College Students' Knowledge and Attitudes About Cesarean Birth

Over the past 25 years, the number of women in the United States giving birth by cesarean section has increased dramatically. In 1970 approximately one in 20 births was by cesarean section; in 1988 the rate was nearly one in four (1,2). Since 1988, however, the rate has declined. In 1994, 22 percent of women delivered by cesarean section (1), and in 1995 the rate declined to 20.8 percent (3). Despite the recent reduction, the striking rise in the cesarean birth rate during the latter part of this century reflects the “medicalization” of childbirth, the treatment of birth as an illness or pathological state needing medical intervention. Electronic fetal monitoring, labor induction, antenatal testing, and epidural anesthesia have all been cited as contributing factors in the rise in cesarean births (2,4–7). In fact, cesarean birth may be preferred by some as an answer to the trials of labor and delivery (8,9). For example, a recent study of London obstetricians found that 31 percent of female and 8 percent of male obstetricians surveyed chose elective cesarean section as their preferred mode of delivery (8).

Although some women may prefer cesarean section, medical indications and elective repeat procedures account for most of them (10,11). In recent years, however, clinicians and researchers have raised concerns about the necessity of many cesarean sections and their potential adverse consequences. Numerous studies have investigated the physical, psychological, and social impact of cesarean birth (particularly unplanned) on parents and infants (12). Women undergoing cesarean sections reportedly have more frequent obstetric complications (13); increased frequency of depression (13,14); high levels of exhaustion and difficult recuperation (13,15); less frequent interaction with infants (16,17); feelings of profound disappointment with the birth (14,15,18,19); feelings of guilt, failure, or low self-esteem (15,18–20); anger and resentment toward their physicians (15,19); and a stated need for more information about what they experienced (15,21). Although some recent studies (22,23) found fewer negative reactions after cesarean delivery, practitioners and educators responded to the needs of cesarean birth parents by designing preventive interventions (24–28), providing social and emotional support (29,30), and giving cesarean education in most childbirth preparation classes (31,32). Moreover, the operations are now routinely attended by fathers (32). Shearer reasoned that because of the rise in the cesarean birth rate, cesarean mothers no longer feel “different” or “abnormal,”—that today, cesarean birth is commonplace and “almost expected” (32).

Is this the case? Do we view cesarean section as a normal, common way of giving birth today or as a feared, disappointing experience posing significant problems for new parents? Do we appreciate the risk or likelihood of giving birth by cesarean section? Does the public question the necessity and physicians' motives for carrying out many cesareans? Does cesarean section carry a stigma? Although some research has explored the attitudes of pregnant women (33,34) and obstetric nurses (31) about cesarean birth, little research has explored more general, societal knowledge and attitudes. In a survey of 103 college women concerning their expectations about pregnancy and childbirth, the most common questions women would want to ask their caregiver if they were told they might need to deliver by cesarean section were, “What are the risks to the baby?” (85%), “What does the procedure involve?” (70%), and “Why do I need it?/Is it necessary?” (63%) (35). These results reflect a need for practical information about cesarean birth, and possibly some concern about the necessity of cesarean delivery, even when recommended by a health practitioner.

To date, however, research has not explored how the general public (including men) views cesarean birth. This is unfortunate because attitudes and knowledge likely play important roles in the decision-making process both prenatally and during labor, and have significant implications for birth outcomes. For example, recent research shows that choosing a midwife as caregiver during pregnancy and childbirth may significantly reduce the likelihood of having a cesarean section (36).

Our study explored knowledge and attitudes about cesarean birth among a sample of college women and men. Previous research suggests that women of higher socioeconomic status and education are more likely to have cesarean sections (37,38), and may be more likely to be distressed by the use of medical intervention in the birth process than other groups of women (39). Therefore, this study surveyed attitudes about cesarean birth in young women and men attending college who had not yet had children (future consumers of maternity services). The following research questions were addressed: (1) Is cesarean section viewed as a potentially negative experience? (2) Is cesarean delivery seen as a normal or acceptable method of childbirth? (3) Are cesarean births generally seen as medically necessary? (4) What do respondents believe about risk and prevention of cesarean birth?

Methods

Analysis

Table 1 presents the exact wording of items and a summary of the results. Pearson χ² tests were used to compare the frequency of each category of response for men and women on each item. A Bonferroni adjustment on the probability level was required for statistical significance due to the large number of tests (0.05/20 tests, p= 0.0025).

Table 1. . Number and Percentage of Responses to Knowledge and Attitude Questions About Cesarean Section (n= 102)

Results

Many respondents were cynical about the cesarean birth rate. Almost 40 percent thought that many unnecessary cesareans are performed in the United States, and about one-fourth believed that most cesareans could be avoided, that doctors perform some cesareans for convenience or financial incentive, and that some cesareans are performed without real need.

Respondents appeared fairly unsure about risk from a cesarean. About 70 percent were not sure whether or not taking prenatal vitamins lowers a woman's risk of cesarean birth, and 43.3 percent were undecided about whether the likelihood of delivering by cesarean was small. Only 35.4 percent disagreed that once a woman delivered by cesarean, all subsequent deliveries will need to be cesarean sections. However, most (60.4%) believed that not taking care of one's health during pregnancy was not a risk factor.

Most respondents did not view cesarean birth as a potentially negative experience (70.6%). Although almost 28 percent agreed they would be profoundly disappointed by the need for a cesarean delivery, far fewer believed that women who deliver by cesarean miss out on something special (16.7%), feel like failures (6.1%), or suffer long-term health consequences (13.3%).

Results were mixed on items examining whether cesarean is viewed as a normal or acceptable way of giving birth. Although only 6 percent believed others think less of a woman who delivers by cesarean, about half of the sample disagreed that cesarean is a normal way of giving birth, and viewed cesarean as an operation rather than as giving birth. The great majority of participants thought that partners should be allowed in the operating room during delivery (86%). Most indicated they would not choose to have a cesarean delivery (71%), but 13 percent indicated they would prefer a cesarean section to avoid (or have their spouse avoid) the process of labor.

To examine gender differences in knowledge and attitudes about cesarean birth, the number of women and men agreeing versus disagreeing with each item were compared using χ² tests. Using the criterion for significance described above, a gender difference on only one item approached statistical significance. Women were more likely than men to agree that they would be profoundly disappointed if they had to deliver by cesarean section (χ² (1) = 7.923, p= 0.0049). A secondary analysis explored whether men and women differed in the frequency of undecided responses. No significant differences were found when comparing the frequency of undecided versus all other responses by gender.

Discussion

Perhaps the most striking finding of this study was the large number of respondents marking undecided on many of the items, ranging from 7.8 to 69.6 percent across the 20 items; on 16 items more than 20 percent of respondents were undecided, more than 30 percent on 9 items, and nearly 40 percent on 6 items. Women and men did not differ in the use of the undecided response, suggesting that young women are not more informed about aspects of cesarean birth than young men. Since these students are likely to be future consumers of maternity services, these results suggest that obtaining childbirth education about cesarean section is important to address uncertainties about the procedure.

It was also somewhat surprising that the students did not generally differ in their beliefs and attitudes about cesarean birth. Although young women were more likely than young men to indicate they would be profoundly disappointed if they needed a cesarean section, gender differences were not found on any other item. The women did not appear more informed or have different opinions than the men, which may indicate that childbirth is not something about which young persons are concerned until they are faced with having children. Once a woman is pregnant, begins prenatal care, and anticipates the birth process, gender differences in feelings about cesarean birth might emerge. However, recent research suggests that pregnant women judge their own risk of cesarean birth as smaller than that of other childbearing women their age (40). Thus, they may “tune out” information about cesarean section because they view it as unlikely to happen to them, even if they may be exposed to more information than men about cesarean birth before and during pregnancy.

Some respondents in this study appeared cynical about the cesarean birth rate in the United States; almost 40 percent agreed that many unnecessary cesarean births are performed, and only 15 percent disagreed. One in four agreed that most cesarean births could probably be avoided, and thought that at least some physicians perform cesarean operations out of convenience or financial incentive. Holding the view that cesarean sections are often unnecessary might contribute to feelings of disappointment and guilt (e.g., How could I have let this happen to me? What did I do wrong?). These types of reactions to cesarean section appear to be common (14,15,18,19), even in recent studies (23,31). Understanding the reasons for cesarean birth, especially aspects outside the mother's or parents' control, could help to reduce such feelings. However, the high cesarean birth rate appears to be caused by a complex combination of factors that have appeared resistant to change. Expectant women and their partners, therefore, may benefit from talking with their physician about his or her personal cesarean birth rate, and the factors that might have some impact on prevention of a cesarean delivery in their particular case.

The low proportions of participants who said that they would view the need for a cesarean section negatively, that a cesarean would have a long-term impact on the mother's health, and that having a cesarean makes a woman feel like a failure may, in part, reflect our society's acceptance of childbirth as a medical event and of cesarean section as a somewhat benign medical procedure. Because the study participants were all college students without children, however, they are unlikely to have given much thought to issues surrounding childbirth, or had much direct experience with it. They might feel differently about the possibility of a cesarean birth after going through pregnancy and childbirth, or even after seeing close friends go through the experience.

Given that only 10 percent of respondents said they would view a cesarean as a negative experience, it is somewhat surprising that almost half disagreed that cesarean is a normal way of giving birth. Furthermore, 27 percent of respondents said they viewed cesarean section as having an operation, not as giving birth. These findings may reflect the fact that cesarean is seldom a visible method of birth in television, movies, and books. In addition, parents experiencing cesarean birth might be less inclined to share the details about it with family, friends, and acquaintances than those who experienced vaginal deliveries. Although the question about whether or not cesarean is a normal way of giving birth was intended to tap into feelings about the acceptability of cesarean section, these results may indicate that cesarean is viewed as atypical, rather than unacceptable. Only one-fourth of respondents agreed that the likelihood of having a cesarean is very small, however, suggesting that it is not simply seen as statistically unlikely. Further research should address how the general public views actual rates of cesarean delivery, and examine how such information is related to assessment of personal risk for having the procedure. Research should also explore the acceptability and preference for cesarean section among future consumers of maternity services. Such tolerance or even preference may help to explain, in part, why the cesarean birth rate has been somewhat resistant to change.

The major limitation of these data is that they come from a nonrandom sample of college students, which makes generalizing the results difficult. Although most questionnaires distributed in classes were returned, the voluntary nature of the task will have caused some self-selection bias. Students consenting to participate may have had a greater interest in childbirth issues than nonparticipants. In addition, most were unmarried and white, further limiting generalizability.

The results of this study provide some preliminary information about college students' attitudes and beliefs about cesarean section. Additional research should explore attitudes about cesarean section among random samples of men and women as well as those from various social classes and cultural backgrounds. Future studies should also assess the amount and types of coverage given to the topic of cesarean birth in childbirth preparation classes, and the roles physicians, midwives, and nurses play in preparing expectant parents for the possibility of surgical birth. Understanding attitudes and expectations about childbirth, in general, and cesarean section, in particular, will help caregivers and childbirth educators gauge the informational needs of pregnant women and their partners about cesarean section.