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Cited by 152Maternal and Perinatal Health InterventionsReproductive Health and ContraceptionAnesthesia and Pain Management

Prevalence of and reasons for women’s, family members’, and health professionals’ preferences for cesarean section in Iran: a mixed-methods systematic review

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Shirzad, Mahboubeh, Shakibazadeh, Elham, Hajimiri, Khadijeh, Betran, Ana Pilar, Jahanfar, Shayesteh, Bohren, Meghan A., Opiyo, Newton, Long, Qian +3 more·2021·Reproductive Health
DOI 10.1186/s12978-020-01047-xPMC PMC7778821
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Abstract

Background: Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women’s, family members’, and health professionals’ preferences for CS in Iran. Methods and findings: In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38–5.50%; χ 2 = 1117.39; df = 28 [p < 0.00001]; I 2 = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86–5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74–3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: ‘Women’s factors’, ‘Health professional factors’, andex ‘Health organization, facility, or system factors’. Conclusion: Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the “health sector evolution policy”. Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS.

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  • An analytical cross-sectional study in Tehran (2016) involving 400 pregnant women found that occupation, education, parity, prior delivery method and participation in childbirth education classes were significantly associated with preference for vaginal delivery.

    “An analytical cross-sectional study in Tehran (2016) involving 400 pregnant women found that occupation, education, parity, prior delivery method and participation in childbirth education classes were significantly associated with preference for vaginal delivery.”

    From Determinants of the choice of delivery mode in pregnant women: a convergent parallel mixed-methods study protocol (2026) · cites this paper as [40]

    Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • A qualitative study among primiparous women with previous vaginal birth experience identified themes such as 'internal control', 'external control' and 'support' as key determinants of positive or negative childbirth experiences.

    “A qualitative study among primiparous women with previous vaginal birth experience identified themes such as ‘internal control’, ‘external control’ and ‘support’ as key determinants of positive or negative childbirth experiences, highlighting the importance of woman-centred care.”

    From Determinants of the choice of delivery mode in pregnant women: a convergent parallel mixed-methods study protocol (2026) · cites this paper as [40]

    The Results (Women’s factors and Qualitative synthesis; page not available) discuss women’s self-control during labour and the importance of supportive, respectful care. But this source is a systematic review, not the qualitative study described, and our copy does not identify ‘internal control’, ‘external control’ and ‘support’ as that study’s themes or establish the stated participant history. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Understanding how psychological, social and systemic factors interact to influence women's choices remains incomplete.

    “Understanding how psychological, social and systemic factors interact to influence women’s choices remains incomplete, underscoring the rationale for the present mixed-methods study.”

    From Determinants of the choice of delivery mode in pregnant women: a convergent parallel mixed-methods study protocol (2026) · cites this paper as [40]

    The Conclusion (page unavailable) identifies individual, health-facility and health-system factors affecting cesarean preference in Iran, and says high cesarean rates despite low preference among women imply influences beyond individual choice. The Results also describe social beliefs and experiences with care. The paper does not establish that understanding of how these factors interact remains incomplete; that knowledge-gap claim goes beyond the cited passages. (LLM, conf=0.77)

    Experimental — accuracy not yet measured

  • While several quantitative and qualitative studies have explored delivery preferences in Iran, there is a limited number of mixed-methods studies.

    “These studies demonstrate that while several quantitative and qualitative studies have explored delivery preferences in Iran, there is a limited number of mixed-methods studies.”

    From Determinants of the choice of delivery mode in pregnant women: a convergent parallel mixed-methods study protocol (2026) · cites this paper as [40]

  • A mixed-methods systematic review of studies in Iran (1990-2019) included 65 quantitative studies and 26 qualitative studies, revealing that despite low individual preference for caesarean section among nulliparous women, national CS rates remain high (47.9%), reflecting the influence of health professional and system-level factors.

    “Furthermore, a mixed-methods systematic review of studies conducted in Iran (1990–2019) included 65 quantitative studies and 26 qualitative studies, revealing that despite low individual preference for caesarean section among nulliparous women, national CS rates remain high (47.9%), reflecting the influence of health professional and system-level factors.4042”

    From Determinants of the choice of delivery mode in pregnant women: a convergent parallel mixed-methods study protocol (2026) · cites this paper as [40]

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Research works printed but not linked: 73

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Authors
Shirzad, M., Shakibazadeh, E., Hajimiri, K., Betran, A. P., Jahanfar, S., Bohren, M. A., Opiyo, N., Long, Q., Kingdon, C., Colomar, M., & Abedini, M.
Affiliations
  • Tehran University of Medical Sciences (IR)
  • Zanjan University of Medical Sciences (IR)
  • Tufts University (US)
  • The University of Melbourne (AU)
  • World Health Organization (CH)
  • Duke Kunshan University (CN)
  • University of Lancashire (GB)
  • Ministry of Health and Medical Education (IR)
Corresponding author
Shakibazadeh, Elham
ORCID
Venue
Reproductive Health
Publisher
Springer Science and Business Media LLC
Published
2021-01-02
Volume
18
Issue
1
Pages
3-3
ISSN
1742-4755 (ISSN-L)
DOI
10.1186/s12978-020-01047-x
PMC
PMC7778821
OpenAlex
W2896431357
Cited by
152
References
184
Citations by year
2026: 10 · 2025: 20 · 2024: 24 · 2023: 26 · 2022: 30 · 2021: 22 · 2020: 12 · 2019: 6 · 2018: 2
FWCI
4.70
Type
journal article
Language
en
Open access
Licence
Locations
  • Reproductive Health (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, other-oa)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • CLOK (University of Central Lancashire) (acceptedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Minerva Access (University of Melbourne) (submittedVersion, cc-by)
Funders
  • Tehran University of Medical Sciences (240.773)
  • Iran National Science Foundation (6532)
Topics
  • Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
  • Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
Keywords
cesarean section, cesarean section preference, mode of delivery, nulliparous women, cesarean section rate, maternal decision-making, pregnancy timing, health system factors, patient-centered care
MeSH terms
Cesarean Section, Choice Behavior, Consumer Behavior, Family, Female, Health Personnel, Humans, Iran, Male, Pregnancy, Prevalence, Patient Preference

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