Selina MW Pang
Danny TN Leung
Tony KH Chung
Increasing caesarean section (CS) rates are a trend observed worldwide.1-6 The CS rate rose from
4% in the 1970s to 21.5% in 2001 in the United Kingdom, from 30.3% in 1978-1979 to 50.8%
in 1994 in Brazil, from 11.1% in 1988 to 38.1% in 2000 in South Korea, and from 4.7 to 22.5%
over the past three decades in Shanghai.4,6-8 In Hong Kong, the CS rate rose from 16.6 to 27.4%
between 1987 and 1999, representing a 65% increase over 12 years.1
could be the improved safety of surgical and anaesthetic skills in modern obstetrics.9 Other
postulated reasons include changing attitudes towards CS among staff and patients. It has been
shown that a significant number of obstetricians would agree to perform an elective CS without
an obstetrical indication upon maternal request.10-13 Thirty-eight percent of Danish obstetricians
agreed to perform elective CS if requested by the mother.10 The corresponding figures in the
United Kingdom and Israel were 69% and 45% respectively.11,12 A survey of the attitude of
obstetricians, midwives, and trainees (n=194) in our unit showed that 58% of them would agree
that elective CS be offered in response to maternal requests.13
The exact reasons for the increase in CS rate are unknown. One of the major reasons
recent years, women’s demands for CS has become a main reason for the abdominal route
of delivery.11,14-16 In a 2-year audit in an Australian teaching hospital, maternal choice was the
commonest indication for elective CS.17 In another audit of a teaching hospital in London in 1999,
the major indications of all elective CS were previous CS (44%), maternal request alone with no
obstetric indications (14%), and maternal refusal of a trial of vaginal breech delivery (13%).14 In
the latter unit, although a trial of vaginal delivery (VD) was the recommended mode of delivery
Because of the increasing emphasis on patients’ participation in medical decision in
Objective To find the clinical and socio-demographic determinants for Hong
Kong Chinese women who preferred elective caesarean section.
Design Cross-sectional interview survey.
Setting University teaching hospital, Hong Kong.
Participants A cohort of consecutive Hong Kong Chinese pregnant women
(n=660) attending a government-funded obstetric unit catering
deliveries in the New Territories in Hong Kong in 2002.
Main outcome measures The clinical and socio-demographic determinants of preference
for elective caesarean section, in women who could have a trial of
Results The overall prevalence for maternal preference for elective
caesarean section was 16.7% (95% confidence interval, 13.8-
19.6). The factors associated with preferring elective caesarean
section were: previous elective caesarean section (odds ratio=7.6;
95% confidence interval, 2.0-28.7) and previous emergency
caesarean section (3.8; 1.8-8.2). Among nulliparous women, the
prevalence of preference for elective caesarean section was 16.8%
(95% confidence interval, 13.0-20.6). Conception by in-vitro
fertilisation was found to be significantly associated with preferring
elective caesarean section in nulliparous women (odds ratio=5.2;
95% confidence interval, 1.0-26.4).
Conclusion Previous caesarean section and conception by in-vitro fertilisation
were determinants for women preferring elective caesarean
Determinants of preference for elective caesarean
section in Hong Kong Chinese pregnant women
Asian continental ancestry group;
Hong Kong Med J 2007;13:100-5
Department of Obstetrics and
Gynaecology, The Chinese University of
Hong Kong, Prince of Wales Hospital,
Shatin, Hong Kong
SMW Pang, MB, ChB
DTN Leung, MD
TY Leung, MD
CY Lai, MNurs (Mid)
TK Lau, MD
TKH Chung, MD
Correspondence to: Dr SMW Pang
(MOD) after one previous CS or breech presentation,
the three commonest indications for elective CS were,
therefore, all related to the maternal refusal of VD.14
for the MOD in Asian countries. In Singapore, with a
population consisting of ethnic Chinese, Malay, and
Indians—only 3.7% of the mothers preferred elective
CS.18 In South Korea, less than 5% of the women
preferred elective CS.19 To date, there were no data on
MOD attitudes among Hong Kong Chinese women.
We therefore aimed to find the clinical and socio-
demographic determinants for preferred elective CS in
the Hong Kong Chinese population.
There were fewer reports on women’s preference
A cross-sectional survey was conducted in an obstetric
unit of a government-funded hospital in Hong Kong during
the period 2002. The delivery rate of the unit during the
study period was approximately 6000 per year. In 2002,
21% of the parturients delivered by CS (5.7% by elective
CS, 15.4% by emergency CS). With a 24-hour epidural
analgesia service available, 20% of the women received
epidural analgesia or anaesthesia during delivery. Over
98% of the parturients were ethnically Chinese.
hospitals and all Hong Kong residents were eligible, and
approximately 75% of Hong Kong women delivered
in such hospitals. There were no planned home birth
or community centres designated for deliveries. In
government-funded hospitals, requests for elective CS
without an obstetrical indication were not entertained.
Women who wished to have delivery in the study
unit were seen in the out-patient clinic of the unit at
least once. The majority of women had no antenatal
complications. They were then referred for continuation
of antenatal care at the maternity and child health
centres until delivery. Midwives were not dedicated to
look after individual’s pregnancies. On a voluntary basis,
mothers were encouraged to attend antenatal classes
in groups in both the government-funded obstetric unit
and in community centres, where the general issues of
pregnancy and childbirth were addressed.
Obstetric service was free in government-funded
their first antenatal visit in the obstetric unit who were
suitable for a trial of VD were included in the study.
Women known to have had two previous CSs, psychiatric
disease, medical disease, multiple pregnancies,
congenital abnormalities and previous maternal or
foetal complications necessitating intensive care unit
admissions were excluded. It was the unit’s policy
that women who had one previous uncomplicated
lower segment CS were encouraged to undergo a VD.
If these women insisted on elective CS, the procedure
was arranged after adequate counselling. All potential
subjects were invited to participate by a research nurse.
Written consent was obtained; the relevant institutional
Hong Kong Chinese pregnant women attending
review board had approved the study protocol.
in the study and the medical personnel involved in the
clinical management of the patients were not privy to
information obtained from the survey.
Antenatal care was not affected by participation
A structured interview was conducted by a single
research assistant. Socio-demographic data, and women’s
obstetrical and gynaecological history were recorded. The
women’s preference for the MOD of the index pregnancy
was explored (given the hypothetical situation that they
had an uncomplicated antenatal course with freedom to
choose VD or elective CS). The most important reason
for each mother’s choice was recorded. At the end of the
interview, women were asked to complete a validated
Chinese version of General Health Questionnaire.20
A sample size of 503 produces a 95% confidence
interval (CI) equal to the sample proportion ±0.03 when
the estimated proportion is 0.145.21
Statistical analysis was performed with Statistical Package
for Social Sciences (Version 10.1; SPSS Inc, Chicago [IL],
US). Univariate analyses were used to identify clinical
and socio-demographic variables associated with
preferring elective CS. Logistic regression analysis was
used to adjust for collinearity among the variables. The
significance and adjusted odds ratio (OR) of determinant
variables for preferring elective CS were thus obtained.
During the study period, 660 Hong Kong Chinese
women fulfilled the inclusion criteria and were invited to
participate in the study. A total of 629 women consented
and completed the survey; 31 women declined to
of the participants are listed in Tables 1 and 2 respectively.
Fifty-nine percent of the respondents were nulliparous.
The overall prevalence of preference for elective CS was
16.7% (95% CI, 13.8-19.6).
The socio-demographic and clinical characteristics
and clinical variables from all valid respondents were
Univariate analyses of the socio-demographic
performed. Table 3 shows the results of the potential
explanatory variables tested to have an association with
preference for elective CS with P≤0.2.22
the potential explanatory variables for which P≤0.2
were detected in the univariate analyses (Table 3).22 After
adjustment, prior elective CS (OR=7.6; 95% CI, 2.0-28.7)
and prior emergency CS (OR=3.8; 95% CI, 1.8-8.2) were
the only variables having a significant association with
the women’s preference for elective CS for the index
Logistic regression analysis was performed with
women’s preference for VD and elective CS are listed in
Table 4. Since previous emergency CS and elective CS
were found to be the determinants for preferring elective
CS at the index pregnancy, analyses were repeated for
the 370 women with no prior childbirth experience. The
preference for elective CS among nulliparous women
was 16.8% (95% CI, 13.0-20.6).
The most important reasons leading to the
socio-demographic and clinical variables among the
nulliparous women. The variables found to have P≤0.2
Univariate analyses were performed on the
Socio-demographic variableNo. (%)
Mean age (SD) [years]29.8 (5.0)
Maternal age ≥35 years 101 (16.1)
Maternal age ≤18 years10 (1.6)
Mean gestation at survey (SD) [weeks] 17.0 (5.9)
Educational level (n=624)†
Primary or below22 (3.5)
Secondary 466 (74.7)
Tertiary or above136 (21.8)
Skilled non-manual 192 (32.3)
Skilled manual 17 (2.9)
Partly skilled manual39 (6.6)
Unskilled manual 9 (1.5)
Family monthly income (HK$) [n=623]†
<10 000116 (18.6)
10 000-20 000 201 (32.3)
20 001-30 000 140 (22.5)
>30 000 166 (26.6)
Drinker 40 (6.4)
History of substance abuse 16 (2.5)
Marital status (married)580 (92.2)
TABLE 1. Socio-demographic variables of the participating
Data are shown in No. (%), except otherwise stated
† Data were missing for some subjects
Clinical variable No. (%)
History of gynaecological surgery
Surgical evacuation of uterus 212 (33.7)
Surgery to cervix9 (1.4)
Hysteroscopic surgery2 (0.3)
Termination of pregnancy226 (35.9)
Epidural analgesia during childbirth36 (5.7)
Normal vaginal delivery/complication 177 (28.1) / 10 (1.6)
Vaginal instrumental delivery/
36 (5.7) / 3 (0.5)
Emergency caesarean section/
39 (6.2) / 6 (1.0)
Elective caesarean section/
10 (1.6) / 0
Stillbirth or neonatal death 5 (0.8)
Planned pregnancy 487 (77.4)
Assisted conception 20 (3.2)
In-vitro fertilisation8 (1.3)
Threatened miscarriage77 (12.2)
Mean General Health Questionnaire
TABLE 2. Clinical variables of the participating women, n=629*
Data are shown in No. (%), except otherwise stated
are shown in Table 5.22
potential explanatory variables listed in Table 5.22 After
adjustment for collinearity, only conception by in-vitro
fertilisation was found to be significantly associated with
preferring elective CS (OR=5.2; 95% CI, 1.0-26.4).
Logistic regression was performed with the
cited reason for choosing elective CS and VD are shown
in Table 4.
Among nulliparous women, the most frequently
This paper reports the determinants for preferring elective
CS in a sample of Hong Kong Chinese pregnant women.
Our finding that previous CS was a significant determinant
for such a preference concurred with studies conducted in
the western populations.23,24 In a randomised controlled
trial, an individualised prenatal education and support
programme was offered to women with previous CS, but
did not demonstrate any clinically significant increase in
the rate of vaginal births after CS.25 Thus, to reduce the
overall CS rate, reducing the proportion of first deliveries
by CS appears pertinent.
previous elective CS were twice as likely to prefer elective
CS than women who had had emergency CS. Since this
was a cross-sectional study, it is impossible to determine
whether this difference was due to a priori difference in
Our results showed that women who had had a
Variable CS, n=105Vaginal delivery, n=524 P value
Continuous variables*, mean (SD)
Maternal age (years) 30.7 (4.8)29.7 (5.0) 0.05
Gestation at survey (weeks)15.9 (5.4) 17.2 (6.0) 0.06
Dichotomous variables†, No. (%)
Family monthly income >HK$30 00035 (33.3) 131 (25.0) 0.08
History of substance abuse0 16 (3.1) 0.07
Previous myomectomy2 (1.9) 3 (0.6)0.16
Previous normal vaginal delivery19 (18.1) 158 (30.2)0.01
Previous emergency CS17 (16.2) 22 (4.2)0.00
Complications of previous emergency CS3 (2.9) 3 (0.6)0.03
Previous elective CS 6 (5.7) 4 (0.8)0.00
In-vitro fertilisation3 (2.9) 5 (1.0)0.11
† Chi squared test
TABLE 3. Socio-demographic and clinical variables associated with preferring elective caesarean section (CS) at univariate analyses (P≤0.2)
ReasonsAll women (%) Nulliparous women (%)
For preferring VD n=508n=308
VD is the natural way of delivery 36.338.3
VD is safer for the baby22.319.5
VD has quicker post-delivery recovery21.3 21.2
VD is safer for the mother15.5 17.2
VD has less overall pain 4.2 3.6
For preferring elective CSn=105 n=62
CS is safer for the baby35.333.9
Fear of vaginal birth23.022.6
CS has less overall pain 18.017.7
CS has less vaginal trauma 13.721.0
CS allows a better control of time of birth 8.91.6
TABLE 4. Frequency distribution of the most important reasons for preferring vaginal delivery (VD) and elective caesarean section (CS)
preference for a certain MOD. Thus, women who had
undergone emergency CS could have been those who
initially wished to deliver vaginally and those who had
undergone elective CS could have been those who wished
to deliver by elective CS. A longitudinal cohort study of
women’s preference at different stages throughout their
pregnancy might be able to provide information as to the
causative factors for such differences.
fertilisation was a significant determinant of preference
for elective CS. It has been well described that the
elective CS rate in in-vitro fertilisation pregnancies was
higher than that for natural conception.26-28 The exact
indications for CS were not known, but seem to imply
that such women’s exceptional anxiety probably has
Among nulliparous women, conception by in-vitro
our study cohort might not be representative of the Hong
Kong pregnant women population, because of potential
selection bias. It is well known to women in Hong Kong
that government-funded units do not perform elective
CS for non-clinical indication. Women with strong
preferences for elective CS might therefore have selected
private maternity care. Nonetheless, we encountered a
higher prevalence preferring elective CS compared to
the figures reported from other populations. Prevalence
figures reported from the United Kingdom, Sweden, and
Australia were 14.5, 8.2, and 6.4% respectively.21,23,29 Our
figure was also higher compared to other Asian countries
such as Singapore (3.7%) and Korea (5%).18,19 However,
the latter two studies were performed in non-pregnant
female subjects. Our study data provide no explanation
for the high prevalence for preferring elective CS even
among nulliparous women.
The 16.7% prevalence for preferring elective CS in
preferred elective CS were similar to those of other
populations.18,19,21,29 Areskog et al30 suggested that
6% of pregnant women experience severe fear during
The reasons cited by our pregnant women who
pregnancy. Concerns for the safety of the baby and
labour pains were partly responsible for such fear.31 It is
well recognised that one manifestation of maternal fear
in pregnancy was a request for elective CS.30-33 To explain
the high prevalence of the preference for elective CS in
our population, a study into fear in pregnancy of our
population is mandatory.
of vaginal birth’, and ‘pain associated with vaginal
birth’ as important reasons for choosing elective CS.
A logical approach to reducing maternal requests for
elective CS is to alleviate fear regarding these aspects.
Observational studies have shown that psychotherapy
and extra obstetric support were associated with fewer
women requesting elective CS at term.32,33 To date, there
were only two randomised controlled trials focusing on
whether interventions were useful to reduce the number
of women making such requests. Fraser et al25 used
individualised educational programme in women with
previous CS and Saisto et al34 used cognitive treatment
in women who suffered from fear of vaginal birth. Both
studies showed that there were no significant differences
between the intervention and control groups with respect
to the women’s request for elective CS. There were also
no differences in the clinical and psychological outcomes
of both groups of women. These results may imply that
once fear is established, treatment is not of significant
Women reported ‘safety of the baby’, ‘fear
preferred elective CS. Previous CS is a determinant of
this preference. Women who conceived by in-vitro
fertilisation preferred elective CS. Women who preferred
elective CS are concerned with safety of the baby, fear
of vaginal birth, and pain associated with delivery.
Further studies into quantification and identification of
the causes and objects of fear among Chinese pregnant
women may help in understanding the reasons why they
prefer elective CS.
In conclusion, one in six of our study cohort
Mann-Whitney U test
† Chi squared test
VariableCS, n=62 Vaginal delivery, n=308 P value
Continuous variables*, mean (SD)
Maternal age (years) 29.9 (4.8)28.5 (5.0)0.04
Gestation at survey (weeks) 15.9 (5.5)17.2 (6.2) 0.13
Dichotomous variables†, No. (%)
Family monthly income >HK$30 000 25/61 (41.0) 93/305 (30.5)0.11
History of substance abuse 0/6210/308 (3.2)0.15
Marital status (married) 59/61 (96.7)275/307 (89.6) 0.08
In-vitro fertilisation3/62 (4.8) 4/308 (1.3)0.06
TABLE 5. Socio-demographic and clinical variables associated with preferring elective caesarean section (CS) at univariate analyses of nulliparous women
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