Journal of Midwifery and Reproductive Health

Journal of Midwifery and Reproductive Health

Socioeconomic, Maternal, Neonatal and Health System Determinants of the Choice of Delivery Mode in Tehran Province: A Cross-sectional Study

Document Type : Original Research Article

Authors
Farbod Ebadi Fard Azar 1
Narges Saeedi 2
Mohammad Hossein Ghafoori 3
Saeed Bagheri Faradonbeh 4
1 Professor, Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran
2 MSc in Mental Health, Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran
3 PhD Student in Health Economics, Iran University of Medical Sciences, Tehran, Iran
4 a) Assistant Professor, Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran b) Department of Healthcare Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
10.22038/jmrh.2026.87446.2646
Abstract
Background & aim: Cesarean section (CS) is a life-saving intervention in specific obstetric situations but has become increasingly common worldwide. This study investigated socioeconomic, maternal, neonatal, and health system determinants of delivery mode in Tehran Province, Iran, from March 2023 to March 2024.
Methods: This cross-sectional study included 400 mothers selected through stratified urban–rural sampling. Data were collected at healthcare facilities using a researcher-developed questionnaire covering demographic, socioeconomic, maternal, and obstetric characteristics and mode of delivery. Data were analyzed using Chi-square and Mann–Whitney U tests, followed by Firth’s penalized binary logistic regression in Stata 17.
Results: Overall, 62% of participants had CS. Maternal age >31 years (OR = 4.02; 95% CI: 1.49–10.87), public-sector maternal employment (OR = 4.50; 95% CI: 1.66–12.22), and supplementary health insurance (OR = 2.01; 95% CI: 1.10–3.68) were associated with higher odds of CS. A history of stillbirth (OR = 0.06; 95% CI: 0.01–0.48), participation in birth-preparation classes (OR = 0.41; 95% CI: 0.24–0.69), and delivery in public hospitals or at home versus private hospitals (OR = 0.30; 95% CI: 0.16–0.56) were associated with lower odds of CS.
Conclusion: Delivery mode is influenced by multiple socioeconomic, maternal, and health system factors, highlighting the importance of supportive prenatal services and evidence-based policies.
Keywords
Cesarean Section
Natural Childbirth
Maternal Health
Prenatal Care
Socioeconomic Factors
Subjects
1.        Ratan RB. Normal and Abnormal Labor and Delivery. Gabbe's Obstetrics Study Guide, E‐Book: A Companion to the 8th Edition. 2020.
2.        Schantz C, De Loenzien M, Goyet S, Ravit M, Dancoisne A, Dumont A. How is women’s demand for caesarean section measured? A systematic literature review. PloS One. 2019; 14(3): e0213352.
3.        WHO. Trends in Maternal Mortality: 1990 to 2015-Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. United Nations (Other); 2015.
4.        Betrán AP, Torloni MR, Zhang J-J, Gülmezoglu A, Aleem H, Althabe F, et al. WHO statement on caesarean section rates. British Journal of Obstetrics and Gynaecology. 2016; 123(5): 667.
5.        Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PloS One. 2016; 11(2): e0148343.
6.        Rafiei M, Saei Ghare M, Akbari M, Kiani F, et al. Prevalence, causes, and complications of cesarean delivery in Iran: a systematic review and meta-analysis. International Journal of Reproductive BioMedicine. 2018; 16(4): 221–234.
7.        Rasoli M, Mirrezaie SM, Fooladi E, Hosseini RZ, Fayaz M. Effects of reviewing childbirth scenarios on choice of delivery type: a randomized controlled trial. Turkish Journal of Obstetrics and Gynecology. 2019; 16(1): 15.
8.        Kankoon N, Lumbiganon P, Kietpeerakool C, Sangkomkamhang U, Betrán AP, Robson M. Cesarean rates and severe maternal and neonatal outcomes according to the Robson 10‐Group Classification System in Khon Kaen Province, Thailand. International Journal of Gynecology and Obstetrics. 2018; 140(2): 191-197.
9.        Torloni MR, Betrán AP, Montilla P, Scolaro E, Seuc A, Mazzoni A, Althabe F, Merzagora F, Donzelli GP, Merialdi M. Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences. BMC Pregnancy and Childbirth. 2013; 13(1): 78.
10.    O'Donovan C, O'Donovan J. Why do women request an elective cesarean delivery for non‐medical reasons? A systematic review of the qualitative literature. Birth. 2018; 45(2): 109-119.
11.    Neuman M, Alcock G, Azad K, Kuddus A, Osrin D, More NS, et al. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ Open. 2014; 4(12).
12.    Begum T, Ellis C, Sarker M, Rostoker J-F, Rahman A, Anwar I, Reichenbach L. A qualitative study to explore the attitudes of women and obstetricians towards caesarean delivery in rural Bangladesh. BMC Pregnancy and Childbirth. 2018; 18(1): 1-11.
13.    Kumar P, Srivastava S, Chaudhary P, Muhammad T. Factors contributing to socio-economic inequality in utilization of caesarean section delivery among women in Indonesia: Evidence from Demographic and Health Survey. Plos One. 2023; 18(9): e0291485.
14.    Verma V, Vishwakarma RK, Nath DC, Khan HT, Prakash R, Abid O. Prevalence and determinants of caesarean section in South and South-East Asian women. PloS One. 2020; 15(3): e0229906.
15.    Kumar P, Dhillon P. Household-and community-level determinants of low-risk Caesarean deliveries among women in India. Journal of Biosocial Science. 2021; 53(1): 55-70.
16.    Hoxha I, Fink G. Caesarean sections and health financing: a global analysis. BMJ Open. 2021; 11(5): e044383.
17.    Shariat M, Ehdaeevand F, Ataie M, Karami Z, Hadipoor Jahromi LHJ, Farahani Z. Effectiveness of community based intervention on improvement of pregnancy and delivery process in district 4 of Tehran. Tehran University Medical Journal Tehran University of Medical Sciences Publications. 2015; 73(7): 527-534.
18.    Sharifirad G, Rezaeian M, Soltani R, Javaheri S, Mazaheri MA. A survey on the effects of husbands’ education of pregnant women on knowledge, attitude, and reducing elective cesarean section. Journal of Education and Health Promotion. 2013; 30; 2: 50.
19.    Omani-Samani R, Mohammadi M, Almasi-Hashiani A, Maroufizadeh S. Cesarean section and socioeconomic status in Tehran, Iran. Journal of Research in Health Sciences. 2017; 17(4): 394.
20.    Amini P, Mohammadi M, Omani-Samani R, Almasi-Hashiani A, Maroufizadeh S. Factors associated with cesarean section in Tehran, Iran using multilevel logistic regression model. Osong Public Health and Research Perspectives. 2018; 9(2): 86.
21.    Rajabi A, Maharlouei N, Rezaianzadeh A, Rajaeefard A, Gholami A. Risk factors for C-section delivery and population attributable risk for C-section risk factors in Southwest of Iran: a prospective cohort study. Medical Journal of the Islamic Republic of Iran. 2015; 29: 294.
22.    Dadipoor S, Madani A, Alavi A, Roozbeh N, Safari Moradabadi A. A survey of the growing trend of caesarian section in Iran and the world: a review article. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2016; 19(27): 8-17.
23.    Manyeh AK, Amu A, Akpakli DE, Williams J, Gyapong M. Socioeconomic and demographic factors associated with caesarean section delivery in Southern Ghana: evidence from INDEPTH Network member site. BMC Pregnancy and Childbirth. 2018; 18: 1-9.
24.    Ahmed MS, Islam M, Jahan I, Shaon IF. Multilevel analysis to identify the factors associated with caesarean section in Bangladesh: evidence from a nationally representative survey. International Health. 2023; 15(1): 30-36.
25.    Okwandu IC, Anderson M, Postlethwaite D, Shirazi A, Torrente S. Racial and ethnic disparities in cesarean delivery and indications among nulliparous, term, singleton, vertex women. Journal of Racial and Ethnic Health Disparities. 2022: 1-11.
26.    Carlson NS, Carlson MS, Erickson EN, Higgins M, Britt AJ, Amore AD. Disparities by race/ethnicity in unplanned cesarean birth among healthy nulliparas: a secondary analysis of the nuMoM2b dataset. BMC Pregnancy and Childbirth. 2023; 23(1): 342.
27.    Ochieng Arunda M, Agardh A, Asamoah BO. Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data. Global Health Action. 2020; 13(1): 1748403.
28.    Hoxha I, Syrogiannouli L, Braha M, Goodman DC, da Costa BR, Jüni P. Caesarean sections and private insurance: systematic review and meta-analysis. BMJ Open. 2017; 7(8): e016600.
29.    Wulandari RD, Laksono AD, Matahari R, Rohmah N. The role of health insurance in cesarean delivery among working mothers in Indonesia. Journal of Public Health. 2024: 1-8.
30.    O’Neill SM, Kearney PM, Kenny LC, Khashan AS, Henriksen TB, Lutomski JE, Greene RA. Caesarean delivery and subsequent stillbirth or miscarriage: systematic review and meta-analysis. PLoS One. 2013; 8(1): e54588.
31.    Mahmood NH, Kadir DH, Yahya RO, Birdawod HQ. The significance of delivery methods and fetal gender in reducing stillbirth rate: Using the generalized regression model. Clinical Epidemiology and Global Health. 2024; 29: 101710.
32.    Milcent C, Zbiri S. Prenatal care and socioeconomic status: effect on cesarean delivery. Health Economics Review. 2018; 8: 1-21.
33.    Chen MM, Hancock H. Women's knowledge of options for birth after Caesarean Section. Women and Birth. 2012; 25(3): e19-e26.
34.    Loke AY, Davies L, Li S-f. Factors influencing the decision that women make on their mode of delivery: the Health Belief Model. BMC Health Services Research. 2015; 15: 1-12.
35.    35. Pakniat H, Akbari R. Effective factors to select cesarean-section. Tehran University of Medical Sciences Journal. 2018; 76(7): 484-491.
36.    Almeida Sd, Bettiol H, Barbieri MA, Silva AAMd, Ribeiro VS. Significant differences in cesarean section rates between a private and a public hospital in Brazil. Cadernos de Saude Publica. 2008; 24: 2909-2918.
37.    Wyatt S, Silitonga PII, Febriani E, Long Q. Socioeconomic, geographic and health system factors associated with rising C-section rate in Indonesia: a cross-sectional study using the Indonesian demographic and health surveys from 1998 to 2017. BMJ Open. 2021; 11(5): e045592.
38.    Mohamadbeigi A, Tabatabaee SH, Mohammad Salehi N, Yazdani M. Factors influencing cesarean delivery method in Shiraz hospitals. Iran Journal Nurse. 2009; 21(56): 37-45.
39.    Dehghani SL, Mehrolhasani N, Rastad H, Ebrahimi M, Motamed Jahromi M. Factors influencing cesarean delivery in women visiting the women's pregnancy clinic in Bam, Iran. Health and Development Journal. 2012; 1(3): 237-243.
Journal of Midwifery and Reproductive Health
Volume 14, Issue 4
Autumn 2026
Pages 5742-5754