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Salient Beliefs Towards Vaginal Delivery in Pregnant Women: a Qualitative Study from Iran Parvin Rahnama1, Khadigheh Mohammadi1 and Ali Montazeri2,3*

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Salient Beliefs Towards Vaginal Delivery in Pregnant Women: a Qualitative Study from Iran Parvin Rahnama1, Khadigheh Mohammadi1 and Ali Montazeri2,3* Rahnama et al. Reproductive Health (2016) 13:7 DOI 10.1186/s12978-016-0120-5 RESEARCH Open Access Salient beliefs towards vaginal delivery in pregnant women: A qualitative study from Iran Parvin Rahnama1, Khadigheh Mohammadi1 and Ali Montazeri2,3* Abstract Background: Childbirth by cesarean section has increased at an alarming rate over the past few years in Iran. The present study was designed to explore pregnant women’s beliefs about the mode of delivery in order to provide some suggestions for future interventions to increase vaginal delivery. Methods: This was a qualitative study framed by the Theory of Planned Behavior conducted in Tehran, Iran in 2013. Pregnant women attending public hospitals were recruited. The data were collected via in-depth interviews and focus group discussions. Interviews were conducted in a semi-structured manner. All interviews were tape recorded and transcribed verbatim. A content analysis approach was used to explore the data. Results: In all 36 pregnant women participated in the study. The mean age of women was 27.8 (SD = 4.5) years. In general, women preferred vaginal delivery. During interviews and focus group discussions several themes emerged related to the pain associated with vaginal delivery, fears of childbirth, related health concerns, and the role of decision makers. The findings were grouped into three main themes namely: behavioral beliefs (negative and positive beliefs towards outcomes of vaginal delivery), normative beliefs (injunctive norms and descriptive norms), and control beliefs (internal and external barriers). Conclusion: Despite the fact that there were positive beliefs regarding vaginal delivery, participants indicated concerns related to loss of control and fear. It is essential that health care providers realize the psychological needs of women during pregnancy and the need for continuous support during childbirth. This type of support may improve their self-control during labor, and decrease fear of childbirth. Keywords: Cesarean section, Theory of Planned Behavior, Normal vaginal delivery Background Apart from the medical or obstetrical indications, The cesarean section rate with no medical indication thechoiceofmodeofdeliverymaybeinfluenceby continues to rise in Iran dramatically. According to the other factors. Two dominant explanations for these Iranian Demographic Health Survey (IDHS) carried out decisions have been raised in the literature: women’s in October 2000, the rate of cesarean section was re- preference for cesarean delivery and service providers’ ported as high as 35 % [1]; however a recent meta- behaviors [6, 7]. Although a number of studies have analysis of 34 studies estimated a cesarean rate of 48 % highlighted women’s preference for elective cesarean in Iran [2]. This is an important public health concern section [8, 9], there is little information regarding as cesarean section is significantly associated with mater- women’s beliefs and attitudes towards vaginal delivery nal and neonatal morbidity [3–5]. [10]. Most existing is quantitative, cross-sectional in nature, and mainly focuses on women’s preference and * Correspondence: [email protected] associated factors derived from statistical analyses [11, 12]. 2Mental Health Research Group, Health Metrics Research Center, Iranian A few qualitative studies looked at women’s beliefs Institute for Health Sciences Research, ACECR, Tehran, Iran 3Faculty of Humanity Sciences, University of Science & Culture, ACECR, regarding vaginal delivery. For instance, a qualitative Tehran, Iran study in Argentina of 29 nulliparous women revealed Full list of author information is available at the end of the article © 2016 Rahnama et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rahnama et al. Reproductive Health (2016) 13:7 Page 2 of 8 that most women preferred vaginal delivery. The Methods study used a pre-designed guide based on the health Design and data collection belief model and social cognitive theory and revealed This was a qualitative study framed by the Theory of that most women preferred vaginal delivery due to Planned Behavior in Tehran, Iran in 2013. The data were cultural, personal, and social factors and it was collected using in-depth interviews and focus group dis- viewed as normal, healthy, and a natural rite of pas- cussions with pregnant women. Participants were re- sage from womanhood to motherhood. The study cruited from pregnant women attending public hospitals found that women viewed pain associated with vagi- willing to participate. Recruitment of participants for the nal delivery positively, while they viewed cesarean in-depth interviews (n = 16) and the focus group discus- section as a medical decision [13]. Similarly an inves- sions (n = 20) were based on purposeful sampling. Preg- tigation from Northern Iran studying 12 pregnant nant women were included if they were: 18–35 years women, 10 women with previous experience of child- old; over 32 weeks of gestational age; without complica- birth, seven midwives, seven obstetricians, and nine tion during pregnancy; and without preexisting medical non-pregnant women and using a ethnographic ap- illness. In-depth interviews were conducted in a semi- proach found that cultural beliefs, values and tradi- structured manner. Interviews focused on the perceived tions significantly affected individuals’ attitudes outcomes of vaginal delivery. The outcomes included towards the mode of delivery, definitions of different the woman’s positive or negative beliefs of having a vagi- modes, and the decisions they made or would make nal delivery. Also, we asked women to indicate how in the future in this regard [14]. Interestingly a study other people, who may be in some ways important to from Sanandaj interviewed 22 Kurdish pregnant them, would approve or disapprove of vaginal delivery. women in their third trimester and found that 18 pre- Finally women were asked about factors that might ferred vaginal delivery while four preferred cesarean sec- inhibit or facilitate vaginal delivery. The duration of in- tion. The authors identified four explanations for terviews ranged from 35 to 45 min. The data collection these preferences: safety of baby, fear of surgery, pre- was continued until data were considered saturated and vious experience and social support [15]. A mixed no new data were emerging. Also two focus group dis- method study in Tehran using the extended parallel cussions consisting of 10 pregnant women each (n = 20) process model (EPPM) reported that there was insuf- were held. The focus group discussions had an open and ficiently knowledge and wide misconceptions regard- semi-structured contradict each other; either it was un- ing modes of delivery, which influenced the choice of structured or semi-structured, each lasting approxi- method for delivery. Results of this study also showed mately 60 to 70 min, and began with a few general that self-confident women were more likely to plan to questions to initiate conversation. Focus group facilita- deliver vaginally [16]. tors used probes as necessary to provoke discussions. Pregnant women’s beliefs in relation to vaginal Participants were encouraged to talk freely and not to delivery are important factor when developing inter- hesitate in sharing their experience and feelings. ventions to reduce unnecessary cesarean sections, All in-depth interviews and focus group discussions especially if a theory-driven approach could be were tape-recorded, transcribed verbatim, and analyzed applied. Thus, the present study aimed to explore subsequently. PR (a female midwife and doctorate in pregnant women’s beliefs regarding vaginal delivery health education) and KM (a female midwife and repro- using the Theory of Planned Behavior (TPB) as a ductive health expert) both with experience in conduct- framework. ing qualitative studies carried out interviews and focus The Theory of Planned Behavior is a social cognitive group discussions. There was no relationship between model of decision-making that provides a useful frame- interviewers and participants. All interviews and focus work for explaining health behaviors [17, 18]. The TPB group discussions were carried out in a private setting in suggests the central determinant of behavior is the the hospitals. intention to perform a given behavior. The three core components to predict intention according to TPB are Data analysis attitude, subjective norms and perceived behavioral con- The transcripts were read, re-read and analyzed separ- trol (PBC). ately by two researchers. A content analysis approach The attitude refers to behavioral beliefs about a par- was used to derive codes, categories, sub-themes, and ticular outcome. The subjective norms refers to whether themes from the data. Transcripts were read several it is believed that others will approve or disapprove of times to gain primary perception and identify the initial the behavior Perceived behavioral control refers to be- codes or meaning units. The combinations
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