Identifying factors associated with adolescents’ Intention for childbirth

Around the world, caesarean section (CS) rates have steadily increased over recent decades [1]. Caesarean sections can effectively prevent maternal and newborn mortality when it is medically indicated. However, there is evidence that they are associated with short- and long-term risks for the woman, the child, and future pregnancies, in addition to considering public healthcare costs [2].

The rise in caesarean section rates can be explained through a complex multivariate analysis of the following contributing factors: changes regarding both the distinguishing characteristics of the mother (with pregnancies being increased in elderly nulliparous women) and professional practice styles; personalized medicine instead of team obstetric care; increased malpractice pressure (defensive medicine); and economic, organizational, social, and cultural factors [3,4,5,6]. A recent study indicates that in Greece, during the financial and COVID-19 pandemic crises, most women continue to give birth by CS, which leads to a major public health problem with economical, ethical, and humanitarian implications [7].

While the debate for interventional approaches is ongoing, the World Health Organization (WHO) guidelines on nonclinical interventions attempt to provide evidence-based recommendations specifically designed to reduce caesarean section rates. The WHO has emphasized educational interventions and support programs, such as childbirth training workshops that include sessions about childbirth fear and pain, non-pharmacological pain-relief methods, and the advantages and disadvantages of caesarean section and vaginal delivery [8].

A cross-sectional study was conducted in 14 vocational high schools in Greece, with ten school units being in the Athens area and four school units being in the countryside. Data was collected via a questionnaire between October 2019 and April 2021. The study protocol was reviewed and approved by the Ιnstitute of Educational Policy, which is the scientific agency that provides support to the Minister of Education and Religious Affairs on issues regarding secondary education (No Φ12/124243/Δ4 1/8/2019). Eligible participants were ensured confidentiality and anonymity in their responses. Written consent was received from all participants and their parents before filling in the questionnaire. Due to the specialized nature of the project, we provided instructions in every school unit and additional clarifications were available in classrooms for each of the students during questionnaire completion.

The sample was comprised of 480 students (54.2% girls) aged 14–17 years, with a mean age of 15.5 years (SD = 0.6). The sample characteristics are presented in Table 1. The majority of the sample (97.7%) was born in Greece. More than half of the participants had parents who had completed high school and 55.8% had chosen to study health sciences.

Participants’ intentions towards vaginal birth and their associations with sources of information are presented in Table 2. Almost nine out of ten (89.0%) of the students could imagine having children at some point in the future and 78.5% would prefer a vaginal birth for them or their partner. The most common source of information on vaginal birth was “experiences/stories of family members” (37.7%). Impressions of the sample regarding vaginal birth were positive for 37.9%, but both negative and positive for 49.0%. The majority of students in the sample (54.1%) would like to be more informed in all subject areas of pregnancy and birth. The mean scores on the five subscales of the TPB were as follows: “Cognitive component of vaginal birth”: 3.53 (SD = 0.61); “Cognitive component of caesarean section”: 3.00 (SD = 0.64); “Affective component of vaginal birth”: 3.78 (SD = 0.63); “Subjective norms”: 4.01 (SD = 1.13); and “Perceived behavior control”: 2.91 (SD = 0.92).

Participants who could imagine having children at some point in the future tended to prefer vaginal birth by a significantly larger percentage than participants who did not imagine having children at some point in the future (Table 3). Furthermore, participants’ intention to have a specific mode of delivery was significantly associated with their impression of vaginal birth. Specifically, a significantly higher percentage of participants who had negative impressions intended to give birth by caesarean section (Table 4).

Multiple logistic regression found that participants’ impressions of vaginal birth and all the TPB constructs were significantly associated with intention towards caesarean section (Table 4). More specifically, participants with a negative impression of vaginal birth had a 2.20-fold higher probability of selecting caesarean section compared to participants with neither negative nor positive impressions. Also, higher scores on the “Cognitive component of vaginal birth,” “Affective component of vaginal birth,” “Subjective norms,” and “Perceived behavior control” subscales were significantly associated with a lower probability of selecting caesarean section. A higher score on the “cognitive component of caesarean section” subscale was also significantly associated with a higher probability of selecting caesarean section.

Birth-related attitudes during pregnancy are frequently considered and analysed. Strategies to raise awareness about the benefits of vaginal birth, to promote women’s confidence in their ability to deliver naturally, are being updated. For young populations, although research indicates that developing and supporting evidence-based education programs is vital, the availability of data regarding adolescents’ attitudes towards birth options is scarce [15, 16].

In our study, most participants would prefer a vaginal birth for them or their partner in a hypothetical healthy future pregnancy. In accordance with this, studies in similar populations indicate that, regardless of the recorded rise in the rate of caesarean sections, young students who are introduced into a medicalized birth culture report a vaginal birth preference for a healthy future pregnancy [17, 18, 19]. However, considering that the mean age of the sample in our study was 15.5 years, the intention for a caesarean delivery was already 21.1%, a percentage remarkably higher than the justified 10–15% of medically indicated caesarean sections according to the WHO. The most common source of information on vaginal birth was “experiences/stories of participants’ family members” and additional studies have indicated the strong influence that family and the peer network have on birth preferences in young adults [20, 21]. Participants’ intentions for a specific mode of delivery were significantly associated with their impression of vaginal labor. Students who had negative impressions had a significantly higher likelihood of intending to give birth by caesarean section. A similar outcome was reported in a survey study that assessed impressions of childbirth in a student population in Northwest England. The authors supported that firsthand observations of birth, especially positive experiences, had implications for salutary outcomes, whereas negative or conflicting perceptions of vicarious experiences were associated with increased levels of fear over childbirth [22].

Regarding the factors on the AIBO scale related to participants’ preference for mode of birth, we found that all subscales were significantly associated with the intention for caesarean section. More specifically, participants with higher scores on the “Cognitive component of vaginal birth,” “Affective component of vaginal birth,” “Subjective norms,” and “Perceived behavior control” subscales had a significantly lower probability of selecting caesarean section. In contrast, a higher score on the “Cognitive component of caesarean section” subscale was significantly associated with a higher probability of selecting caesarean section. This outcome is consistent with the effectiveness of the TPB to predict and explain the correlation between factors and intention.

Taking into consideration the significant association between intention and the AIBO scale constructs, we indicate the necessity to modify the negative attitudes towards vaginal birth and educate young populations about the benefits and risks of different modes of delivery. In line with recent WHO guidelines for nonclinical interventions to reduce caesarean section rates, such as childbirth preparation workshops, we suggest introducing health and reproduction education programs into the school curricula in primary schools and most certainly in high schools. The fact that only 13% of our sample reported school-based education programs as a source of information in birth issues indicates the educational inadequacy in Greece. Furthermore, our study showed that significant others, obstetricians, and midwifes can affect adolescents’ intention towards a particular mode of delivery; thus, they could, and should, be involved with providing information from a more scientific perspective.

Perceived behavior control over childbirth seems to be another factor related to delivery preference. A recent study suggests that increased self-efficacy in childbirth is associated with a wide variety of improved perinatal outcomes and that self-efficacy is a psychosocial factor that can be modified through various efficacy-enhancing interventions [23]. This outcome emphasizes the power of prenatal education for improving individuals’ confidence in coping with a vaginal delivery.

A more recent study examined stakeholders’ views on the barriers and facilitators of nonclinical interventions to reduce unnecessary caesarean sections, targeted at organizations, facilities, and systems. The authors reported that these interventions were strongly mediated by organizational power differentials and stakeholder commitment. The study also indicated that the barriers are greatest where the implementation plans contradict both system and cultural norms [24].

In conclusion, in our study, we assessed sources of information and TPB constructs to identify factors influencing adolescents’ preference and intention towards vaginal birth and caesarean sections. To the best of our knowledge, this is the first such study in Greece with such a low average age of participants, and it indicated that adolescents’ birth preferences were significantly associated with sources of information, attitudes towards the delivery mode, subjective norms, and childbirth perceived behavior control. The findings highlight the necessity to implement nonclinical interventions to reduce the preference for caesarean section, providing evidence for developing school-based educational programs. We propose that these interventions should be implemented both consistently and in a timely manner. Our study also purports that the rise in caesarean section rates should be approached through a multivariable model that involves individuals, families, educational systems, health professionals, and communities.