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Spontaneous vaginal delivery or caesarean section? What do Turkish women

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Article  in  International Journal of Nursing Practice · February 2013

DOI: 10.1111/ijn.12029 · Source: PubMed

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International Journal of Nursing Practice 2013; 19: 1–7

RESEARCH PAPER

Spontaneous vaginal delivery or caesarean

section? What do Turkish women think?
Şenay Ünsal Atan RN PhD
Assistant Professor, Department of Gynaecological and Obstetric Nursing, Ege University Nursing Faculty, Izmir, Turkey

Emel Tasci Duran RN PhD

Assistant Professor, Department of Gynaecological and Obstetric Nursing, Suleyman Demirel University Health Sciences Faculty, Isparta, Turkey

Oya Kavlak RN PhD

Assistant Professor, Department of Gynaecological and Obstetric Nursing, Ege University Nursing Faculty, Izmir, Turkey

Sevgul Donmez RN PhD student

Research Assistant and Instructor, Department of Gynaecological and Obstetric Nursing, Ege University Nursing Faculty, Izmir, Turkey

Umran Sevil RN PhD

Professor, Department of Gynaecological and Obstetric Nursing, Ege University School of Nursing, Izmir, Turkey

Accepted for publication February 2012

Atan ŞÜ, Duran ET, Kavlak O, Donmez S, Sevil U. International Journal of Nursing Practice 2013; 19: 1–7
Spontaneous vaginal delivery or caesarean section? What do Turkish women think?

The aim of this study was to describe women’s feelings, attitudes and beliefs about different modes of childbirth. A
descriptive cross-sectional study was conducted at the obstetrics clinics of Ege University and Dr Ekrem Hayri Ustundag
Obstetrics and Gynaecology Hospital in Izmir, Turkey. Three-hundred forty-two women who had given birth via
spontaneous vaginal delivery (SVD) or caesarean section (C/S) between June and December 2009 voluntarily agreed to
participate. Fifty-seven per cent of participants were aged 20–24. Sixty per cent of the women (n = 205) had undergone
C/S during their last delivery; among these women, the birth method of 90% (n = 185) was decided by their doctors,
whereas the remaining 10% (n = 20) made the decision themselves or with their partners. Sixty-three per cent (n = 250)
of women who underwent C/S said that if they gave birth again, they would prefer to deliver via SVD. Eighty-eight per
cent (n = 300) of women wanted the legal right to choose their birth method. Although the rate of C/S was high, most
women stated that if given the choice, they would prefer a SVD if they had another child.
Key words: caesarean section, delivery, ethical issues, Turkey, women’s health.

Correspondence: Şenay Ünsal Atan, Department of Gynaecological and
Obstetric Nursing, Ege University Nursing Faculty, 35100 Bornova,
Izmir, Turkey. Email: unsalsenay@yahoo.com; senay.unsal.atan@
ege.edu.tr
INTRODUCTION
In Turkey, the Ministry of Health says that caesarean
sections (C/S) can be performed when a spontaneous
vaginal delivery (SVD) cannot be safely completed or
when there is a significant risk of maternal and/or foetal
morbidity or mortality.1 According to data from the
Turkish Ministry of Health, 31% of childbirths in public

doi:10.1111/ijn.12029 © 2013 Wiley Publishing Asia Pty Ltd

2 ŞÜ Atan et al.
hospitals in 2001 were via C/S, which declined to 45% in
2010.2 According to the results of the 2008 Turkey
Demographic and Health Survey, 37% of births were via
C/S.3,4 In some university hospitals in Turkey, the pro-
portion of C/S deliveries has reached 70%.5 However,
the target of the World Health Organization (WHO) for
the percentage of caesarean births, taking into account
maternal and perinatal mortality rates, is 10–15%.6,7
According to Gibbons et al., approximately 18.5 million
C/S are performed yearly worldwide. Approximately
10% of countries have C/S rates between 10% and 15%,
and approximately 50% of countries have C/S rates
above 15%.2
According to the laws of Turkey, midwives and obste-
tricians decide the mode of delivery. However, studies
conducted in Turkey have found that one of the indica-
tions for C/S is elective maternal request. In our country,
some women leave midwives and obstetricians to decide
the mode of delivery, whereas other women insist on
delivery by C/S. In 2003, The American Congress of
Obstetricians and Gynecologists recommended accept-
ance of medically elective caesarean delivery based on the
principles of patient autonomy and informed consent.
The committee opinion stated, ‘If the physician believes
that caesarean delivery promotes the overall health and
welfare of the women and her foetus more than vaginal
delivery, he or she is ethically justified in performing a
caesarean delivery’.8 The International Federation of
Gynecology and Obstetrics guidelines, however, state
that ‘because hard evidence of net benefit does not exist,
performing caesarean delivery for nonmedical reasons is
not ethically justified’.9 In Italy, ‘Law 23’ guarantees the
pregnant woman’s right to take part in all stages of
decision-making during pregnancy and birth and to
choose the method of birth.10,11 According to feminist
thinking, the woman must have the right to choose the
type of birth and the type of aesthetic.12 In Turkey, the
Ministry of Health does not look favourably upon elective
caesareans.
METHODS
Design and sample
The aim of this study was to describe women’s feelings,
attitudes and beliefs about different modes of childbirth. A
descriptive cross-sectional study was conducted at the
obstetrics clinics of Ege University and Dr Ekrem Hayri
Ustundag Obstetrics and Gynecology Hospital in Izmir,
Turkey, between June and December 2009. A total of
© 2013 Wiley Publishing Asia Pty Ltd
6507 women gave birth in the two hospitals between
June and December 2008. A sample size calculation was
performed, which yielded a necessary sample size of
363 women.13,14 This formula is given in the following.
Random sampling was adopted. In total, 375 women
were invited to take part in the study; 342 accepted the
invitation, yielding a recruitment rate of 91.2%.
NZ 2P (1 − P )
n′ =
d 2 (N − 1) + Z 2P (1 − P )
n′ = Sample size with finite population correction,
N = 2057 (Population size),
Z = 1.96 (Statistic for a level of confidence),
P = 0.5 (Expected proportion (in proportion of one)),
d = 0.05 (Precision (in proportion of one)).
Exclusion criteria included severe medical complica-
tions and the inability to answer questions for psychologi-
cal reasons; in addition, those who underwent assisted
births using vacuum or forceps were excluded from the
study.
Procedure
A questionnaire was designed by researchers on the basis
of published research. We used a two-page questionnaire
(consisting of 37 questions). This questionnaire included
closed and open-ended questions on various aspects of
different modes of childbirth. The questionnaire had
three parts. The first part covered sociodemographic char-
acteristics (age, education, occupation, monthly income,
partner education, partner occupation, etc.) and women’s
background fertility characteristics (number of pregnan-
cies, number of births, number of abortions, etc.). The
second part consisted of questions about examination
behaviour the women most recent pregnancies, informa-
tion relating to birth methods and other sources of infor-
mation relating to birth methods (Did you receive any
information about the birth method before birth?, Which
delivery method generally was suggested to you in this
information?, Did you follow the news about method of
birth on TV/radio and newspapers during your preg-
nancy?, etc.). The third part consisted of questions about
the feelings, attitudes and behaviours of women who
chose different birth methods (Did you delivered your
baby with which method?, Who decided about method of
birth?, If you were pregnant again and decided the method
of birth by yourself, would you prefer which method of
birth?, Do you think that women should be given the legal
right to choose the method of delivery?, etc.). The face
What do Turkish women think? 3

validity of the questionnaire was obtained by asking expert Table 1 Characteristics of participants (n = 342)
opinion: the opinions of five university lecturers in gynae-
cology and obstetrics nursing department. Changes to the n %
questionnaire were made according to the experts’ sug-
gestions. The questionnaire was subsequently tested for Age
comprehensibility by 20 women who were not included 19 and under 113 33.0
20–24 196 57.3
in the study and changes were made based on their rec-
25–29 33 9.7
ommendations. It was found to be acceptable. Research-
Education
ers collected the study data from women in face-to-face Literate 16 4.7
interviews approximately 24 h after the birth. Elementary and junior school 180 52.6
High school and above 146 42.7
Occupation
Data analysis Employed 88 25.7
The data were analysed using the SPSS version 11.0 for Unemployed 254 74.3
Windows (SPSS Inc., Chicago, IL, USA). The obtained Monthly income (1USD ª 1.84 TL)
data were analyzed for the numerical and percentage 500 TL and below 52 15.3
distribution, average, standard deviation and chi-square 500–1000 TL 165 48.2
tests. The results were reported as numbers (percentages) 1000 TL and above 125 36.5
and as means. Chi-square analysis was used to determine Number of pregnancies
the relationship between some variables and method of 1 157 45.9
birth. P < 0.05 and P < 0.00 were accepted as the crite- 2 and above 185 54.1
rion for statistical significance. Number of births
1 164 48.0
2 and above 178 52.0
Ethical considerations Delivery method
The study was carried out in accordance with the princi- SVD 137 40.1
ples of Helsinki Declaration. For conducting the study, C/S 205 59.9
permission was taken from the scientific ethics committee
of Ege University Nursing Faculty. Also for conducting
the study, a written permit has been taken from the Ege On examining the participants’ most recent pregnan-
University Hospital and Dr Ekrem Hayri Ustundag cies, it was found that 99% had check-ups during their
Gynaecology and Maternity Hospital. Verbal consent was pregnancy; 45% had 11 or more check-ups and 69%
obtained from all women stating that they were willing to (n = 236) had check-ups or treatment at a hospital. Sixty-
participate in the study. five per cent of the women had obtained information
relating to birth methods in the period before giving
birth, 28% (n = 96) had obtained information from
RESULTS their families, 24% (n = 83) from the printed media and
Thirty-three per cent of the participants were 19 years old 37% (n = 125) from the health team (physician, midwife
or younger, and 57% were aged 20–24; the average age or nurse). Over 70% (n = 160) of the women had obtained
was 27.7 ⫾ 5.3 years. Fifty-three per cent of the women information advising an SVD, 21% (n = 49) had obtained
giving birth completed elementary and junior school, information advising a C/S and 6% (n = 14) had not
74% were housewives, 17% were government employees obtained information advising either birth method. When
and 48% had a monthly income of 500–1000 TL asked whether the information they had received on birth
(1 USD ª 1.84 TL). Forty-nine per cent of the women’s methods had been sufficient, 28% (n = 97) of the women
partners were educated to a high school and above, and stated that they had not found the information adequate,
94% were working. Forty-six per cent of the women had and 24% (n = 82) said that they had found the information
a history of one pregnancy (n = 157), for 48% (n = 164) partly sufficient. Sixty-six per cent (n = 224) of the women
this was their first live birth and 2% (n = 7) had under- stated that they had followed news relating to birth
gone an abortion (Table 1). methods on the radio or television or from newspapers

© 2013 Wiley Publishing Asia Pty Ltd

4 ŞÜ Atan et al.

during their pregnancy, and 92% (n = 205) said that the
news they had seen advised an SVD.
Sixty per cent (n = 205) of the women had undergone
a C/S, whereas 40% (n = 137) had delivered via SVD
(Table 1). In their most recent pregnancy, 17% of primi-
parous women (n = 28) had SVD and 83% (n = 136) had
a C/S, whereas 61% (n = 109) of multiparous women
had SVD and 39% (n = 69) had a C/S. In addition, it was
found that 77% (n = 262) had become pregnant deliber-
ately. A significant difference was found between the
work status (c2 = 7.036, P = 0.00), the number of
check-ups (c2 = 7.704, P = 0.05), go to private clinics
for check-ups (c2 = 3.685, P = 0.03) and method of
birth. Rates of C/S are higher in working women, women
who are making eleven times check-ups and who are
going to private clinics for check-ups.
This study found that health professionals determined
the method of birth in 75% of cases, whereas the
woman and her partner made the decision in 25% of
cases. For 47% (n = 65) of women who had SVD
(n = 137) and 10% (n = 20) of the women who had a
C/S (n = 205), the choice of birth method was made
by the woman and her partner. In cases where they
chose SVD, there were no contraindications to SVD. All
women who chose a C/S were primiparous (Table 2).
Although health professional preferred a C/S as the
method of birth in 72% (n = 185) of cases, in 77%
(n = 65) of cases where the woman and her partner
decided, SVD was preferred.
Among couples who chose SVD, 54% (n = 34) did so
because they thought that this method was more healthy,
34% (n = 22) chose SVD because the risk was lower and
14% (n = 9) chose SVD because they thought it was a
more comfortable method of delivery. Among the
couples who chose a C/S, 45% (n = 9) chose it because
they were afraid of an SVD, 30% (n = 6) chose it because
they thought it would be a more comfortable method of
birth, and 25% (n = 5) chose it because they thought C/S
was more healthy (Table 3).
In addition, 84% (n = 115) of women who had an SVD
(n = 137) and 64% (n = 130) of women who had a C/S
(n = 205) stated that they would choose SVD if they had
another child; 88% of women (n = 300) stated that
women should be given the legal right to choose the
method of delivery.
DISCUSSION
The aim of this study was to describe women’s feelings,
attitudes and beliefs about different modes of delivery. In
our study, approximately three-fifths (60%) of women had
caesarean deliveries. Although the WHO recommends
that the proportion of caesarean births be limited to
10–15% in high-income countries, such as Australia,
France, Germany, Italy, North America and Britain, as
well as in low-income countries, such as Brazil and India,15
the C/S rate is dramatically increasing, which is also true in
Turkey.4,16,17 C/S rates were 7% in 1993, but rose to 14%
in 1998,18 21% in 2003, 37% in 20084 and 45% in 2010.1
C/S rates in Turkey vary by region, and the same study
shows a C/S rate of 16% in the east of the country and a rate
of 54% in the west.3,19 The higher rate in the west can be
attributed to the higher socioeconomic level compared
with the east. Other studies recently carried out in Turkey
show caesarean rates varying between 40% and 75%
depending on the hospital or region where the study was
conducted.16,17,20,21 The rapid rise in the proportion of C/S
in Turkey has exceeded WHO recommended levels and
also those of European countries, and therefore, the Min-
istry of Health has begun to take measures to reduce the

Table 3 Couple reasons for choosing a delivery method

Table 2 Person who decided the method of the most recent birth
Reasons for choosing a Delivery method Total
Person who Delivery method Total delivery method
decided the SVD C/S
delivery method SVD C/S n (%) n (%) n (%)
n (%) n (%) n (%)
Less risk 22 (33.8) 0 (0.0) 22 (25.9)
Health professional 72 (52.6) 185 (90.2) 257 (75.1) Birth fear 0 (0.0) 9 (45.0) 9 (10.7)
Women and her 65 (47.4) 20 (9.8) 85 (24.9) More healthy 34 (52.4) 5 (25.0) 39 (45.9)
partner More comfortable 9 (13.8) 6 (30.0) 15 (17.5)
Total 137 (100.0) 205 (100.0) 342 (100.0) Total 65 (100.0) 20 (100.0) 85 (100.0)

© 2013 Wiley Publishing Asia Pty Ltd

What do Turkish women think?
rate of C/S. The performance scores of doctors who attend
births via SVD will be raised, whereas those of doctors who
perform C/S will be reduced. All-inclusive prices paid to
hospitals for births will be weighted in favour of SVD.
Physicians who perform C/S without indications will
receive training, and university hospitals where C/S rates
are high will be examined. In addition, there is a plan to
prepare a new informed consent form that will explain that
a C/S should not be performed unnecessarily. In new
hospitals, labour wards and delivery rooms will be as single
rooms, and new campaigns will encourage mothers-to-be
who have chosen a C/S for personal reasons to accept an
SVD. Finally, the health ministry has started a mother-
friendly hospital programme.
In our study, approximately 1 in 10 women who had a
C/S chose the method themselves, a rate similar to those
found in studies of developed countries. Although 17% of
women in Italy,22 9% of women in Chile23 and 6% of
women in Australia preferred a C/S,24 studies carried out
in Turkey show that women choose C/S at a rate of
7–30%.20,25–27 It has been shown that one of the reasons
for the current rise in the overall C/S rate is the perform-
ance of elective caesareans.20
More than half of the women who chose SVD in our
study stated that they chose it because it was healthier, and
approximately one-third stated that there was less risk.
Studies have found many reasons why women choose
SVD, including the view of birth as a natural event, the
wish to retain control, the desire to experience vaginal
birth, quick recovery and discharge from the hospital,
lower complication rates, fear of anaesthesia or opera-
tions, safety of the mother, better bonding with the child,
less pain in the postnatal period, the idea that it is healthier
and that the baby will be able to suckle immediately, the
idea that it is safer, that ‘SVD is best’ and the support of
the partner with respect to vaginal birth. Women who
chose C/S chose this method because of the fear of the
pain of SVD, the fear of contractions or tearing, safer
childbirth, or safety for the baby.20,23–31 These findings are
consistent with the literature. Almost half of the women
who chose C/S chose it because they feared vaginal birth.
For example, there were up to 10 women in the labour
ward at any one time waiting to give birth. When one
woman cried out, it could cause panic among the others.
A mother-to-be in this state of psychological stress, fear
and panic might prefer a C/S.
In our study, approximately three-quarters of women
who had an SVD and roughly two-thirds of those who had
5
a C/S said that they would choose SVD if they had addi-
tional children. Similarly, in other studies of primiparous
and nulliparous women, most women who were planning
to have another child said that they would choose
SVD.22,24,28,29 We believe that the number of women
choosing SVD would rise if women received correct
information on birth methods, if women were prepared
for delivery with antenatal courses, if the conditions in
maternity wards were improved and if the right to
informed consent was properly applied.
The great majority (88%) of women who took part in
our study wanted the right to autonomy concerning birth
method. In recent years, the adoption of a family-centred
approach has encouraged women to decide for themselves
the type of care that they wish to receive, the sort of
professional they wish to carry it out, the desired location
of delivery and the desired degree of intervention. The
rights of women to request C/S have been discussed.32
The ethical, legal and economic implications of perform-
ing C/S for maternal request are significant and have been
discussed at length, but a consensus has yet to be reached.
Therefore, it is the duty of midwives and obstetricians
to have information available for expectant mothers
asking about SVD and C/S. Additionally, this topic must
be included in a wide-ranging discussion in Turkey. The
results of this study are important for future studies
related to this subject and could be used as guidance for
prenatal care consultants and for the development of
future policies.
In conclusion, the study has identified women’s feel-
ings, attitudes and beliefs about different modes of deliv-
ery in Turkey. Although the C/S rate is high, most
women, regardless of whether they had an SVD or a C/S,
stated that if they had another child and could choose the
mode of delivery, they would choose an SVD. In addition,
the great majority of women wanted the legal right to
choose the method of birth. With medical advances in the
past few years, C/S has reached epidemic proportions
worldwide. In Turkey, methods are being sought to
reduce the level of C/S to the level recommended by the
WHO. In response to this, attempted description of
women’s feelings, attitudes and beliefs about different
modes of delivery was made. The results of this study will
increase awareness of this issue among health profession-
als. Health professionals should be able to fully inform
women of the advantages and disadvantages to themselves
and their babies of various birth methods and should take
into account women’s views and concerns about mode of
© 2013 Wiley Publishing Asia Pty Ltd
6 ŞÜ Atan et al.
delivery.33,34 In addition, the results of this survey can
serve to inform future studies on their thoughts to decide
method of birth was conducted.
LIMITATIONS
A limitation of the study is that it was performed in a
single city in the western part of the country. Izmir is a
region inhabited by people migrating from different
regions of Turkey. Turkey has different cultural groups,
which might influence the choice of birth method in dif-
ferent regions of Turkey. However, it is thought that the
sample size was sufficient to detect differences in this
population. The inclusion of women with different socio-
economic levels is an advantage of this study.
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