Iran Journal of Nursing

1. Introduction
According to World Health Organization (WHO), the increase in Cesarean sections rate above 10% is not associated with decreased mortality rates. Considering the associated risks with Cesarean sections, it is essential that this mode of delivery would only be considered when reasonable medical indications exist. Nevertheless, the rate of Cesarean sections has consistently elevated worldwide during recent decades, and in particular, high rates of Elective Cesarean Delivery (ECD) are concerning. This is a more pressing matter in specific regions, such as Iran, where  the Cesarean section rate far exceeds any reasonable threshold. 
The increase in ECD has been associated with various psychological factors, among which fear of childbirth is prominent. Perceived stress is the semi-subjective stress level that an individual experiences over a while due to objective stimulants. In contrast to fear of birth, the impact of the perceived stress during pregnancy on the odds of opting for ECD is unclear, and the few studies concerned with this subject contradict it. Given the associated risks with ECD and its impact on the economics and policies of healthcare systems, delineation of the underlying factors for ECD is of great importance. Thus, this study aimed to help shed light upon the possible association of multiple factors, including perceived stress, with rates of ECD in primiparous women. In addition, the potential factors affecting the levels of perceived stress will be explored.
2. Materials and Methods
The current study was conducted in 2019 under the approval of the ethics committee of the Iran University of medical sciences, Tehran, Iran (Code: IR.IUMS.REC.1398.1230). Signed informed consent for participation in this study was obtained from all the 230 subjects. 
Among the 21 healthcare centers in Bandar Abbas City, 10 centers were selected based on a randomized clustering method: All 21 centers were categorized into five groups based on their locations in the city. Two centers from each category were randomly selected, and 23 subjects from each center were enrolled. 
Data acquisition was carried out using a demographic and gynecological information checklist (whose validity was confirmed by three Iran University of medical sciences) and Cohen's 14-item perceived stress questionnaire. Cohen's perceived stress questionnaire consists of 14 questions designed to measure the stress level that an individual experienced during the past month. The score ranges from 0 to 56 and is calculated based on the five-point Likert scale.
Statistical analysis was carried out using SPSS software v. 23. The statistically significant association between factors was enquired using the Chi-squared test, Welch's t-test, and one-way and two-way Analysis of Variance (ANOVA) with post-hoc Tukey test. In addition, the quality of models for explaining the data was assessed using the The Akaike information criterion (AIC). The P equal to or below 0.05 were considered significant. 
3. Results
A total of 230 primiparous pregnant women who met our inclusion criteria from 10 healthcare centers were enrolled. The Mean±SD age of the samples was 25.84±5.09, and the majority of participants were unemployed (86.9%), had high school education (50%), and had moderate economic status (66.1%), and preferred vaginal delivery as the mode of parturition (75.7%). The Mean±SD perceived stress score was 23.14±8.70 (ranged: 2-52). Item 12 of Cohen's perceived stress questionnaire had the highest Mean±SD score (2.18±1.09), and item 2 had the lowest Mean±SD score (1.11±1.09).
The results of Welch's t-test and one-way ANOVA have shown that there is a statistically significant relationship between the perceived stress score and preferred mode of delivery (P=0.033), type of pregnancy (wanted/unwanted; P=0.029), and economic status (P=0.004). The post-hoc Tukey test has revealed that the difference between the group with good and the group with poor financial quality is significant (P=0.02), with people with good economic status experiencing less overall stress. However, the mean perceived stress score difference between the groups with moderate financial status and poor economic status and groups with the excellent and poor economic situation could not pass the significance threshold (P=0.092 and P=0.053, respectively) is probably probable due to the small sample size. The results of AIC. have indicated that the quality of the model that includes all three significant factors far exceeds that of the models with any other combination of these three factors.
Our exploration of the associated factors with delivery mode preference has shown that there is a statistically significant relationship between the preferred mode of delivery and the level of the education of the participants (P=0.043) and their spouses (P=0.005), the employment status of the participant (P=0.005), the number of years that the participants and their spouses were educated (P=0.001 and P=0.001), and the overall perspective towards benefits and harms of different modes of parturition.
4. Conclusion
The present study aimed to help shed light on the possible association of perceived stress with the choice of delivery mode and explore the underlying factors affecting this issue. For this reason, 230 primiparous pregnant women from 10 different healthcare centers across the city of Bandar Abbas were enrolled to complete standard questionnaires regarding their demographic and gynecological information. The level of perceived stress in these women during the last month was measured via Cohen's perceived stress questionnaire.
The results of the current study indicate that there is a statistically significant association between the levels of perceived stress and the preferred mode of delivery; that is, a higher level of stress is a positive predictor of the higher probability of opting for Cesarean delivery (mean perceived stress score of 25.35 in subjects who chose Cesarean section compared to 22.43 in subjects who chose vaginal delivery mode). These results are in contrast to that of a previous study carried out in Ahwaz City by Sinaei et al., which indicated that no significant association between levels of perceived stress and the choice of delivery mode can be observed and is following the study performed by Matinnia et al. in Hamadan which observed that the mean level of stress is significantly higher in expectant mothers who chose ECD over vaginal delivery. One explanation for these inconsistent results is the inhomogeneity of the cultural structures in the populations under study. However, a definite conclusion can't be drawn until large-scale studies with large cohorts, preferably nationwide participants. For the time being, it can be stated that there is a meaningful difference in the mean levels of perceived stress between the group who opt for ECD and those who prefer vaginal delivery. Still, the universality of this matter and the extent to which it is applicable is unclear and demands further investigation.
We have also observed that higher levels of perceived stress are significantly associated with poor economic status (P=0.004) and unwanted pregnancy (P=0.029). It has been previously concluded elsewhere that symptoms of depression can accompany unwanted pregnancy and that this issue is more afflictive to mental health than physical health. Thus, women who experience unwanted pregnancy should be prioritized for social support, educative programs, and parenthood preliminary plans to assist them in coping with the situation.
The factors significantly associated with the preferred mode of delivery included the level and years of education, the employment status, and the overall perspective toward different delivery modes. It can be observed that vaginal delivery is more trending among unemployed women and women with lower levels of education. The connection between higher levels of education and the higher probability of choosing a Cesarean section has also been observed previously. 
An explanation might be that women in more frequent contact with the social environment, either due to their employment or through education programs, are subjected to misplaced social beliefs and stereotypes. Hence, they tend to consider a Cesarean section as a modern and luxurious means of parturition. A highly significant association between the preferred mode of delivery and the overall attitude towards different delivery modes points out that this issue can be effectively resolved through proper educational programs.
Overall, the results of our study carry several important messages. First, higher levels of perceived stress can indicate a higher probability of opting for ECD. Second, higher levels of perceived stress in women who experienced unwanted pregnancy are concerning and demand efforts to design interventions that would assist these women in coping with the situation. Third, there is a need for appropriate educational programs to inform expectant couples of the validated benefits and harms of different modes of delivery to counter the spread of misplaced social beliefs. Future large-scale and nationwide efforts are required to enhance our understanding of this critical subject and facilitate the design of effective interventions and educative policies.

Ethical Considerations
Compliance with ethical guidelines
This study has been approved by the ethics committee of Iran University of Medical Sciences with the ethics code IR.IUMS.REC.1398.1230.  Other ethical considerations in this study are as follows: informed consent was received from all participants, confidentiality of information, permission to leave the research, permission to refuse to use information in the final analysis and the right to receive research results.

Funding
This study is part of the results of the master's thesis in the field of community education in the health system with the number 17379-3-4-98, which has been approved and financially supported by Iran University of Medical Sciences.

Authors' contributions
Conceptualization: Soheila Nazeri, Leila Amini; Methodology: ‌Soheila Nazeri, Leila Amini, Homa Sadeghi Avalshahr; Data Analysis: Shima Haqqani, Writing - Original Draft and Writing - Review and Editing: All Authors.

Conflict of interest
The authors declared no conflict of interest.



References

1. Shearer EL. Cesarean section: Medical benefits and costs. Soc Sci Med. 1993; 37(10):1223-31. [DOI:10.1016/0277-9536(93)90334-Z] [PMID]
2. Betran A, Torloni M, Zhang J, Gülmezoglu A, Aleem H, Althabe F, et al. Statement on Caesarean Section Rates. BJOG. 2016; 123(5):667-70. [DOI:10.1111/1471-0528.13526] [PMID][PMCID]
3. Mylonas I, Friese K. Indications for and risks of elective cesarean section. Dtsch Arztebl Int. 2015; 112(29-30):489-95. [DOI:10.3238/arztebl.2015.0489] [PMID] [PMCID]
4. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018; 392(10155):1349-57. [DOI:10.1016/S0140-6736(18)31930-5]
5. Mittal S, Pardeshi S, Mayadeo N, Mane J. Trends in cesarean delivery: Rate and indications. J Obstet Gynecol India. 2014; 64(4):251-4. [DOI:10.1007/s13224-013-0491-2] [PMID] [PMCID]
6. Karlström A, Rådestad I, Eriksson C, Rubertsson C, Nystedt A, Hildingsson I. Cesarean section without medical reason, 1997 to 2006: A Swedish register study. Birth. 2010; 37(1):11-20. [DOI:10.1111/j.1523-536X.2009.00373.x] [PMID]
7. Azami-Aghdash S, Ghojazadeh M, Dehdilani N, Mohammadi M, Asl Amin Abad R. Prevalence and causes of cesarean section in Iran: Systematic review and meta-analysis. Iran J Public Health. 2014; 43(5):545-55. [PMID] [PMCID]
8. Sanavi FS, Rakhshani F, Ansari-Moghaddam A, Edalatian M. Reasons for elective cesarean section amongst pregnant women; A qualitative study. J Reprod Infertil. 2012; 13(4):237-40. [PMID] [PMCID]
9. Ryding EL, Lukasse M, Parys AS Van, Wangel AM, Karro H, Kristjansdottir H, et al. Fear of childbirth and risk of cesarean delivery: A cohort study in six european countries. Birth. 2015; 42(1):48-55. [DOI:10.1111/birt.12147] [PMID]
10. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983; 24(4):385-96. [DOI:10.2307/2136404] [PMID]
11. Sinaei A, Abbaspoor Z, Hashemi S, Javadifar N. The relationship between perceived stress and attitude towards delivery and choosing mode of delivery among pregnant women. J Babol Univ Med Sci. 2018; 20(5):61-7. [DOI:10.18869/acadpub.jbums.20.5.61]
12. Matinnia N, Haghighi M, Jahangard L, Ibrahim FB, Rahman HA, Ghaleiha A, et al. Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae. Rev Bras Psiquiatr. 2017; 40(1):83-8. [DOI:10.1590/1516-4446-2017-2229] [PMID] [PMCID]
13. Huang L, Chen Q, Zhao Y, Wang W, Fang F, Bao Y. Is elective cesarean section associated with a higher risk of asthma? A meta-analysis. J Asthma. 2015; 52(1):16-25. [DOI:10.3109/02770903.2014.952435] [PMID]
14. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: Causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008; 199(1):36.e1-36.e5. [DOI:10.1016/j.ajog.2008.03.007] [PMID]
15. Jafarzadeh A, Hadavi M, Hasanshahi G, Rezaeian M, Vazirinejad R, Aminzadeh F, et al. Cesarean or cesarean epidemic? Arch Iran Med. 2019; 22(11):663-70. [PMID]
16. Akbarzadeh F, Talaei A, Tavassoli F, Jalaliani S, Talebi M, Modarres Gharavi M, et al. [Psychological characteristics of women with vaginal delivery, elective and emergency cesarean section (Persian)]. Mashhad Univ of Med Scien. 2016; 58(10): 611-19. [DOI:10.22038/mjms.2016.6789]
17. Khavari F, Golmakani N, Saki A, Aghamohammadian Sherbaf H. [Investigating labor pain coping according to irrational beliefs in pregnancy (Persian)]. Iran J Obstet Gynecol Infertil. 2017; 20(5):58-67. [DOI:10.22038/ijogi.2017.9081]
18. Maroufizadeh S, Zareiyan A, Sigari N. [Psychometric properties of the 14, 10 and 4-item “Perceived Stress Scale” among asthmatic patients in Iran (Persian)]. Payesh. 2014; 13 (4):457-65. http://payeshjournal.ir/article-1-292-en.html
19. Bastani F, Rahmatnejad L, Jahdi F, Haghani H. [Breastfeeding self efficacy and perceived stress in primiparous mothers (Persian)]. IJN. 2008; 21(54):9-24. http://ijn.iums.ac.ir/article-1-456-en.html
20. Raksha G, Anjali T, Kirna T. An exploratory study to assess the factors causing anxiety among primigravida planned for normal vaginal delivery and caesarean section admitted at mata kaushalya hospital, patiala, punjab. Matern Pediatr Nutr. 2017; 03(1):1-8. [DOI:10.4172/2472-1182.1000122]
21. Alimohammadzade K, Mohebi S, Labbaf T. [Systematic review of research papers in the recent three decades on the “Reasons of Cesarean Section” and population health management strategies in Iran (Persian)]. Womens Stud. 2013; 16(61):7-57. http://www.jwss.ir/article_12098.html?lang=en
22. Sadighi J, Tavousi M, Montazeri A, Mozafari Kermani R, Eslami M, Rostami R, et al. Fertility indicators and its correlates among women in Iran. Payesh. 2020; 19 (6):645-72. [DOI:10.29252/payesh.19.6.645]
23. Milcent C, Zbiri S. Prenatal care and socioeconomic status: Effect on cesarean delivery. Health Econ Rev. 2018; 8 (1):7. [DOI:10.1186/s13561-018-0190-x] [PMID] [PMCID]
24. Adhikari K, McNeil DA, McDonald S, Patel AB, Metcalfe A. Differences in caesarean rates across women’s socio-economic status by diverse obstetric indications: Cross-sectional study. Paediatric and Perinatal Epidemi. 2018; 32(4):309-17. [DOI:10.1111/ppe.12484] [PMID]
25. Abdolkarimy M, Zareipour MA, Rezaie Moradali M, Mahmoodi H, Movahed E, Alinejad M. [Prediction of delivery type based on the theory of planned behaviors (Persian)]. NVJ. 2016; 3 (7):47-58. http://njv.bpums.ac.ir/article-1-713-en.html