BIRTH 39:1 March 2012

39

Requesting Cesareans without Medical Indications: An Option Being Considered by Young Canadian Women
Frances Gallagher, RN, PhD, Linda Bell, RN, PhD, Guy Waddell, MD, FRSC, Annie Beno^ BA (Hons), and Nathalie C^ t, RN, BSc t, oe
ABSTRACT: Background: Cesarean delivery on maternal request is a worldwide growing

phenomenon. The goal of this study was to describe young nulliparous womens attitudes about cesarean delivery on maternal request. Methods: A total of 140 nulliparous women in Canada aged between 18 and 24 years and attending school from the vocational (n = 53), college (n = 61), and university (n = 18) levels (n = 8 other) participated in the survey. The self-administered questionnaire consisted of 23 open-ended questions. The outcome measure was the participants attitude toward cesarean delivery on maternal request. Descriptive, bivariate, and multiple regression analyses were performed. Results: Many of the respondents (63%) had previously heard about cesarean delivery on maternal request, and of these women 28.6 percent had a favorable attitude toward the procedure. Sociodemographic variables were not associated with participants attitudes toward cesarean delivery on maternal request except for place of residence and type of professional preferred for pregnancy care. Thinking that vaginal birth was more painful than cesarean delivery (p = 0.012) and had more consequences for the mother (p < 0.001) were related to a positive attitude toward cesarean delivery on maternal request. A positive attitude by peers was also associated with participants favorable attitude toward cesarean delivery on maternal request (p < 0.001). The overall predictive success of the model was 66.5 percent. Conclusions: Young women are spreading the word about cesarean delivery on maternal request and may inuence one another about their preferred delivery method. During prenatal visits practitioners need to address womens fear of vaginal birth and its consequences for the mother, counseling, and womens understanding of the consequences of cesarean delivery. This study supports the urgent need to systematically document cesarean delivery on maternal request as a medical procedure and to study its prevalence and related factors. (BIRTH 39:1 March 2012) Key words: cesarean section, maternal choice, obstetrics, prenatal counseling

A new birthing phenomenon is emerging worldwide: cesarean delivery on maternal request (1). Viswanathan et al have dened cesarean delivery on maternal request as a cesarean delivery for a singleton pregnancy, on maternal request, at term, and in the absence of any
Frances Gallagher is a Professor, Linda Bell is a Professor, Annie te Benot is a Research Assistant, and Nathalie Co is a Masters Degree Student at the School of Nursing, Faculty of Medicine and Health Sci bec; and Guy ences, Universite de Sherbrooke, Sherbrooke, Que Waddell is a Professor in the Department of Obstetrics and Gynecol ogy, Faculty of Medicine and Health Sciences, Universite de Sherbec, Canada. brooke, Sherbrooke, Que

maternal or fetal indication for cesarean delivery (2, p 1). According to the Canadian Maternity Experiences Survey (3), 8.1 percent of participants requested a cesarean delivery from their health care practitioner before their labor or birth, and 1.5 percent of participants who
Address correspondence to Frances Gallagher, RN, PhD, School of Nursing, Faculty of Medicine and Health Sciences, Universite de Sherbec J1H 5N4, Canada. brooke, 3001 12e Avenue Nord, Sherbrooke, Que Accepted July 19, 2011 2012, Copyright the Authors Journal compilation 2012, Wiley Periodicals, Inc.

40 did so were primiparas (4). In the United States, the rate of cesarean delivery in the absence of medical indications is estimated to be between less than 1 and 7 percent (5,6). A Swedish study of medical records from 1997 to 2006 showed an increase of cesarean sections without medical indication over this 10-year period in the capital region (1.3% vs 3.6%) (7). As cesarean delivery on maternal request and cesarean section without medical indication are related but may encounter different issues, it is right to say that cesarean delivery on maternal request is neither a well-recognized clinical entity nor an accurately reported indication for diagnostic coding (2, p 6). An increasing number of women are aware of the possibility of planning their delivery. For instance, in Brazil, before arriving at the hospital 40 percent of women participating in an ethnographic study expected to have a cesarean section (8). In Canada, the issue is generating widespread debate, and it is essential for health professionals to gain a better understanding of young womens views about cesarean delivery on maternal request. Little is known about the views on childbirth and birthing preferences of the next generation of women. Viswanathan et al reported no major differences between primary cesarean delivery on maternal request and planned vaginal delivery (2). However, the evidence is actually too weak to conclude that differences are entirely absent. Individual outcomes for mothers or infants differ with respect to these modes of delivery. Other data suggest that the risks of placenta previa, placenta accrete, and gravid hysterectomy increase with the number of previous cesarean deliveries (9). In addition, a cesarean birth requires more medical interventions than vaginal birth, longer hospital stays, is not always conducive to early mother-child bonding (10), and is associated with a decreased rate of exclusive breastfeeding (11). Various organizations representing maternity health care practitioners and experts have released position statements about cesarean delivery on maternal request, most noting that the lack of quality scientic evidence on the risks associated with elective cesarean delivery requires a vigilant approach (9,1214). For example, to prevent overmedicalization and preserve the natural process of giving birth, the Society of Obstetricians and Gynaecologists of Canada (SOGC) developed the Joint Policy Statement on Normal Childbirth (14). It states that cesarean delivery should only occur in the presence of medical indications and not for reasons of convenience. The National Institutes of Health in the United States suggest that cesarean delivery on maternal request may be a reasonable alternative to vaginal delivery after thorough individualized discussion with women requesting cesarean delivery and not because

BIRTH 39:1 March 2012

of the unavailability of effective pain management (9, p 18). Several factors have been identied with respect to womens reasons for requesting a cesarean delivery. Some women explain their positive attitude by the belief that cesarean delivery is safer for the infant and less painful than vaginal birth (8,15,16). Fear of vaginal delivery (1620) and issues relating to physical consequences (e.g., on the perineum) associated with vaginal delivery have also been reported (1621). Moreover, having a planned cesarean may be preferred for reasons of convenience (22,23). Practitioners perceptions of womens views and their own personal preferences may also be important factors involved in the cesarean delivery on maternal request phenomenon (21,2427). The laws and ethics surrounding the patients choice principle and maternal autonomy have become vital factors inuencing womens childbirth attitudes and decisions (28,29). Sociodemographic factors, such as older age, higher education levels, and higher income, are associated with requests for cesarean delivery (8,30). Sociocultural factors may also increase cesarean delivery on maternal request rates. In North America, requests have become more popular since public gures such as pop stars have said that they are keen on this type of delivery. In addition, nulliparas and multiparas may have different perspectives on the most desirable way to give birth (31). For example, a larger percentage of nulliparas (51% nulliparas vs 28% percent multiparas) think that cesareans should be offered to all women during prenatal care. Nulliparas and multiparas who prefer cesareans give different reasons for the preference, with the former more likely to cite the fear of pain and the latter to mention the risks associated with vaginal birth. Research aimed at understanding cesarean delivery on maternal request has focused mainly on women who were pregnant and had already given birth, and little of this research was conducted in Canada. However, as young women approach pregnancy it is important to know what they think to gain a better understanding of this emerging trend (9). It is surprising to see how few studies have examined the attitudes of young nonpregnant nulliparous women toward cesarean delivery on maternal request. Furthermore, no study has explored if these young women would actually request a cesarean delivery. The primary goal of this study was to describe the attitudes of young nulliparas about cesarean delivery on maternal request. The study also examined the womens personal characteristics, perceptions, and fears related to vaginal birth and cesarean delivery, and the social network characteristics associated with a favorable attitude toward cesarean delivery on maternal request.

BIRTH 39:1 March 2012

41 Methods Participants characteristics similar to those of the sample. The questionnaire was completed in 20 minutes.

This survey was conducted with Canadian nulliparas aged between 18 and 24 years who could read and write French; women who were pregnant or had already given birth were excluded from the study. We recruited the participants from May 2008 to May 2009. The sample size of 139 women was calculated based on the rate of cesarean delivery on maternal request, which is thought to be between 3 and 7 percent (5), with an alpha of <0.05 and a beta of 0.80.

Statistical Analysis Descriptive statistics were calculated for the attitude toward cesarean delivery on maternal request, the sociodemographic data, and other personal characteristics; participants responses to the questionnaire items about their fear of vaginal birth and cesarean delivery; and their perceptions about these two delivery methods and social network characteristics. Preliminary bivariate analyses (chi-squared tests, Fisher exact test, Pearson correlations, and analysis of variance [ANOVA] methods) were conducted to select the predictors to be considered in the regression analysis. Finally, a multivariate logistic regression analysis was executed to predict having a favorable attitude toward cesarean delivery on maternal request using the signicant predictors in the preliminary analyses, and adjusting for sociodemographic variables, allowing for entry at the 5 percent level. At this phase, the undecided group (n = 29) was retrieved to clearly differentiate favorable from unfavorable attitudes toward cesarean delivery on maternal request. Data were analyzed using the Statistical Package for Social Scientists (SPSS; 34).

Procedure Data were collected from young women attending school at three educational levels: 1) high school (n = 53: beauty school); 2) college (n = 61: education, natural sciences); and 3) university (n = 18: medicine, nursing, and psychology). The study was presented in class by a research assistant. Questionnaires were distributed together with instructions to return them in a closed box to maintain condentiality. The research was approved by the Ethics Committee of the Universite de Sherbrooke, Sherbrooke, Quebec. The research team developed the self-administered questionnaire based on the one used by Chong and Mongelli (17). Denitions of vaginal birth, cesarean delivery, and cesarean delivery on maternal request were given at the beginning of the questionnaire to ensure a common understanding of the terms used. The questionnaire consisted of 23 open-ended, semi-open, and multiple-choice questions. Three examples of questions were: 1) Have you ever heard about cesarean delivery on maternal request? 2) What would be your favorite delivery method? 3) Do any of your friends (male and female) have a favorable attitude to cesarean delivery on maternal request? The independent variables were personal characteristics, perceptions, and fear of vaginal and cesarean delivery, and social network characteristics. The dependant variable was the attitude toward cesarean delivery on maternal request (favorableunfavorableundecided), which was estimated based on the response to the following question: If you were pregnant, would you talk to your health care professional about cesarean delivery on maternal request, in order to possibly ask for one? Construct and face validity of the questionnaire were evaluated by the Delphi group method (32,33). The group was composed of an obstetrician gynecologist, a general practitioner, two maternalchild health nurses, and a statistician specializing in test theory. The questionnaire was then pretested with 10 young women with

Results A total of 140 nulliparas aged between 18 and 24 years completed the survey, and 260 questionnaires were distributed to eligible women, yielding a 54 percent response rate. The personal characteristics of the respondents are presented in Table 1. Their mean age was 20.4 years (SD = 1.8); 51.4 percent were 18 to 20 years old inclusively, and 48.6 percent were between 21 and 24 years. Ninety-ve percent of the women were born in the province of Quebec (Canada), their parents were gener ally born in Quebec (94.4%), and over half (58.6%) said they were Roman Catholics. The women lived with their parents (43.6%) or in their own apartment (48.6%), and 74 (52.9%) were single and 46.4 percent were married or in a common law relationship. The highest levels of education completed by the women were high school or vocational education (37.9%), college (43.6%), and university (12.9%); 5.7 percent identied another educational level. Nearly two-thirds of the women (63.3%) had previously heard about cesarean delivery on maternal request; their main sources of information were television, family, friends, magazines, and movie television stars. When asked which health professional they would prefer

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BIRTH 39:1 March 2012

Table 1. Personal Characteristics of Respondents According to their Attitude Toward Cesarean Delivery on Maternal Request

Unfavorable (n = 71) Characteristics

Age (yr) 1820 2124 Social status* Single Couple Place of residence Living with parents Living in an apartment Other Religion None Catholic Other Education High school College University Other Has heard of CDMR (yes) Preferred caregiver (yes) Family doctor Obstetrician gynecologist Midwife Does not know

Favorable (n = 40) No. (%)

22 (55.0) 18 (45.0) 24 (60.0) 16 (40.0) 16 (40.0) 22 (55.0) 2 (5.0) 15 (37.5) 19 (47.5) 6 (15.0) 16 (40.0) 19 (47.5) 4 (10.0) 1 (2.5) 26 (65.0) 19 (47.5) 26 (65.0) 7 (17.5) 5 (12.5)

Undecided (n = 29) No. (%)

18 (62.1) 11 (37.9) 16 (55.2) 13 (44.8) 17 (60.7) 6 (21.4) 5 (17.9) 10 (34.5) 18 (62.1) 1 (3.4) 12 (41.4) 13 (44.8) 3 (10.3) 1 (3.4) 14 (48.3) 19 (65.5) 19 (65.5) 4 (13.8) 1 (3.4)

No. (%)
32 (45.1) 39 (54.9) 34 (48.6) 36 (51.4) 28 (40.0) 40 (57.1) 2 (2.9) 22 (31.0) 45 (63.4) 4 (5.6) 25 (35.2) 29 (40.8) 11 (15.5) 6 (8.5) 48 (67.6) 42 (59.2) 35 (49.3) 27 (38.0) 5 (7.0)

p
0.263

0.499

0.005

0.266

0.791

0.167 0.291 0.163 0.013 0.385

bec college level corresponds to posthigh school education in the United States; Que bec university *One case missing; two cases missing; Que level corresponds to college or university levels in the United States. CDMR = cesarean delivery on maternal request.

for their prenatal care and birthing experience, more than one-half of the women said they would prefer a family doctor or obstetrician (57.1%) and just over one-fourth would prefer midwifery care (27.1%). Respondents could select more than one option.

Factors Related to a Favorable Attitude Personal characteristics Personal characteristics were not signicantly associated with participants attitudes toward cesarean delivery on maternal request except for the place of residence and the type of practitioner preferred for pregnancy and intrapartum care (Table 1). The women considering obtaining midwifery care (27.1%) were less likely to have a favorable attitude toward cesarean delivery on maternal request (p = 0.013) than those who said they were not considering retaining the services of a midwife in the future. Perceptions about vaginal and cesarean birth Our ndings suggested that women who thought negatively about vaginal birth were more likely to have a favorable attitude toward cesarean delivery on maternal request (Table 2). Specically, this positive relationship

Womens Attitude Toward Cesarean Delivery on Maternal Request When asked if they would talk to their health care practitioner about cesarean delivery on maternal request, in order to possibly ask for one, 40 women (28.6%) answered yes and were deemed to have a favorable attitude toward the procedure. The 71 women (50.7%) who answered no to this question were classied as having an unfavorable attitude toward it. The remaining 20.7 percent (n = 29) of respondents thought they did not know whether they would ask for information about cesarean delivery on maternal request or not. These women were categorized in the undecided group.

BIRTH 39:1 March 2012

43 delivery = 5; Table 2). A one-way ANOVA was conducted to explore the impact of womens attitudes toward cesarean delivery on maternal request (favorable, unfavorable, or undecided) on their self-rated levels of fear of vaginal birth. The ratings differed signicantly (p < 0.001). Post hoc comparisons using Scheffes test indicated that the mean rating of women with an unfavorable attitude toward cesarean delivery on maternal request (M = 5.00, SD = 2.38) was signicantly lower than those of women who favored it (M = 7.90, SD = 1.79) or were undecided (M = 6.90, SD = 1.86). The mean fear rating for the undecided women and those with a favorable attitude did not differ. Levenes test of homogeneity of variances was signicant (p < 0.05),

was seen for thinking that vaginal birth was more painful than cesarean delivery (p = 0.012) and that it had more consequences for the mother (p < 0.001). In addition, thinking that cesarean delivery was less stressful (p = 0.001) and safer (p = 0.002) were both related to having a favorable attitude toward cesarean delivery on maternal request. All other perceptions about vaginal and cesarean birth (Table 2) were unrelated to the womens attitude toward cesarean delivery on maternal request. On a scale ranging from 1 (no fear) to 10 (extreme fear), the average was 6.21 for overall fear of vaginal birth and 6.09 for overall fear of cesarean delivery (mode for vaginal birth = 7; mode for cesarean

Table 2. Perceptions and Fear Related to Vaginal and Cesarean Birth According to the Attitude Toward Cesarean Delivery on Maternal Request

Unfavorable (n = 71) Perceptions

Perceptions related to vaginal birth Vaginal birth is less dangerous for the baby Overall, vaginal birth is more painful Women recover faster from a vaginal birth* Vaginal birth is less expensive for the health care system Women feel like better mothers after a vaginal birth Vaginal birth carries more consequences for the mother Babies born vaginally are less beautiful Perceptions related to cesarean delivery Risks of maternal complications are greater with a cesarean birth Cesarean birth increases the risk of miscarriage in the future Cesarean birth is less stressful Cesarean birth is safer More women of our generation will want to have a cesarean birth Cesarean birth can affect a womans future sexual life Perceptions related to CDMR If desired, it is possible to obtain a CDMR in Quebec Ideal mode of delivery Vaginal birth (unmedicated, pain relief by massage, bath) Vaginal birth (with pain relief medication) Vaginal birth (with epidural analgesia) Cesarean birth Does not matter I dont know Fear of vaginal birth*, mean rating (SD) Fear of cesarean birth, mean rating (SD)

Favorable (n = 40) No. (%)

8 (20.0) 34 (85.0) 20 (51.3) 22 (55.0) 12 (30.0) 13 (32.5) 2 (5.0) 10 (25.0) 1 (2.5) 15 (37.5) 9 (23.1) 30 (75.0) 6 (15.0) 19 (47.5) 5 (12.5) 3 (7.5) 8 (20.0) 5 (12.5) 11 (27.5) 8 (20.0) 7.90 (1.79) 5.08 (2.29)

Undecided (n = 29) No. (%)

7 (24.1) 23 (79.3) 14 (48.3) 16 (55.2) 5 (17.2) 3 (10.3) 1 (3.4) 11 (37.9) 1 (3.4) 5 (17.2) 1 (3.4) 15 (51.7) 1 (3.4) 13 (44.8) 5 (17.2)

No. = Yes
40 98 83 82 27 19 10 48 8 26 12 83 12 61 50 23 33 5 15 14

No. (%)
25 (35.2) 41 (57.7) 49 (69.0) 44 (62.0) 10 (14.1) 3 (4.2) 7 (9.9) 27 (38.0) 6 (8.5) 6 (8.5) 2 (2.9) 38 (53.5) 5 (7.0) 29 (40.8) 40 (56.3) 10 (14.1) 15 (21.1) 0 (0.0) 1 (1.4) 5 (7.0) 5.00 (2.38) 6.61 (2.62)

p
0.424 0.012 0.140 0.077 0.292 <0.001 0.577 0.389 0.029 0.001 0.002 0.071 0.172 0.652 <0.001

10 (34.5) 10 (34.5) 0 (0.0) 3 (10.3) 1 (3.4) 6.90 (1.86) <0.001 6.21 (2.38) 0.009

*One case missing; two cases missing; Levenes test of homogeneity of variance: F = 3.91 (2, 136), p Chi-squared analyses are 3 (attitudes toward CDMR) 3 (responses to the item). CDMR = cesarean delivery on maternal request.

= 0.022.

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Table 3. Social Network Characteristics According to the Respondents Attitude Toward Cesarean Delivery on Maternal Request

Unfavorable (n = 71) Characteristics

Has friends with a favorable opinion toward CDMR Has friends with an unfavorable opinion toward CDMR Has talked about CDMR with friends family Mothers mode of delivery Cesarean birth Vaginal birth
CDMR = cesarean delivery on maternal request.

Favorable (n = 40) No. (%)

15 (37.5) 7 (17.5) 24 (60.0)

Undecided (n = 29) No. (%)

6 (20.7) 6 (20.7) 17 (58.6)

No. = Yes
35 39 81

No. (%)
14 (19.7) 26 (36.6) 40 (56.3)

v2
19.98 9.47 0.15

p
<0.001 0.049 0.928

31 121

15 (21.1) 62 (87.3)

13 (32.5) 31 (77.5)

3 (10.3) 28 (96.6)

4.87 5.30

0.095 0.069

possibly partly because of a positively skewed distribution of the fear of cesarean delivery ratings. Womens fear ratings for cesarean delivery differed according to their attitudes toward cesarean delivery on maternal request (p = 0.009). Women who had an unfavorable attitude rated their fear of cesarean delivery signicantly higher than those with a favorable attitude (M = 6.61, SD = 2.62 vs M = 5.08, SD = 2.30). The mean rating of women who were undecided (M = 6.21, SD = 2.38) did not differ from those of the favorable and unfavorable groups (Scheffes post hoc test). The relationship between participants ratings for fear of cesarean delivery and fear of vaginal birth was investigated using the Pearson product-moment correlation coefcient. The two fear variables were not associated (r = 0.04, n = 139, p = 0.64), meaning that there seemed to be an actual difference between the fear of vaginal birth and the fear of cesarean delivery and not just a general fear of delivery. Social network factors Our results showed a signicant relationship between peers positive attitude toward cesarean delivery on maternal request and the participants favorable attitude toward it (p < 0.001), suggesting that women who thought that their friends had a favorable attitude toward cesarean delivery on maternal request tended to be favorable toward it themselves (Table 3). No signicant relationship was observed between the attitude toward the procedure and the other characteristics of the support network examined in this study. For the regression analysis, the undecided group (n = 29) was retrieved to clearly differentiate between favorable and unfavorable attitudes toward cesarean delivery on maternal request. A multivariate logistic regression analysis was conducted to predict having a

favorable attitude toward the procedure using the signicant predictors at the bivariate level and adjusting for the following sociodemographic variables: age, social status, and education. Table 4 shows the most parsimonious model, which is composed of four predictors. Participants were more likely to have a favorable attitude toward cesarean delivery on maternal request if they perceived that vaginal birth had more negative consequences for the mother than a cesarean delivery, had fears related to vaginal birth, thought that cesarean delivery was less stressful than vaginal birth, and said that they had friends with a favorable attitude toward it.

Table 4. Regression Analysis

Variables
Vaginal birth has more consequences No Yes Does not know Fear of vaginal birth Fear of cesarean birth Cesarean birth is less stressful No Yes Does not know Friends favorable toward CDMR* Age (2124 yr vs 1820 yr) Social statuscouple versus single Education High school College University Other

OR (95% CI)
1 10.5 (1.668.1) 1.1 (0.34.3) 2.0 (1.42.8) 0.8 (0.61.0) 1 8.0 (1.159.9) 5.4 (0.932.1) 7.5 (1.537.2) 0.8 (0.23.5) 1.0 (0.34.0) 1 3.6 (0.816.7) 0.9 (0.19.7) 0.1 (0.01.6)

0.014 0.936 <0.001 0.109

0.042 0.062 0.013 0.808 0.982

0.103 0.91 0.091

*Yes versus no or does not know. CDMR = cesarean delivery on maternal request.

BIRTH 39:1 March 2012

45 The results of our study call for a response on the part of maternal health professionals. The prenatal period provides an outstanding and probably underused opportunity to review womens conceptions and fears about delivery methods. Preference for a particular delivery method is observed early in the pregnancy (38), which is another argument in favor of early intervention to provide health education and support decision-making. With the same aim prepregnancy consultations could include counseling about delivery methods, but at present, these interventions are not priorities during the prepregnancy period (39). Health education initiatives targeting pregnancy and delivery could also be developed for high schoolers (40). Respondents in our study showed a convergence between favorable attitudes toward cesarean delivery on maternal request and thinking their friends had the same attitude. Chong and Mongelli conducted one of the few studies showing that the views of friends and relatives can also encourage pregnant women to decide to ask for cesarean delivery on maternal request (17). Young women talk to each other about their plans to have children and their preferences in terms of delivery. This phenomenon may be closely linked to the young age of our participants, as the inuence of peers on young people is well known (41). Therefore, this factor should be taken into consideration in prenatal education strategies, especially with respect to delivery method. However, we should point out that many respondents did not know what their friends thought about cesarean delivery on maternal request, which reinforces the idea of focusing on educational programs during pregnancy because they could have a snowball effect on friends in the womens social network and affect their thinking about delivery methods and cesarean delivery on maternal request. The secondary results of our study suggest that young women may have some general knowledge about cesarean delivery on maternal request, because slightly more than six of ten knew it existed even though they had never been pregnant. The existence of a social trend in favor of cesareans as a modern delivery method is a plausible suggestion. Women of the present generation who are used to technology may think that A technologically managed labour and birth that can be fast and efcient is not negative (42, p 88). Furthermore, many women want to participate in medical decisions and may feel empowered by making informed choices about their birthing experience. In popular and professional culture today, it has become the norm for women to have access to various medical procedures, such as abortion, tubal ligation, and different types of cosmetic surgery. Cesarean delivery on maternal request, however, is an entirely different matter, because it is an intervention that runs counter to the natural birth process and the desire to avoid overmedicalizing it. However, considering the

The overall predictive success of the model was 66.5 percent.

Discussion The results of our study showed that one of four young nulliparous women said they had a favorable attitude toward cesarean delivery on maternal request (28.6%). However, we cannot be sure that all of those women would have the intention to ask for a cesarean delivery. Possibly some might ask so as to determine the birth politics of the health care professional. Notwithstanding, this nding is different from the results of the Canadian survey of university students conducted by Stoll et al (16), in which only 8.8 percent of respondents expressed a favorable attitude to cesarean sections. In our study, nearly 30 percent of respondents with various education levels said they intended to nd out more about this procedure so they could ask for it if they became pregnant. As intention is closely linked to the adoption of a behavior (35,36), it is reasonable to assume that in the near future many women would bring up this issue with their physicians during prenatal care. A negative perception of vaginal birth and the resulting fear are part of the reason for the participants favorable attitude toward cesarean delivery on maternal request. These fears about vaginal birth are similar to those expressed by women who are pregnant or have given birth to explain their choice of, or preference for, a cesarean delivery on maternal request (1720). They are also identical to those of young women without a history of childbirth (16). This nding indicates the need for health practitioners to pay attention to the psychological support needs of women during pregnancy, to address their questions and concerns about childbirth, and to provide evidence-based information to answer womens questions, change their mistaken beliefs, and help them make informed decisions. In addition, participants who had a favorable attitude toward cesarean delivery on maternal request thought that vaginal birth had more adverse consequences for the mother and that cesareans were safer. Our results are similar to those of studies conducted with women who are pregnant or have given birth who think that cesareans are safer, less stressful, and more predictable (15,22,23). A recent study showed the instability of womens decision-making about delivery methods, because knowledge acquisition during pregnancy is a dynamic process (37). These ndings highlight the importance for health professionals of providing comprehensive and sufcient information about delivery methods, and offering ways to manage pain and provide psychological support for women who are inordinately afraid of a particular delivery method.

46 biases associated with a convenience sample, respondents in this study with a knowledge of cesarean delivery on maternal request could have been overrepresented, which could have inuenced the results. Faced with the possibility that during prenatal care an increasing number of women will raise the issue of cesarean delivery on maternal request, health professionals should be conscious of the inuence that their own views may have on womens attitudes to it. Recent studies have shown a susceptibility among obstetricians in various countries to personally adopt a favorable attitude toward cesarean delivery on maternal request (4346). In a study performed in Quebec by Lamb and Pasquier, 30 percent of obstetricians said they were favorable to cesarean delivery on maternal request and 20 percent added that they had performed this type of delivery (45). These results corroborate those of an American study (43) and an Australian study (47) showing that 57 percent and 75 percent of obstetricians, respectively, would agree to perform a cesarean section at the womans request. The practice of maternal health professionals with respect to cesarean delivery on maternal request thus stands at the conuence of various points of view, including young womens current attitudes toward delivery and having control over their own bodies, health practitioners position about method of delivery, guidelines issued by professional bodies, and the current state of knowledge of the issue. We think the time has come for a constructive, open debate about the issue of cesarean delivery on maternal request among physicians, midwives, nurses, researchers, and women to recognize its practice, discuss the ethical considerations, and ultimately set professional guidelines for its use. This study highlights the importance of the phenomenon and the urgent need to systematically document cesarean delivery on maternal request as a medical procedure and study its prevalence. Our study has some limitations. The convenience sample composed of students in certain educational programs in one area of Canada, the absence of information about the nonrespondents (e.g., respondents may have been more aware of cesarean delivery on maternal request than nonrespondents), and the sample size limited the choice of statistical analyses and reduced the generalizability of the ndings. More detailed validation tests are needed on the questionnaire used, which was designed to be short and easy to complete.

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the word about cesarean delivery on maternal request and may inuence one another about their preferred delivery method. During prenatal visits practitioners need to address womens fear of vaginal birth and its consequences for the mother, counseling, and womens understanding of the consequences of cesarean delivery. This study supports the urgent need to systematically document cesarean delivery on maternal request as a medical procedure and to study its prevalence and related factors. Acknowledgments The authors wish to thank the School of Nursing (Uni versite de Sherbrooke) for their nancial support, and the Research and Graduate Studies Comity, especially Marie-Josee Godin and Cecile Michaud, for revising a previous version of this paper. References
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Conclusions This study sheds new light on the attitudes of young women toward cesarean delivery on maternal request before they get pregnant. Young women are spreading

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