Identifying factors contributing to health workers' preferences for elective caesarean section: a qualitative study.

Caesarean section (CS) is a life-saving intervention when medically indicated; however, CS rates have risen substantially worldwide, and the increasing use of non-medically indicated CS has become a growing concern for maternity care systems []. Pregnancy and childbirth are multidimensional life events shaped by physical, psychological, social, and contextual factors, and women’s experiences of maternity care are influenced by both individual circumstances and the care environment [–]. Although vaginal birth is a physiological process that often occurs without surgical intervention, caesarean section can be necessary when clinical indications arise to reduce maternal or fetal risks []. In the absence of a clear medical indication, however, caesarean section may increase avoidable maternal risks, including infection, and may be associated with higher rates of neonatal respiratory morbidity and other adverse outcomes compared with vaginal birth [, ]. The increase in CS has generated debate regarding the appropriate population-level CS rate. In 1985, the World Health Organization (WHO) suggested a historically cited reference range of 10–15% for caesarean section rates []. Subsequent evidence has suggested that, at the population level, CS rates above approximately 10% are not associated with further reductions in maternal and neonatal mortality []. In Iran, a systematic review and meta-analysis reported a pooled CS prevalence of 48% (95% CI, 41–55) across 197,514 births, indicating that CS prevalence in Iran is markedly higher than the historically cited WHO reference range []. According to official statistics from 2019 to 2021, among 2,322,500 recorded births in Iran, the CS rate was 53.6% []. Therefore, non-medically indicated CS represents an important challenge for healthcare systems because it may expose women and newborns to avoidable health risks and can increase healthcare expenditure [, ]. Multiple interacting factors, including fear of labour pain, concerns about newborn safety, uncertainty about vaginal birth, previous childbirth or maternity-care experiences, and recommendations from clinicians, influence decisions regarding mode of birth [–]. In Iran, a mixed-methods systematic review showed that preferences for caesarean section among women, family members, and health professionals are shaped by fear of pain, concerns about complications, and perceptions of bodily consequences and predictability []. Evidence from Iranian research on birth after caesarean section further suggests that mode-of-birth decision-making is shaped by women’s perceived ability, self-efficacy, participation in decision-making, concerns about complications or failure, and the information and support provided by clinicians []. Together with wider evidence on childbirth experiences, these findings indicate that childbirth preferences are shaped not only by clinical risk assessment, but also by women’s expectations of care, perceived control, relationships with birth companions and interactions with healthcare professionals [, , ]. However, the literature does not always clearly distinguish whether “health professionals’ preferences” refer to their views as maternity-care providers, their own preferences as maternity clients, or both [, ].