Attitudes, Perceptions and Determinants of Non-Medically Indicated Caesarean Section Preference Among Pregnant Women in Thailand: A Three-Phase Mixed-Methods Study

Abstract

Background: Non-medically indicated caesarean section (CS) is a growing contributor to rising CS rates globally and in Thailand, influenced by maternal preference, socio-cultural factors and clinical decision-making. Understanding women’s perspectives is essential to guide counselling strategies and inform policy targeted at reducing unnecessary CS. Objective: To explore pregnant women’s attitudes, perceptions and determinants of preference for non-medically indicated CS and identify factors associated with CS preference. Methods: This prospective, descriptive, three-phase mixed-methods study was conducted from May 1 to July 30, 2024. The study was conducted at an antenatal clinic. The study comprised three phases: in-depth interviews with 40 pregnant women, questionnaire development and validation, and a survey of 400 participants. Descriptive statistics summarised had demographic data, while univariable chi-squared tests and multivariable logistic regression analysed factors associated with non-medically indicated CSs. Odds ratios and 95% confidence intervals (CIs) were reported, with statistical significance set at P < 0.05. The main outcomes and measures were the attitudes, perceptions, policy, implementation science, counselling frameworks, and clinician–patient power dynamics of pregnant women towards non-medically indicated caesarean sections. Results: Among the 400 women surveyed, 75% preferred vaginal delivery as a more natural and less risky option. However, 60% 60% reported they would still agree to a CS if recommended by a doctor, indicating high reliance on physician guidance even in situations without clear medical indication. Key factors affecting delivery preferences included prior caesarean delivery (adjusted odds ratio 2.5, 95% CI 1.5‒4.0) and maternal age over 35 years (adjusted odds ratio 1.8, 95% CI 1.1‒2.9). Comprehensive counselling was deemed essential by 80% of participants, who reported greater confidence in choosing vaginal delivery after thorough discussions of risks and benefits. Auspicious timing influenced 39.5%, while 37.3% were swayed by pain perception. Higher education levels, assisted conception methods and concerns about safety, such as blood loss, also shaped CS preferences. Conclusion: Pregnant women in Thailand generally prefer vaginal birth but are highly influenced by physician recommendations. Strengthening counselling, addressing misconceptions and incorporating shared decision-making into routine antenatal care may reduce non-indicated CS demand. Findings support future development of counselling frameworks and policy interventions to promote safe, evidence-based delivery choices. Thai Clinical Trials Registry Reference: TCTR 20230913007: Date of registration 13 September 2023.