European Journal of Cardiovascular Medicine

Over the past few decades, the global rate of cesarean sections (CS) has risen significantly, surpassing the World Health Organization’s recommended threshold of 10–15% in many countries (WHO, 2015). While CS is a critical surgical intervention that can prevent maternal and perinatal morbidity and mortality in medically indicated situations, the growing prevalence of elective cesarean deliveries—those chosen without clinical necessity—has prompted public health concerns and ethical discussions. Understanding the maternal motivations behind elective cesarean sections is essential in providing respectful maternity care and addressing unnecessary surgical interventions.

One of the most frequently cited maternal reasons for requesting an elective CS is the intense fear of labor and vaginal delivery, known as tokophobia. This condition can stem from a wide range of sources, including anxiety disorders, previous traumatic birth experiences, or the anticipation of pain and loss of control during vaginal birth [1]. For some women, the predictability and perceived safety of a scheduled cesarean are reassuring, especially in contrast to the uncertainties of spontaneous labor [2].

In addition to psychological factors, socio-cultural and personal beliefs significantly influence maternal preferences. In certain cultures, auspicious dates and times for birth are highly valued, leading women to choose CS as a way to ensure their child is born at a specific moment [3]. Moreover, women with higher educational backgrounds and career responsibilities may prefer the convenience and planning flexibility offered by elective cesareans [4]. Media portrayals and anecdotal experiences shared online or within social circles can also skew perceptions of vaginal birth as inherently risky or traumatic, reinforcing preferences for surgical delivery [5]. Previous negative obstetric experiences, such as prolonged labor, emergency cesareans, or perineal trauma, further contribute to maternal decisions for elective CS in subsequent pregnancies. Some women may also have experienced a lack of autonomy or respectful care during prior births, leading them to view CS as a way to reclaim control over their birthing experience [6]. Additionally, healthcare providers’ attitudes and the availability—or lack—of supportive services such as midwifery care or birth education can either discourage or reinforce maternal requests for elective cesareans.

As elective cesarean sections become more prevalent, it is crucial to consider the maternal rationale within a broader context of informed choice, bodily autonomy, and psychological well-being. While unnecessary cesareans pose risks such as infection, blood loss, and longer recovery times, dismissing maternal concerns can compromise the trust between women and healthcare systems. Therefore, a balanced approach— one that acknowledges maternal fears and preferences while offering evidence-based guidance—is imperative for ethical and patient-centered obstetric care.

·         Study Area: LD Hospital Srinagar

·         Study Design: Qualitative Observational study

·         Study Duration: 1st July 2023 – 31st December 2023.

·         Study Population: Women who requested cesarean sections and fulfilling inclusion criteria

Inclusion Criteria:

·         Singleton pregnancy of women aged 18 and above

·         No medical indication for cesarean section

·         Informed consent to participate in the study

Exclusion Criteria:

·         Medical indications necessitating cesarean section

Data Analysis: By Content analysis.

Four stages:

·         Decontextualization

·         Recontextualization

·         Categorization

·         Compilation

Data Collection

·         Women          were        invited    to            participate             and         assured  with        regard     to confidentiality and anonymity.

·         Women were individually interviewed) in the antenatal clinic in a private room using a narrative style

·         Opening with: “Could you please tell me the reasons why you choose to have cesarean birth?”

·         If the concept was not clear, participants were asked to explain in more detail, until the reasons were clarified

Table 1: Questions asked to patients

The total number of deliveries done during study period of 6 months were 9720. Out of the 6,480 cesarean sections performed, 386 were due to maternal request.

Maternal indications for cesarean section are a major contributor to the global rise in cesarean delivery rates and reflect the complexities of maternal health during pregnancy and childbirth. These indications are medically justified when vaginal delivery poses significant risks to the mother’s health, and they include conditions such

as obstructed labor, hypertensive disorders, infections, previous uterine surgery, and certain chronic diseases.

Obstructed labor, often due to cephalopelvic disproportion or fetal malpresentation, is one of the leading maternal indications for cesarean delivery. If not managed promptly, it can result in severe maternal complications such as uterine rupture, fistula formation, or sepsis [7]. In such scenarios, a cesarean section becomes a critical intervention to prevent maternal morbidity and mortality.

Hypertensive disorders of pregnancy, including preeclampsia and eclampsia, represent another significant indication. These conditions can lead to severe complications such as stroke, liver failure, and placental abruption if not treated appropriately. In many cases, cesarean delivery is recommended to expedite birth and reduce risks to the mother [8]. Maternal infections such as active genital herpes or HIV with a high viral load also justify cesarean delivery to minimize the risk of vertical transmission to the neonate [9]. Additionally, women with pre-existing medical conditions like cardiac disease, poorly controlled diabetes, or neurological disorders may be unable to tolerate the physiological stress of labor, making cesarean delivery a safer alternative [10]. Women with previous cesarean sections face the risk of uterine rupture during a trial of labor after cesarean (TOLAC), especially in the absence of adequate monitoring or surgical readiness, thereby justifying a repeat cesarean in certain cases [11]. Despite being necessary in many cases, cesarean sections should be carefully considered due to associated risks like infection, hemorrhage, and prolonged recovery. A balanced approach involving risk assessment, evidence-based guidelines, and individualized care planning is essential to ensure cesarean sections are reserved for appropriate maternal indications.

Maternal reasons for cesarean section represent a crucial component of obstetric care, often acting as life-saving interventions in the face of medical or obstetric complications. Conditions such as obstructed labor, hypertensive disorders, infections, prior uterine surgeries, and chronic illnesses can significantly compromise the safety of vaginal delivery, making cesarean section the most appropriate and safest mode of delivery in such cases. While cesarean delivery can reduce the risk of adverse maternal outcomes when medically indicated, it is not without potential complications, including surgical risks, longer recovery times, and implications for future pregnancies.

Therefore, careful assessment, timely diagnosis, and individualized clinical decision- making are essential to ensure cesarean sections are performed based on sound medical justification rather than non-medical preferences or convenience. In doing so, healthcare providers can promote maternal safety while avoiding unnecessary surgical interventions. As global cesarean rates continue to rise, reinforcing adherence to evidence-based guidelines and improving access to quality maternal care will be key to ensuring optimal outcomes for both mothers and their babies.

1.       Bayrampour, H., Heaman, M., Duncan, K. A., & Tough, S. (2012). Advanced maternal age and risk perception: A qualitative study. BMC Pregnancy and Childbirth, 12, 100.

2.       Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. Childbirth Connection.

3.       Hofberg, K., & Brockington, I. (2000). Tokophobia: An unreasoning dread of childbirth. The British Journal of Psychiatry, 176(1), 83–85.

4.       Karlström, A., Nystedt, A., Johansson, M., & Hildingsson, I. (2011). Behind the myth – few women prefer caesarean section in the absence of medical or obstetric indications. Midwifery, 27(5), 620–627.

5.       Størksen, H. T., Garthus-Niegel, S., Adams, S. S., Vangen, S., & Eberhard- Gran, M. (2015). Fear of childbirth and elective caesarean section: A population-based study. BMC Pregnancy and Childbirth, 15(1), 221.

6.       World Health Organization. (2015). WHO Statement on Caesarean Section Rates. Geneva: WHO.

7.       Yazdizadeh, B., Nedjat, S., Mohammadi, E., Majdzadeh, R., & Rashidian,(2006). Cesarean section rate in Iran, multidimensional approaches for behavioral change of providers: A qualitative study. BMC Health Services Research, 6(1), 83.

8.       American College of Obstetricians and Gynecologists. (2020). Practice Bulletin No. 207: Gynecologic care for women with HIV. Obstetrics & Gynecology, 135(5), e221–e236.

9.       Dolea, C., & AbouZahr, C. (2003). Global burden of obstructed labour in the year 2000. World Health Organization.

10.    Guise, J. M., Denman, M. A., Emeis, C., et al. (2010). Vaginal birth after cesarean: New insights. Evidence Report/Technology Assessment No. 191. AHRQ.

11.    Magee, L. A., Pels, A., Helewa, M., Rey, E., & von Dadelszen, P. (2014). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertension, 4(2), 105–145.