women should be adequately
informed about the use of different pain relief options in
labor and be given a choice so that interventions during
the labor would be reduced notably. The results of a
qualitative study in Iran on the experiences of women
with an uncomplicated natural delivery and no medical
intervention, who previously participated in childbirth
classes, showed that women’s experiences of pain during
delivery have been described as
“
A time for psycho-
spiritual transcendence” (59). Interestingly, ethnographic
studies from other cultures also confirm the findings of
this study and highlight the importance of giving birth
naturally and even unattended in some cases. Among
these cultures, even until recent times, giving birth
naturally, without any help from the others, has meant
self-reliance and the assertion of personhood by women,
establishing their credibility as accomplished members of
their social group. In such cultures, the intervention of
outsiders, especially doctors and midwives is perceived
as a threat to the existing authoritative knowledge of the
elderly and received wisdom, as opposed to that of the
biomedical expert (60).
Ensuring the Sexual Function Following Natural Delivery
One of the important issues regarding choosing CS by
convinced couples is the concern about sexual satisfaction
later in life which has been previously highlighted in
qualitative studies in Iran. It seems that the psychological
impact of these advertised deployments has a significant
effect on couples’ socio-cultural beliefs (61). With suitable
consulting, pregnant women should be assured that
normal delivery does not have a negative and considerable
impact on their sexual function in the future so that to
correct negative attitudes.
Demedicalization of Labor and Childbirth Process
The medicalization of childbirth has changed the concept
of pregnancy, and thus delivery and childbirth are not
considered as the natural events of life but as medical
events in Iran (62,63). Medicalized childbirth, unlike
the physiologic birth which is based on woman’s self-
confidence and empowerment, will cause fear, anxiety,
uncertainty, and the lack of self-confidence in pregnant
women. Considering only the medical aspect of care causes
fears, anxiety, and non-indicated medical interventions in
pregnant women (64). The concept of informed choice
and informed consent are also unreal and many women
accept medical advice without any more inquiry. However,
in medicalized delivery, women are actually treated
like children and passive recipients, and the personal
identity of women is ignored in hospital environments
because of the lack of control over their bodies (65). It is
not surprising that invasive interventions during labor,
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International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020 253
CS, and maternal mortality and morbidity increase by
eliminating the traditional system of support with family
members and gradually removing the midwifery system
in managing pregnant women (64).
Increasing unnecessary medical interventions in the
course of pregnancy and childbirth in Iran has reduced
the positive experience of women with childbirth. The
medicalized and non-physiologic processes of labor
include early admissions, the lack of opportunity for
mothers to initiate physiological pain, the unnecessary
induction of labor pain with oxytocin, and frequent
vaginal examinations during labor. In addition, other
processes are the impossibility of changing the position
of the mother for monitoring the fetal heart, shortening
the length of the labor in different ways, and the early
tearing of amniotic sac and routine episiotomy. The
impossibility of the presence of spousal attendance during
labor, separation care for the mother and the baby after
birth, few seconds of symbolic mother-and-baby skin-to-
skin contact after birth, and the mistreatment of women
during labor creates negative birth experiences. Afshari et
al showed that 94% of the evaluated centers in this study
administered oxytocin for mothers. Further, 70% of these
centers immediately clamp the umbilical cord and 65% of
them applied controlled cord tractions (66). Many of these
unnecessary medical interventions in pregnancy and
childbirth lead to the loss of self-confidence and decrease
the value of women
’s
experiences and abilities (Johnson,
2018).
Williams and McShane pointed to structural problems
and insisted that structural flaws can be the basis of
disruptive behaviors (55). In the management area of
the MOHME and at highest levels, most top officials or
ministry-level deputies are physicians and specialists,
therefore, they cannot be expected to act for the benefit of
all involved individuals. Preserving oneself and individual
interests and reaching satisfaction contentment are
considered as inherent human characteristics. Hence,
human behavior is toward his profits. Unfortunately,
individual interests are preferred to the collective interests
in less developed countries and the tendency to deviate
in these societies is higher and sharper. This concern is
clearly observed in the top layers of the health system, and
non-doctors and basic medical science specialists do not
have a position in the high level of management and major
decision-making.
No country accepts a rate higher than 15% for CS
However, its rate was estimated at 48% in Iran. In a
qualitative study entitled
“
Factors That Affect CS” in
Sweden, midwives and gynecologists suggested that
Aurora (the midwifery team that advises women on
childbirth fear) plays an important role in changing the
mother’s opinion who are applying for CS. In this study,
gynecologists emphasized that those women who still
desire to do CS even after adequate counseling should
be visited by senior obstetricians rather than junior
specialists. Based on the findings of this study, belief in
a normal delivery and multidisciplinary team approach
had a positive impact on CS reduction. The teamwork
of gynecologists and midwives improved the outcomes,
and group discussion and retrospective case analysis
helped the teams to learn lessons from poor outcomes
and improve the quality of care without blaming the team
members (67). Therefore, some steps should be taken
in new policies to strengthen the collaboration between
midwives and obstetricians/gynecologists in delivery in
Iran.
Design and Implementation of the New Model of
Maternity Care
Replacing the family support process with a midwifery
system and midwives who are familiar with their activities
and expertise throughout the entire period of pregnancy
and childbirth and its subsequent care is highly important
for women. “One-to-one” and “continuity of care”
approaches are the main components of promoting natural
delivery and reducing the CS in Sweden. More precisely,
the provision of systematic midwifery care and highly
qualified midwives is extremely essential for women (68).
Women’s emotional support and care continuity during
pregnancy and childbirth have partially been considered
in the package of PNC in Iran through the presence of
skilled birth attendant (midwife) in the labor process.
The theoretical and practical training in physiologic
birth, its related skills, and non-pharmacological
pain management should be added to the midwifery
curriculum, and these courses should not be postponed
util after graduation. Moreover, providing the opportunity
to gain experience regarding complicated deliveries
for midwifery students and eliminating the constraints
created for midwifery students in learning natural delivery
in educational hospitals should be considered in future
planning.
Midwifery counseling can improve the self-confidence
of women for delivery and make the pain of delivery
manageable (69). In addition, pregnant women need
useful and reliable information to assist them in decision-
making for the delivery method, and it is assumed that
giving information to a pregnant woman may affect this
choice. However, limited and unsystematic clinical trials
have not shown significant efficiency in encouraging
women to attempt NVD. The defects in designing these
studies also show that the results are unreliable and thus
more research is needed in this area (70). Contracts of
midwifery counseling centers, midwives, and gynecologists
with public and private hospitals in the country is a
major step toward the continuity of care and promotion
of NVD. However, the current model of maternity care
is still far apart from continuous midwifery care models
in developed countries. The refusal of some hospitals to
contract with midwives was the first resistance to the PNC
in Iran. These conditions emphasize the importance of a
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International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
254
performance bond for the PNC package. Providing home
birth and home care should also be considered in future
policies. Although almost all Iranian women have access to
prenatal care, the physical and psychological preparation
of women for pregnancy and childbirth has not received
adequate attention. In a qualitative study conducted in
Iran, women were informed that the presence of a birth
attendant (the husband and a family member or a doula)
helps them to better deal with the birth process (71).
In recent years, in line with efforts made to encourage
pregnant women to have a normal delivery, preparing
for birth is offered over 8 sessions of childbirth education
classes to pregnant women, and the husband is also present
in one of these sessions. However, it is practically done in
a limited number of hospitals and health centers and there
are some problems regarding its implementation (72).
However, the possibility of the presence of a husband or
an unskilled birth attendant during the labor process is
not clear in the PNC package.
The Safe Way of Delivery in Case of Precious or Golden
Babies
Some of the cases where gynecologists agree with CS
on maternal request are pregnancy following in vitro
fertilization (IVF) or intracytoplasmic sperm injection
(ICSI), namely, precious or golden babies, recurrent
abortions, and pregnancy in advanced ages. To the best of
our knowledge, no study has reported information about
the CS rate on these types of deliveries in Iran. Considering
the increasing prevalence of pregnancy through assisted
reproductive techniques and the typical process of delivery
of cesarean, CS seems to be worthwhile. However, in a
study in Belgium, one in five gynecologists agreed with
the request of a nulliparous mother at high ages for doing
CS after ICSI/IVF (73).
In another study in Australia, the rate of CS in
singleton pregnancy after ICSI/IVF was also reported to
be about 50%. Regardless of how stressful and worrying
the pregnancy process is in these couples, they are not
interested in accepting the risk of natural delivery, and
gynecologists usually do not accept the risk of normal
delivery and offer CS. Whichever decision made to
choose the delivery method should be evidence-based
(74). Therefore, normal delivery after assisted pregnancy
should be encouraged in the future policies of MOHME in
Iran because of the high prevalence of CS among women
with infertility history.
MOHME Policies
Following providing the PNC by the MOHME,
gynecologists tried to defend women’s rights in decision-
making regarding the mode of birth. Among the merits
of the new guideline, considering the rate of CS in
nulliparous women is mandatory in the hospital grading
system. The other benefits of this guideline include the
possibility of the presence of a trained birth attendant
beside the mother and possibility of taking care of her in
personal rooms in delivery block, as well as emphasizing
the reduction of unnecessary interventions and setting
criteria for establishing independent birthing facilities
(Birth centers).
Some conflicts between gynecologists and midwives
need to be further explored in new guidelines. For
example, increasing the responsibility and power of
the midwives and the professional independence of the
midwife in managing low-risk pregnancies and delivery
has remained a point of disagreement in Iran. Additionally,
article 4, working guide 20 on the PNC required to pay
35% of the professional part of a doctor’s wage from NVD
in addition to fee-for-service payment model to midwives
as an incentive fee of a natural delivery. However, the
article invoked protests by physicians, and thus needs
further analysis. Gynecologists also opposed contracting
with private midwives due to an increase in patients out-
of-pocket costs which needs to be paid by patients.
Closing Reflections
The findings of this study showed that the practice of CS
is disproportionately high in Iran compared to the rest of
the world. This increase stems from a number of factors,
which have been highlighted throughout this article and
have their roots in the medicalization of birth, which is
itself a reflection of the position gained by biomedicine
in society as a source of authoritative knowledge. An
indisputable factor in choosing CS over natural birth is
the pervasive influence of biomedical sciences challenging
traditional and natural birth practices. Two distinct
factors merit attention when analyzing social and cultural
factors that are responsible for the rise of CS to this
extent. The first one is the role of biomedicine and the
power of physicians over their patients. Brigit Jordan first
coined the term
“
authoritative knowledge” in her ground-
breaking work
“
Birth in four cultures” (1993), According
to her, authoritative knowledge means “having the power
of special knowledge or showing the confidence of having
special knowledge, which is not simply produced by access
to complex technology or an abstract will to hierarchy. It is
a way of organizing power relations in a room that makes
them seem literally unthinkable in any other way.” In
Jordan’s word, “The power of authoritative knowledge is
not that it is correct but that it counts, on the basis of which
decisions are made and action was taken” (75,76). In such
a relationship of power and subordination, women believe
that their doctors know best about their pregnancy and
what they should or should not do. Thus, they frequently
follow medical advice without any question. As Foucault
argues, in entering the field of knowledge, the human
body also enters the field of power, becoming a possible
target for manipulation. In case of childbirth, therefore,
reproductive politics become the guiding principle in the
interaction between the physicians and the patients, and
the financial gains by the physicians besides the process of
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childbirth practices becomes a game of power and control
by all involved parties. In ‘guiding’ women to opt for CS,
indirect pressure is applied by the physicians, apparently
by giving them a choice, but in reality, placing them in
an inferior and even humiliating position if they choose
the natural birth over the physician’s advice. For example,
cases that are abound of conversations between expecting
mothers and their gynecologists in Iran, when the woman
asks for natural birth delivery and the gynecologist
indicates that “I only perform CS and not NVD. If you
want natural birth delivery you had better go to another
doctor who does it”. This statement is often told with a
hint of dismissing the woman suggesting that she should
not waste the gynecologist’s time and has an undertone
of humiliation, implying that the woman is ignorant and
backward.
Moving on from the power of physicians, who believe
to be the custodians of knowledge, interestingly, in case
of Iran, the second factor stems not only from what may
appear as the imposition of medical knowledge on women
and a one-way procedure but also, in reality, from the
coalescence of the agenda of a medical profession with
that of women’s themselves. The interest of the physicians
in persuading women to opt for CS over natural birth
is instrumental in choices that women make on what
they deem the ‘best’ method of childbirth. Wom e n’s
enthusiastic responses to CS has its roots, predominantly,
in social changes which have taken place altering women’s
reproductive values and practices and in the way they
perceive and manage their reproductive life. These changes
have their roots in a number of factors, which have opened
up new possibilities for women to express their identity
through means other than motherhood. Education has
played a major role in offering women alternatives as
the producers of future generations alone. It has paved
the way for women’s participation in all spheres of life
such as industry, arts, sports, agriculture, or other social
activities. However, the most crucial factor responsible
for the transformation of values on childbearing has
been Iran’s population policies implemented in 1986 to
reduce population growth. Policy-makers realized that
policies would not succeed without the full inclusion
of women and their cooperation, and thus addressed
women directly, asking for their cooperation in refraining
from having large families (77). These policies were also
strongly endorsed and supported by the Islamic leaders, a
fact that made them acceptable to the majority of people,
especially men, who might otherwise have objected to
them. More importantly, policies effectively paved the way
for women to take control of their reproductive life and
reduce the size of their families (77, 78). In other words,
the objectives of these policies were then inculcated into
the generation of school children, who grew up to believe
in the merits of having fewer children and, who are now at
the reproductive age and reject the idea of larger families.
The total fertility rate has currently fallen to 1.2 per
woman, which is below the replacement level. In addition,
having fewer children further relies on a choice rather
than any other reason in spite of the reversal of population
policies to pronatalist ones by the state. This trend applies
to rural and urban areas, educated and less educated, as
well as wealthy and less well-off families, who either do
not want any children or only one child or a maximum of
two children (79).
As women have gradually taken charge of their
reproductive life, they have also realized that having no
children may not be an option in a society which still
greatly values children. Therefore, whether voluntarily or
reluctantly, women do have children, but they opt for the
most suitable method which meets their other agendas
when deciding about pregnancy. Accordingly, CS seems to
be the solution in allowing them the overall control of their
reproductive life, from managing the time of their child’s
birth to making the labor painless, keeping their body
intact and more desirable, and establishing their positions
in society through adopting the most fashionable method
of giving birth, which all have been discussed throughout
this study. Among the prior reasons stated by women in
opting for CS, avoiding the pain was also another reason.
Some women mentioned that having witnessed their
mothers or other close female relatives going through
the pain of natural birth, they would not dream of going
through that kind of agony. In their words ‘it is stupid to
endure so much pain if one can avoid it’. Another main
factor for the choice of CS was the complications involved
in childbirth through the natural way. Examples are given
of female relatives having suffered from the consequences
of going down the route of natural birth, which has
been traumatic and a decisive factor in choosing CS. In
addition, women are sending the signal that, if they have
to reproduce, they will do so on their own terms and
with a minimum effort albeit at higher costs. However,
the findings of this study demonstrated that CS itself is
not without serious negative consequences. This is not
readily disclosed by the physicians, who have no incentive
to do so and mislead women into blindly stepping into
unknown territories.
Finally, two further but important factors in favoring
CS over the other methods of childbirth in women
’s
viewpoints
are the trust in the superiority of the Western
medical technologies offering the state-of-the-art solution,
which promise a safe way of giving birth tally with the
‘modern’ woman’s image and status in society. In such
cases, CS, as a Western-imported technology, becomes
a signifier of modernity and wealth and acts as a social
equalizer for women from all walks of life to aspire to in
this regard.
The Way Forward
The reduction in the rate of CS needs the de-medicalization
of birth, creating cultural awareness through the
mass media, and informing women of the long-term
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International Journal of Women’s Health and Reproduction Sciences, Vol. 8, No. 3, July 2020
256
complications of CS. Additionally, several measures should
be taken seriously in conjunction with specialized training
in the new policies of MOHME, including changing
the attitudes of midwives and gynecologists toward
collaborative activities in planning and implementing
successful delivery and teaching various aspects of medical
ethics and related professional rules. The other actions
include defining duties for midwives and gynecologists,
resolving inter-professional disagreements between these
two groups, and more legal support of delivery against
medical complaints. Examining the impact of successful
policies of other countries, including the provision of
midwifery-led care, continuous support and the integrated
care system, and home birth and home care, it can be
concluded that such systems need to be localized based on
the social and cultural context of Iran.
Solving all issues and problems needs a precise and
long-term policy although short-term policies are not
welcomed in this regard. The current interdisciplinary
teamwork for childbirth management is inadequate thus
gynecologists, midwives, and social media should work
together to stop this process, otherwise, maternal and
neonatal mortality rates rise in subsequent pregnancies in
women with one previous CS in the near future.
Conflict of Interests
Authors declare that they have no conflict of interests.
Ethical Issues
Not applicable.
Financial Support
This research received no specific grant from any funding
agency, commercial entity, or not-for-profit organization.
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