Psychological Determinants of Preferring Vaginal Birth After Cesarean: Fear and Self-Efficacy

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This cross-sectional study included 400 participans. Data were analyzed using multivariable logistic regression and ROC analysis. Contrary to expectations, the preferring vaginal birth after cesarean group reported significantly lower childbirth self-efficacy (p = 0.045) and higher specific birth fears (p < 0.001). Multivariable analysis identified husband’s education (OR: 2.32), negative previous birth experience, and fear of pregnancy and childbirth problems (OR: 0.84) as significant predictors of preferring vaginal birth after cesarean preference. ROC analysis demonstrated that the fear of pregnancy and childbirth problems had statistically significant discriminative ability in predicting birth preference (AUC = 0.68, 95% CI: 0.63–0.73, Sensitivity: 76%). A paradoxical association exists where women with higher fears and lower self-efficacy are more inclined to choose preferring vaginal birth after cesarean, which may reflect a motivation to avoid repeated surgery. High fear levels may indicate a strong motivation for a trial of labor rather than a request for cesarean. vaginal birth after cesarean fear of childbirth self-efficacy Figures Figure 1 Figure 2 Introduction The World Health Organization has raised concerns regarding the global escalation of cesarean section (CS) rates, suggesting that figures exceeding the 15% threshold no longer contribute to a further decline in maternal, neonatal, or infant mortality (WHO, 2015 ). The World Health Organization underscores that cesarean sections yield beneficial outcomes only when they are performed based on medical indications (Parasiliti et al., 2023 ). Although a cesarean section can be a critical life-saving intervention, it is associated with a range of immediate and enduring health implications for both mothers and their infants (Sandall et al., 2018 ). Elective repeat CS is a significant contributor to the current CS rate in Turkey and many other countries worldwide (Uzunkaya-Öztoprak et al., 2023 ). The decision-making process regarding the mode of delivery after a previous cesarean is not merely a clinical evaluation but is profoundly influenced by complex psychological factors. Among these, fear of childbirth (FOC) and childbirth self-efficacy stand out as primary determinants (Hou et al., 2022 ; Ma et al., 2025 ). Fear of childbirth (FOC) is conceptualized as a distressing psychological state that arises when reflecting on future delivery, often triggered by internalizing the traumatic birth narratives or painful experiences shared by others (Nilsson et al., 2018 ). Furthermore, childbirth-related anxieties can emerge throughout the gestational period, primarily revolving around the anticipation of intense pain, the inherent unpredictability of labor, and concerns regarding a loss of autonomy. These fears are often compounded by deep-seated worries about potential neonatal complications or stillbirth (Hou et al., 2022 ). FOC has many negative effects on women’s physical and mental health, including deficit social support, experience with previous cesarean section, childbirth self-efficacy, pain, distressing the infant, prolonged childbirth, unplanned CS, vacuum delivery, depression and anxiety (Elgzar et al., 2023 ; Hou et al., 2022 ; Nath et al., 2021 ; Takegata et al., 2018 ; Vaajala et al., 2023 ). Self-efficacy represents an individual’s subjective conviction in their ability to successfully carry out specific behaviors. Within the realms of obstetrics and parenting, a woman's sense of self-efficacy serves as a fundamental determinant in her psychological preparedness and her overall experience of these significant life transitions (Bandura, 1978 ). Research indicates that a robust sense of self-efficacy functions as a protective factor, promoting better pain management and resilience during labor, which ultimately leads to a more positive and fulfilling birth experience for the mother (Sánchez-Cunqueiro et al., 2018 ; Zaman et al., 2025 ). Literature evidence has demonstrated that childbirth self-efficacy may be impacted by sociodemographic and obstetric factors such as antenatal education, maternal age, educational level, and social support (Çankaya & Şimşek, 2021 ; Gao et al., 2015 ; Hosseini Tabaghdehi et al., 2020 ). While the existing literature highlights the individual significance of FOC and childbirth self-efficacy, there is limited evidence comparing these psychological determinants specifically between women preferring Vaginal Birth After Cesarean (VBAC) and those opting for Cesarean After Vaginal Birth (CAVB). Understanding the interplay between fear and perceived competence is essential for developing targeted interventions to reduce unnecessary surgical births. Therefore, this study aims to investigate the psychological determinants of preferring VBAC and CAVB, with a specific focus on the predictive roles of fear of childbirth and self-efficacy. Methods Study Design and Setting This study was designed as a descriptive and cross-sectional research, adhering to the STROBE statement for observational studies. Data were collected between October 2025 and January 2026 at the Van Training and Research Hospital in Van, Turkey. Sample and Participants The study population consisted of pregnant women who had a history of at least one previous delivery. Inclusion criteria were: (1) aged 18–45 years, (2) having a single pregnancy, (3) women with a history of both vaginal birth and cesarean section, and (4) voluntary participation. Women with high-risk pregnancies, cognitive impairments, or emergency complications were excluded. The minimum required sample size was calculated a priori using the G*Power 3.1.9.4 software. Based on reference findings (Bayrı Bingöl et al., 2022 ), with an effect size (d) of 0.722, a significance level (α) of 0.05, and a targeted power (1- β ) of 0.99, the threshold was set at 144 participants (72 per group). However, to enhance the statistical power, improve the representativeness of the findings, and account for potential data attrition, the recruitment process was expanded. Consequently, the study was completed with a total of 400 participants who met the inclusion criteria and voluntarily agreed to participate Data Collection Tools Descriptive characteristics form This form was of participants’ demographic and obstetrics characteristics. This part collects data such as age, BMI, income, educational level, husband educational level, and occupation. Obstetric history includes gravidy, parity, planned pregnancy status, abortion history, latest birth planning status, participation in prenatal classes and previous birth experience. Childbirth self-efficacy scale (CSES) Childbirth self-efficacy was assessed using the scale originally designed by Chu et al. (Chu et al., 2017 ). This instrument consists of nine items, each rated on an 11-point Likert scale ranging from 0 ('no confidence') to 10 ('very confident'). The total score is derived by summing the responses, yielding a range between 0 and 90. In the current study, the Turkish adaptation validated by Kahraman et al. was utilized, which demonstrated high internal consistency with a Cronbach’s alpha of .90 (Kahraman & Alparslan, 2022 ). In the present study, the Cronbach's alpha coefficient was calculated as 0.88. Fear of childbirth scale (FCS) : Fear of childbirth was assessed using the scale developed by Nuraliyeva and Kaya (Nuraliyeva & Kaya, 2022 ). The scale is designed as a 5-point Likert-type instrument, with responses ranging from 1 (Strongly Agree) to 5 (Strongly Disagree). Positive items (Items 4, 7, 9, 11, 13, 16, 18, and 19) are scored directly as follows: Strongly Agree = 1, Agree = 2, Undecided = 3, Disagree = 4, and Strongly Disagree = 5. Conversely, negative items (Items 1, 2, 3, 5, 6, 8, 10, 12, 14, 15, 17, and 20) are reverse-coded, ranging from 'Strongly Agree' = 5 to 'Strongly Disagree' = 1. The total score obtainable from the scale varies between 34 and 170. Lower scores indicate a higher level of fear regarding childbearing among women of reproductive age. The scale comprises three sub-dimensions: 'Fear of pregnancy, childbirth, and the role of motherhood,' 'Fear of not meeting physical and social needs,' and 'Fear of pregnancy and childbirth problems. Cronbach's alpha coefficient of the draft Childbirth Fear Scale was found to be 0.86 for the overall scale, 0.88 for factor 1, 0.76 for factor 2, and 0.75 for factor 3. For this study, the Cronbach's alpha reliability coefficient was found to be 0.79. Statistical Analysis Statistical analyses were performed using SPSS version 27.0 and python 3.12.10 for advanced modeling. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test and visual inspections (Q-Q and Histogram plots,). Descriptive data were reported as frequencies, percentages, or means and standard deviations. To compare the groups (VBAC vs. CAVB), the independent samples t-test was used for continuous variables, while the Chi-square test or Fisher’s exact test was employed for categorical data. To identify the predictors of birth preference, univariable and multivariable logistic regression analyses were conducted. Factors showing significant associations in the univariable model were entered into the multivariable model to calculate adjusted odds ratios (ORs) with 95% confidence intervals. A nomogram was constructed based on the multivariable logistic regression results to provide a visual predictive tool for birth preference. The predictive performance and discriminatory power of the model were evaluated using Receiver Operating Characteristic (ROC) curve analysis. The Area Under the Curve (AUC) was calculated, and optimal cut-off values were determined using the Youden index. A p-value of < 0.05 was considered statistically significant. Ethical Considerations The study was conducted in accordance with the principles of the Declaration of Helsinki. Prior to the commencement of the research, ethical approval was obtained from the Van Education and Research Hospital Ethics Committee (Date: 24.10.2025, Decision No: 2025-08-33). Furthermore, institutional permission for data collection was granted by the administration of Van Education and Research Hospital. All participants were provided with a comprehensive explanation regarding the study’s objectives, and their informed consent (either written or verbal, depending on your protocol) was obtained before data collection. Participants were assured that their involvement was entirely voluntary, that they maintained the right to withdraw from the study at any time without prejudice, and that all collected data would remain anonymous and strictly confidential. The information gathered was utilized solely for scientific research purposes Results Table 1 presents the sociodemographic and obstetric profiles of the participants ( $ N = 400 $ ), with a mean age of 28.63 (5.01) years and a mean BMI of 28.12 (4.63) kg/m 2 . While no significant differences were found between the CAVB and VBAC groups regarding maternal age, BMI, income, or education (p > 0.05), a significant disparity was observed in husband’s education level (p = 0.017), where high school graduation was more prevalent in the VBAC group (34.0%) than in the CAVB group (20.2%).Regarding obstetric characteristics, significant differences emerged in birth planning and prior experiences (p < 0.001). Nearly half of the VBAC group (49.2%) initially planned for an elective cesarean, whereas 60.6% of the CAVB group had planned for a vaginal birth. Furthermore, 66.5% of the CAVB group reported positive prior birth experiences, while the majority of the VBAC group (57.9%) characterized their previous experience as negative. Factors such as gravidity, parity, and prenatal class participation showed no statistical significance (p > 0.05) (Table 1 ). Table 1 Comparison of socio demographic and obstetric characteristics of women Variable Cesarean Section After Vaginal Birth (CAVB) (n = 203) Vaginal Birth After Cesarean Section (VBAC) (n = 197) Total (N = 400) P-Value Age (mean (SD)) 28.35 (5.10) 28.90(4.92) 28.63(5.01) 0.275 BMI (mean (SD)) 28.30(4.71) 27.94(4.55) 28.12(4.63) 0.448 Gravidity (mean (SD)) 3.06(1.19) 3.08(1.18) 3.07(1.19) 0.853 Parity (mean (SD)) 2.07(1.12) 2.09(1.02) 2.08(1.07) 0.908 Income (%) Low 68(33.5) 71(36.0) 139(34.8) Average 117(57.6) 115(58.4) 232(58.0) 0.431 High 18(8.9) 11(5.6) 29(7.2) Education level (%) Primary school 67(33.0) 57(28.9) 124(31.0) Middle school 56(27.6) 60(30.5) 116(29.0) 0.811 High school 47(23.2) 49(24.9) 96(24.0) University 33(16.3) 31(15.7) 64(16.0) Husband education (%) Primary school 38(18.7) 27(13.7) 65(16.3) Middle school 70(34.5) 61(31.0) 131(32.8) 0.017* High school 41(20.2) 67(34.0) 108(27.0) University 54(26.6) 42(21.3) 96(24.0) Employment status (%) Unemployed 180(88.7) 165(83.8) 345(86.3) 0.191 Employed 23(11.3) 32(16.2) 55(13.8) Planned pregnancy status (%) Yes 105(51.7) 96(48.7) 201(50.2) 0.617 No 98(48.3) 101(51.3) 199(49.8) Abortion history (%) Yes 49(24.1) 46(23.4) 95(23.8) 0.907 No 154(75.9) 151(76.6) 305(76.3) Latest birth planning status Vaginal birth after cesarean section 21(10.3) 44(22.3) 65(16.3) Elective cesarean section 45(22.2) 97(49.2) 142(35.5) < 0.001* Vaginal birth 123(60.6) 43(21.8) 166(41.5) Uncertain (physician decision) 14(6.9) 13(6.6) 27(6.8) Participation in prenatal classes Yes 38(18.7) 29(14.7) 67(16.8) 0.349 No 165(81.3) 168(85.3) 333(83.3) Previous birth experience Positive 135(66.5) 83(42.1) 218(54.5) < 0.001* Negative 68(33.5) 114(57.9) 182(45.5) Table 2 compares the psychological determinants between the groups. The VBAC group exhibited significantly lower mean scores on the Fear of Childbirth scale (51.04 (12.58)) compared to the CAVB group (53.43 (11.17); p = 0.003). Since lower scores indicate higher fear levels, this finding demonstrates that fear of childbirth is significantly more intense in the VBAC group. Specifically, fear regarding "pregnancy and childbirth problems" was more pronounced in the VBAC cohort (p < 0.001). Consistent with this, the VBAC group also demonstrated significantly lower childbirth self-efficacy (61.09 (15.83) than the CAVB group (65.74 (15.08); p = 0.045) (Table 2 ). Table 2 Comparison of fear of childbirth and childbirth self-efficacy of participants Variable CAVB (n = 203) VBAC (n = 197) Total (N = 400) P-Value Mean (SD) Mean (SD) Mean (SD) Fear of childbirth 53.43(11.17) 51.04(12.58) 52.25(11.93) 0.003 Fear of pregnancy, childbirth, and the role of Motherhood 22.17(7.81) 22.91(8.24) 22.54(8.02) 0.353 Fear of not meeting physical and social needs 15.88(4.62) 15.06(4.57) 15.48(4.61) 0.077 Fear of pregnancy and childbirth problems 15.38(3.86) 13.07(3.58) 14.24(3.90) < 0.001 Childbirth self-efficacy 65.74(15.08) 61.09(15.83) 63.45(15.61) 0.045 Reference: Primary school Table 3 presents the results of the multivariable logistic regression analysis conducted to identify independent predictors of preferring VBAC. Two separate models were established. In Model 1, husband’s university education (p = 0.010), previous birth experience (p < 0.001), childbirth self-efficacy (p = 0.002), and total fear of childbirth score (p = 0.031) were identified as significant predictors. In Model 2, the total fear score was replaced by the fear of pregnancy and childbirth problems sub-dimension to examine specific anxieties. This model revealed that, alongside husband’s education and previous birth experience, this specific fear domain was a highly significant predictor (p < 0.001) with an Odds Ratio of 0.84 (95% CI: 0.79–0.89). Based on the significant predictors in the multivariable analysis, a prognostic nomogram was constructed to predict the probability of VBAC preference visually (Fig. 1 ). In the nomogram, each predictor is assigned a point value on the uppermost scale. The total points are then summed to determine the individual's probability of choosing VBAC on the bottom risk axis (Table 3 ). Table 3 Multivariable logistic regression analysis of predictors for VBAC preference Variable Model 1 Model 2 OR (95% CI) p OR (95% CI) p Husband education 0.022 0.024 Husband education (1) 0.94 (0.47–1.82 0.878 1.01(0.49–2.07) 0.966 Husband education (2) 1.17(0.65–2.10) 0.582 1.18(0.64–2.16) 0.589 Husband education (3) 2.21(1.21–4.04) 0.010 2.32(1.23–4.39) 0.009 Previous birth experience 0.34(0.22–0.52) < 0.001 0.34(0.22–0.53) < 0.001 Prenatal education 0.95(0.53–1.71) 0.878 0.99(0.54–1.79) 0.978 Childbirth self-efficacy 0.97(0.96–0.99) 0.002 0.97(0.96–0.99) 0.002 Fear of childbirth 0.98(0.96–0.99) 0.031 Fear of pregnancy and childbirth problems 0.84(0.79–0.89) < 0.001 Reference last, OR: Odds Ratio, CI: Confidence Interval. Model 1 includes total fear score; Model 2 includes specific sub-dimension scores Receiver Operating Characteristic (ROC) curve analysis was performed to evaluate the discriminatory power of the psychological predictors for VBAC preference. As shown in Fig. 2 and Table 4 , the 'Fear of pregnancy and childbirth problems' sub-dimension demonstrated a statistically significant discriminative ability (AUC = 0.68, 95% CI: 0.63–0.73; p < 0.001). The optimal cut-off value was determined to be 15.50. At this threshold, the scale exhibited a sensitivity of 76% and a specificity of 51% in predicting birth preference. Additionally, Childbirth Self-Efficacy showed a statistically significant, albeit weaker, predictive performance (AUC = 0.58, 95% CI: 0.53–0.64; p = 0.028). The optimal cut-off point for self-efficacy was calculated as 67.50, with a sensitivity of 54% and a specificity of 43% (Table 4 , Fig. 2 ). Table 4 ROC analysis of predictors for VBAC preference Risk factor AUC (95%CI) p Cut-off Sensitivity (%) Specificity (%) Fear of pregnancy and childbirth problems 0.68 (0.63–0.73) < 0.001 15.50 0.76 0.51 Chilbirth efficacy 0.58 (0.53–0.64) 0.028 67.50 0.54 0.43 AUC: Area Under the Curve, CI: Confidence Interval, ROC: Receiver Operating Characteristic Discussion This study provides a comprehensive evaluation of the factors influencing the birth method preference of women with a history of cesarean section. While previous literature often associates fear of childbirth with a request for elective cesarean, this study revealed a complex relationship where women with higher specific birth anxieties and negative past experiences were more inclined to choose VBAC. This suggests that the preference for VBAC may be driven by a desire to overcome past trauma or avoid surgery, despite existing fears. A remarkable finding of this study is the positive association between high levels of specific birth fears (fear of pregnancy and childbirth problems), negative previous birth experiences, and the preference for VBAC. Traditionally, existing literature suggests that high fear of childbirth is a primary driver for requesting elective cesarean sections (Elgzar et al., 2023 ; Størksen et al., 2015 ). However, our results present a contrasting dynamic. The fact that the VBAC group reported significantly more negative previous experiences suggests that their current fear may not be of vaginal birth itself, but rather a fear of repeating the previous traumatic cesarean experience. Studies by Nilsson et al. and Keedle et al. support this interpretation, indicating that women often view VBAC as an opportunity to overcome from a previous traumatic birth and regain a sense of control (Keedle et al., 2020 ; Nilsson et al., 2017 ). Thus, the preference for VBAC in this high-anxiety group can be interpreted as a coping mechanism to avoid a recurrence of past trauma The present study found that women whose husbands have a university degree were more than twice as likely to prefer VBAC, suggesting that partner-related social support and informed engagement may influence women’s mode of birth preferences; although few studies have examined spousal education specifically, the broader literature on VBAC decision-making highlights the importance of external support including partner and family encouragement as facilitators of VBAC choice (Cosmai et al., 2025 ). Moreover, shared decision-making where women, their partners, and healthcare providers discuss options collaboratively has been shown to improve involvement in decisions about mode of birth and is associated with higher engagement in VBAC planning (Yussuph & Alwy Al-Beity, 2023 ). Higher educational attainment of husbands may therefore be linked to greater health literacy, more effective participation in antenatal counselling, and better support of evidence-based birth options, all of which could contribute to a woman’s likelihood of preferring VBAC in the context of informed and collaborative decision-making. In the present study, childbirth self-efficacy emerged as a significant predictor of VBAC preference in both Model 1 and Model 2, indicating that higher levels of self-efficacy were independently associated with an increased likelihood of preferring VBAC. This finding aligns with recent evidence that maternal self-efficacy is a modifiable psychological construct that positively influences childbirth experiences and related outcomes; antenatal education interventions have been shown to significantly increase self-efficacy while concomitantly reducing fear of childbirth and increasing rates of vaginal delivery and lower cesarean rates in meta-analytic synthesis (Zaman et al., 2025 ). A large 2024 observational study also confirms that childbirth self-efficacy varies across groups (primiparas vs multiparas) and is inversely related to fear and labor pain intensity, suggesting that confidence in coping with labor may shape attitudes toward physiological birth options, including VBAC (Huang et al., 2024 ). Taken together, these recent data support the interpretation that higher childbirth self-efficacy contributes to a greater likelihood of preferring VBAC, likely through mechanisms of increased confidence, reduced fear, and enhanced ability to engage in active coping and informed decision-making. Finally, the ROC analysis underscores the discriminatory power of specific birth fears in predicting birth preference. The fear of pregnancy and childbirth problems sub-dimension demonstrated a significant discriminative ability with a relatively high sensitivity of 76% at the cut-off value of 15.50. This high sensitivity indicates that the scale is particularly effective in correctly identifying women who are inclined towards VBAC. In clinical practice, distinguishing women's birth preferences early in pregnancy is crucial for appropriate counseling. While most existing studies focus on cut-off points to diagnose 'tocophobia' for requesting cesarean (Lai et al., 2022 ; Nilsson et al., 2018 ; Størksen et al., 2015 ), our study is one of the few to establish a cut-off value for predicting a preference for vaginal birth after cesarean. This study has several limitations that should be considered when interpreting the results. First, the cross-sectional design of the study prevents the establishment of causal relationships between psychological variables and birth preference. Second, the data were collected from a single center, which may limit the generalizability of the findings to other populations with different cultural or socioeconomic backgrounds. Conclusion Our findings demonstrate a paradoxical yet significant association: women who prefer vaginal birth after cesarean exhibit higher specific birth fears, lower self-efficacy, and more negative previous birth experiences compared to those choosing a repeat cesarean. This suggests that for many women, the desire for VBAC is driven to overcome a past traumatic experience or to avoid repeated surgery, rather than by a lack of fear or high self-confidence. In clinical practice, health professionals should not interpret high levels of birth fear solely as a request for cesarean. Instead, the cut-off value identified in this study can be used as a screening tool to identify high-risk women who are nevertheless motivated for a trial of labor. These women require targeted antenatal counseling and enhanced psychological support to improve their self-efficacy and ensure a positive birth experience. Declarations Acknowledgments We would like to thank the administration of Van Training and Research Hospital for their permission and support during the data collection process. We also express our sincere gratitude to all the women who voluntarily participated in this study and shared their valuable experiences Conflıct of Interest The author has no conflicts of interest to disclose. Supporting Information This research received no external funding. Ethical Approval Approval for the research was obtained from the Scientific Research and Publication Ethics Committee (Approval No: GOKAEK/2025-08-33). I have declared that that none of the paper's contents have been published or are under consideration else where. I have declared that all authors have read and approved the manuscript. Author contributions Study conception/design: MCG, YS, SG, ÜY Data collection/analysis: MCG YS, SG, ÜY Drafting of manuscript: MCG, YS Critical revisions for important intellectual content: supervision; MCG, YS, SG, ÜY Statistical expertise: YS Administrative/ technical material support: MCG, YS, SG, MY References Bandura, A. (1978). 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Bmc Pregnancy And Childbirth , 20 (1), 381. https://doi.org/10.1186/s12884-020-03075-8 Lai, T. H. T., Kwok, S. T., Wang, W., Seto, M. T. Y., & Cheung, K. W. (2022). Fear of childbirth: Validation study of the Chinese version of Wijma delivery expectancy / experience questionnaire version B. Midwifery , 108 , 103296. https://doi.org/10.1016/j.midw.2022.103296 Ma, L., Lu, J., Chong, M. C., Lee, W. L., & Wu, M. (2025). Association between postpartum post-traumatic stress disorder, maternal functioning, and self-efficacy in women after cesarean section. African Journal Of Reproductive Health , 29 (10), 62–74. https://doi.org/10.29063/ajrh2025/v29i10.6 Nath, S., Lewis, L. N., Bick, D., Demilew, J., & Howard, L. M. (2021). Mental health problems and fear of childbirth: A cohort study of women in an inner-city maternity service. 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J., Comeche, M. I., & Docampo, D. (2018). On the relation of self-efficacy and coping with the experience of childbirth. J Nurs Educ Pract , 8 (6), 48. Sandall, J., Tribe, R. M., Avery, L., Mola, G., Visser, G. H., Homer, C. S., Gibbons, D., Kelly, N. M., Kennedy, H. P., Kidanto, H., Taylor, P., & Temmerman, M. (2018). Short-term and long-term effects of caesarean section on the health of women and children. Lancet , 392 (10155), 1349–1357. https://doi.org/10.1016/s0140-6736(18)31930-5 Størksen, H. T., Garthus-Niegel, S., Adams, S. S., Vangen, S., & Eberhard-Gran, M. (2015). Fear of childbirth and elective caesarean section: a population-based study. BMC pregnancy and childbirth , 15 (1), 221. https://doi.org/10.1186/s12884-015-0655-4 Takegata, M., Haruna, M., Morikawa, M., Yonezawa, K., Komada, M., & Severinsson, E. (2018). Qualitative exploration of fear of childbirth and preferences for mode of birth among Japanese primiparas. Nursing & Health Sciences , 20 (3), 338–345. https://doi.org/10.1111/nhs.12571 Uzunkaya-Öztoprak, P., Koç, G., & Özyüncü, Ö. (2023). The Effect of Kinesio Taping on Acute Pain, Breastfeeding behavior and Comfort Level in Women with Cesarean Section: A Randomized Controlled Trial. Nigerian Journal of Clinical Practice , 26 (8). https://journals.lww.com/njcp/fulltext/2023/08000/the_effect_of_kinesio_taping_on_acute_pain,.5.aspx Vaajala, M., Liukkonen, R., Kuitunen, I., Ponkilainen, V., Mattila, V. M., & Kekki, M. (2023). Factors associated with fear of childbirth in a subsequent pregnancy: a nationwide case-control analysis in Finland. Bmc Women'S Health , 23 (1), 34. https://doi.org/10.1186/s12905-023-02185-7 WHO (2015). WHO statement on caesarean section rates . https://www.who.int/publications/i/item/WHO-RHR-15.02 Yussuph, Z. H., & Alwy Al-Beity, F. M. (2023). Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania. PLoS One , 18 (10), e0291809. https://doi.org/10.1371/journal.pone.0291809 Zaman, A., Fadlalmola, H. A., Ibrahem, S. E., Ismail, F. H., Abedelwahed, H. H., Ali, A. M., Abdelgadim, N. H., Mustafa, A. M. A., Ahmed, I. H., Ahmed, N. M., Eltyeb, A. A., Gaafar, D. A., Alnassry, S. M., Adam, A. A., Yasin, N. S., Ali, R. A., Fadlalla, A. A., Eltayeb, A. E., & Saad, A. M. (2025). The role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes: A systematic review and meta-analysis. Eur J Midwifery , 9. https://doi.org/10.18332/ejm/200747 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8945877","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597389053,"identity":"06ec637d-2e83-4455-a598-35c6d048b021","order_by":0,"name":"Mert Cenker GÜNEY","email":"","orcid":"","institution":"Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mert","middleName":"Cenker","lastName":"GÜNEY","suffix":""},{"id":597389054,"identity":"edb3c0e5-c4ab-4245-a6ed-7356d0458bcc","order_by":1,"name":"Yılmaz SARIBOĞA","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYJCCw2CSmbkBSNoAMWPjASK1MIK0pIG0NBDUwgyhwFog2vFqkW8/+/BwQUWtvMFxxtYNP/6ct1vbfhhoS41NNC4tBmfSDQ7POHPccMNhxrabPTy3k7edSQRqOZaW24BLC9D1h3nbjjGCtNzgkbidbHYAqIWx4TBOLfL9z8Ba7MG2/DE4l2x2/iF+LQw3wLbUJIK03OZJOGBndoOALQY3gLbMOHMgeSZIi8yB5ASzG0BbEvD4Rb4/jflzQUWdbd/5w8duvvljZ292Pv3hgw81NrgdBgGHGRQOQFiJYJUJ+JWDQB2DPNRQe8KKR8EoGAWjYKQBAJ6pbiw/CzmQAAAAAElFTkSuQmCC","orcid":"","institution":"Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yılmaz","middleName":"","lastName":"SARIBOĞA","suffix":""},{"id":597389055,"identity":"3647fa86-2b1e-4e4a-96db-c5ddce8f0a60","order_by":2,"name":"Selin GÜNEY","email":"","orcid":"","institution":"Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Selin","middleName":"","lastName":"GÜNEY","suffix":""},{"id":597389056,"identity":"4aff551f-a198-4548-87ca-be1840b03977","order_by":3,"name":"Ünsal YEŞİLOVA","email":"","orcid":"","institution":"Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ünsal","middleName":"","lastName":"YEŞİLOVA","suffix":""}],"badges":[],"createdAt":"2026-02-23 10:23:58","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8945877/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8945877/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104168608,"identity":"df4843ad-a95e-4643-aeab-3c52a6a20493","added_by":"auto","created_at":"2026-03-08 14:33:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131830,"visible":true,"origin":"","legend":"\u003cp\u003eNomogram based on the prediction model for calculating the risk scores of women\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8945877/v1/ae4809a4674799a7e39884d9.png"},{"id":104168607,"identity":"527b5c3e-069c-430f-be2b-d0c752869027","added_by":"auto","created_at":"2026-03-08 14:33:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":123137,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis for determining the discriminativeability of the prediction model.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8945877/v1/218d8b6359a8397eb96f2ecb.png"},{"id":104786386,"identity":"df1799a1-75fd-4e5b-b86b-c665788b6d3c","added_by":"auto","created_at":"2026-03-17 08:16:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1224428,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8945877/v1/9ab0cb5f-d9f9-4f5b-a782-53d0ce04d837.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Determinants of Preferring Vaginal Birth After Cesarean: Fear and Self-Efficacy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe World Health Organization has raised concerns regarding the global escalation of cesarean section (CS) rates, suggesting that figures exceeding the 15% threshold no longer contribute to a further decline in maternal, neonatal, or infant mortality (WHO, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The World Health Organization underscores that cesarean sections yield beneficial outcomes only when they are performed based on medical indications (Parasiliti et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Although a cesarean section can be a critical life-saving intervention, it is associated with a range of immediate and enduring health implications for both mothers and their infants (Sandall et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Elective repeat CS is a significant contributor to the current CS rate in Turkey and many other countries worldwide (Uzunkaya-\u0026Ouml;ztoprak et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The decision-making process regarding the mode of delivery after a previous cesarean is not merely a clinical evaluation but is profoundly influenced by complex psychological factors. Among these, fear of childbirth (FOC) and childbirth self-efficacy stand out as primary determinants (Hou et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ma et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFear of childbirth (FOC) is conceptualized as a distressing psychological state that arises when reflecting on future delivery, often triggered by internalizing the traumatic birth narratives or painful experiences shared by others (Nilsson et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, childbirth-related anxieties can emerge throughout the gestational period, primarily revolving around the anticipation of intense pain, the inherent unpredictability of labor, and concerns regarding a loss of autonomy. These fears are often compounded by deep-seated worries about potential neonatal complications or stillbirth (Hou et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). FOC has many negative effects on women\u0026rsquo;s physical and mental health, including deficit social support, experience with previous cesarean section, childbirth self-efficacy, pain, distressing the infant, prolonged childbirth, unplanned CS, vacuum delivery, depression and anxiety (Elgzar et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hou et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Nath et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Takegata et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Vaajala et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSelf-efficacy represents an individual\u0026rsquo;s subjective conviction in their ability to successfully carry out specific behaviors. Within the realms of obstetrics and parenting, a woman's sense of self-efficacy serves as a fundamental determinant in her psychological preparedness and her overall experience of these significant life transitions (Bandura, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). Research indicates that a robust sense of self-efficacy functions as a protective factor, promoting better pain management and resilience during labor, which ultimately leads to a more positive and fulfilling birth experience for the mother (S\u0026aacute;nchez-Cunqueiro et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Zaman et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Literature evidence has demonstrated that childbirth self-efficacy may be impacted by sociodemographic and obstetric factors such as antenatal education, maternal age, educational level, and social support (\u0026Ccedil;ankaya \u0026amp; Şimşek, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Gao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Hosseini Tabaghdehi et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the existing literature highlights the individual significance of FOC and childbirth self-efficacy, there is limited evidence comparing these psychological determinants specifically between women preferring Vaginal Birth After Cesarean (VBAC) and those opting for Cesarean After Vaginal Birth (CAVB). Understanding the interplay between fear and perceived competence is essential for developing targeted interventions to reduce unnecessary surgical births. Therefore, this study aims to investigate the psychological determinants of preferring VBAC and CAVB, with a specific focus on the predictive roles of fear of childbirth and self-efficacy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study was designed as a descriptive and cross-sectional research, adhering to the STROBE statement for observational studies. Data were collected between October 2025 and January 2026 at the Van Training and Research Hospital in Van, Turkey.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample and Participants\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of pregnant women who had a history of at least one previous delivery. Inclusion criteria were: (1) aged 18\u0026ndash;45 years, (2) having a single pregnancy, (3) women with a history of both vaginal birth and cesarean section, and (4) voluntary participation. Women with high-risk pregnancies, cognitive impairments, or emergency complications were excluded. The minimum required sample size was calculated a priori using the G*Power 3.1.9.4 software. Based on reference findings (Bayrı Bing\u0026ouml;l et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), with an effect size (d) of 0.722, a significance level (α) of 0.05, and a targeted power (1-\u003cem\u003eβ\u003c/em\u003e) of 0.99, the threshold was set at 144 participants (72 per group). However, to enhance the statistical power, improve the representativeness of the findings, and account for potential data attrition, the recruitment process was expanded. Consequently, the study was completed with a total of 400 participants who met the inclusion criteria and voluntarily agreed to participate\u003c/p\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive characteristics form\u003c/h2\u003e \u003cp\u003eThis form was of participants\u0026rsquo; demographic and obstetrics characteristics. This part collects data such as age, BMI, income, educational level, husband educational level, and occupation. Obstetric history includes gravidy, parity, planned pregnancy status, abortion history, latest birth planning status, participation in prenatal classes and previous birth experience.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChildbirth self-efficacy scale (CSES)\u003c/strong\u003e \u003cp\u003eChildbirth self-efficacy was assessed using the scale originally designed by Chu et al. (Chu et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This instrument consists of nine items, each rated on an 11-point Likert scale ranging from 0 ('no confidence') to 10 ('very confident'). The total score is derived by summing the responses, yielding a range between 0 and 90. In the current study, the Turkish adaptation validated by Kahraman et al. was utilized, which demonstrated high internal consistency with a Cronbach\u0026rsquo;s alpha of .90 (Kahraman \u0026amp; Alparslan, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In the present study, the Cronbach's alpha coefficient was calculated as 0.88.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFear of childbirth scale (FCS)\u003c/b\u003e: Fear of childbirth was assessed using the scale developed by Nuraliyeva and Kaya (Nuraliyeva \u0026amp; Kaya, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The scale is designed as a 5-point Likert-type instrument, with responses ranging from 1 (Strongly Agree) to 5 (Strongly Disagree). Positive items (Items 4, 7, 9, 11, 13, 16, 18, and 19) are scored directly as follows: Strongly Agree\u0026thinsp;=\u0026thinsp;1, Agree\u0026thinsp;=\u0026thinsp;2, Undecided\u0026thinsp;=\u0026thinsp;3, Disagree\u0026thinsp;=\u0026thinsp;4, and Strongly Disagree\u0026thinsp;=\u0026thinsp;5. Conversely, negative items (Items 1, 2, 3, 5, 6, 8, 10, 12, 14, 15, 17, and 20) are reverse-coded, ranging from 'Strongly Agree' = 5 to 'Strongly Disagree' = 1. The total score obtainable from the scale varies between 34 and 170. Lower scores indicate a higher level of fear regarding childbearing among women of reproductive age. The scale comprises three sub-dimensions: 'Fear of pregnancy, childbirth, and the role of motherhood,' 'Fear of not meeting physical and social needs,' and 'Fear of pregnancy and childbirth problems. Cronbach's alpha coefficient of the draft Childbirth Fear Scale was found to be 0.86 for the overall scale, 0.88 for factor 1, 0.76 for factor 2, and 0.75 for factor 3. For this study, the Cronbach's alpha reliability coefficient was found to be 0.79.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 27.0 and python 3.12.10 for advanced modeling. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test and visual inspections (Q-Q and Histogram plots,). Descriptive data were reported as frequencies, percentages, or means and standard deviations. To compare the groups (VBAC vs. CAVB), the independent samples t-test was used for continuous variables, while the Chi-square test or Fisher\u0026rsquo;s exact test was employed for categorical data. To identify the predictors of birth preference, univariable and multivariable logistic regression analyses were conducted. Factors showing significant associations in the univariable model were entered into the multivariable model to calculate adjusted odds ratios (ORs) with 95% confidence intervals.\u003c/p\u003e \u003cp\u003eA nomogram was constructed based on the multivariable logistic regression results to provide a visual predictive tool for birth preference. The predictive performance and discriminatory power of the model were evaluated using Receiver Operating Characteristic (ROC) curve analysis. The Area Under the Curve (AUC) was calculated, and optimal cut-off values were determined using the Youden index. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the principles of the Declaration of Helsinki. Prior to the commencement of the research, ethical approval was obtained from the Van Education and Research Hospital Ethics Committee (Date: 24.10.2025, Decision No: 2025-08-33). Furthermore, institutional permission for data collection was granted by the administration of Van Education and Research Hospital. All participants were provided with a comprehensive explanation regarding the study\u0026rsquo;s objectives, and their informed consent (either written or verbal, depending on your protocol) was obtained before data collection. Participants were assured that their involvement was entirely voluntary, that they maintained the right to withdraw from the study at any time without prejudice, and that all collected data would remain anonymous and strictly confidential. The information gathered was utilized solely for scientific research purposes\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the sociodemographic and obstetric profiles of the participants (\u003cspan\u003e$\u003c/span\u003eN\u0026thinsp;=\u0026thinsp;400\u003cspan\u003e$\u003c/span\u003e), with a mean age of 28.63 (5.01) years and a mean BMI of 28.12 (4.63) kg/m\u003csup\u003e2\u003c/sup\u003e. While no significant differences were found between the CAVB and VBAC groups regarding maternal age, BMI, income, or education (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), a significant disparity was observed in husband\u0026rsquo;s education level (p\u0026thinsp;=\u0026thinsp;0.017), where high school graduation was more prevalent in the VBAC group (34.0%) than in the CAVB group (20.2%).Regarding obstetric characteristics, significant differences emerged in birth planning and prior experiences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Nearly half of the VBAC group (49.2%) initially planned for an elective cesarean, whereas 60.6% of the CAVB group had planned for a vaginal birth. Furthermore, 66.5% of the CAVB group reported positive prior birth experiences, while the majority of the VBAC group (57.9%) characterized their previous experience as negative. Factors such as gravidity, parity, and prenatal class participation showed no statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of socio demographic and obstetric characteristics of women\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCesarean Section After Vaginal Birth (CAVB) (n\u0026thinsp;=\u0026thinsp;203)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVaginal Birth After Cesarean Section (VBAC) (n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;400)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (mean (SD))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.35 (5.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.90(4.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.63(5.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (mean (SD))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.30(4.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.94(4.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.12(4.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGravidity (mean (SD))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.06(1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.08(1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.07(1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity (mean (SD))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.07(1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.09(1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.08(1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.908\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68(33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71(36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139(34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117(57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115(58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e232(58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18(8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11(5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29(7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67(33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57(28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e124(31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56(27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60(30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e116(29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47(23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49(24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96(24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33(16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31(15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64(16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband education (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38(18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27(13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65(16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70(34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61(31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e131(32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.017*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41(20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67(34.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e108(27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42(21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96(24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e180(88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165(83.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e345(86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23(11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32(16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55(13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlanned pregnancy status (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e105(51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96(48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e201(50.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98(48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101(51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e199(49.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbortion history (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49(24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46(23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.907\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e154(75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e151(76.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e305(76.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLatest birth planning status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal birth after cesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44(22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65(16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective cesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97(49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e142(35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123(60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43(21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e166(41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncertain (physician decision)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14(6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13(6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27(6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipation in prenatal classes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38(18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29(14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67(16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e165(81.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e168(85.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e333(83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious birth experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e135(66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e218(54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68(33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114(57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e182(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e compares the psychological determinants between the groups. The VBAC group exhibited significantly lower mean scores on the Fear of Childbirth scale (51.04 (12.58)) compared to the CAVB group (53.43 (11.17); p\u0026thinsp;=\u0026thinsp;0.003). Since lower scores indicate higher fear levels, this finding demonstrates that fear of childbirth is significantly more intense in the VBAC group. Specifically, fear regarding \"pregnancy and childbirth problems\" was more pronounced in the VBAC cohort (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Consistent with this, the VBAC group also demonstrated significantly lower childbirth self-efficacy (61.09 (15.83) than the CAVB group (65.74 (15.08); p\u0026thinsp;=\u0026thinsp;0.045) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of fear of childbirth and childbirth self-efficacy of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCAVB (n\u0026thinsp;=\u0026thinsp;203)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVBAC (n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;400)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFear of childbirth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53.43(11.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.04(12.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.25(11.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of pregnancy, childbirth,\u003c/p\u003e \u003cp\u003eand the role of Motherhood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.17(7.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.91(8.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.54(8.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of not meeting physical\u003c/p\u003e \u003cp\u003eand social needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.88(4.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.06(4.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.48(4.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of pregnancy and\u003c/p\u003e \u003cp\u003echildbirth problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.38(3.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.07(3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.24(3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildbirth self-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65.74(15.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.09(15.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.45(15.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eReference: Primary school\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the results of the multivariable logistic regression analysis conducted to identify independent predictors of preferring VBAC. Two separate models were established. In Model 1, husband\u0026rsquo;s university education (p\u0026thinsp;=\u0026thinsp;0.010), previous birth experience (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), childbirth self-efficacy (p\u0026thinsp;=\u0026thinsp;0.002), and total fear of childbirth score (p\u0026thinsp;=\u0026thinsp;0.031) were identified as significant predictors. In Model 2, the total fear score was replaced by the fear of pregnancy and childbirth problems sub-dimension to examine specific anxieties. This model revealed that, alongside husband\u0026rsquo;s education and previous birth experience, this specific fear domain was a highly significant predictor (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with an Odds Ratio of 0.84 (95% CI: 0.79\u0026ndash;0.89). Based on the significant predictors in the multivariable analysis, a prognostic nomogram was constructed to predict the probability of VBAC preference visually (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the nomogram, each predictor is assigned a point value on the uppermost scale. The total points are then summed to determine the individual's probability of choosing VBAC on the bottom risk axis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression analysis of predictors for VBAC preference\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband education (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.94 (0.47\u0026ndash;1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.01(0.49\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband education (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.17(0.65\u0026ndash;2.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.18(0.64\u0026ndash;2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband education (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.21(1.21\u0026ndash;4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.32(1.23\u0026ndash;4.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious birth experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.34(0.22\u0026ndash;0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.34(0.22\u0026ndash;0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrenatal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.95(0.53\u0026ndash;1.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.99(0.54\u0026ndash;1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.978\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildbirth self-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.97(0.96\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97(0.96\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.98(0.96\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of pregnancy and childbirth problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84(0.79\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eReference last, OR: Odds Ratio, CI: Confidence Interval. Model 1 includes total fear score; Model 2 includes specific sub-dimension scores\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eReceiver Operating Characteristic (ROC) curve analysis was performed to evaluate the discriminatory power of the psychological predictors for VBAC preference. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the 'Fear of pregnancy and childbirth problems' sub-dimension demonstrated a statistically significant discriminative ability (AUC\u0026thinsp;=\u0026thinsp;0.68, 95% CI: 0.63\u0026ndash;0.73; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The optimal cut-off value was determined to be 15.50. At this threshold, the scale exhibited a sensitivity of 76% and a specificity of 51% in predicting birth preference. Additionally, Childbirth Self-Efficacy showed a statistically significant, albeit weaker, predictive performance (AUC\u0026thinsp;=\u0026thinsp;0.58, 95% CI: 0.53\u0026ndash;0.64; p\u0026thinsp;=\u0026thinsp;0.028). The optimal cut-off point for self-efficacy was calculated as 67.50, with a sensitivity of 54% and a specificity of 43% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eROC analysis of predictors for VBAC preference\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCut-off\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of pregnancy and childbirth problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68 (0.63\u0026ndash;0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChilbirth efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.58 (0.53\u0026ndash;0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAUC: Area Under the Curve, CI: Confidence Interval, ROC: Receiver Operating Characteristic\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comprehensive evaluation of the factors influencing the birth method preference of women with a history of cesarean section. While previous literature often associates fear of childbirth with a request for elective cesarean, this study revealed a complex relationship where women with higher specific birth anxieties and negative past experiences were more inclined to choose VBAC. This suggests that the preference for VBAC may be driven by a desire to overcome past trauma or avoid surgery, despite existing fears.\u003c/p\u003e \u003cp\u003eA remarkable finding of this study is the positive association between high levels of specific birth fears (fear of pregnancy and childbirth problems), negative previous birth experiences, and the preference for VBAC. Traditionally, existing literature suggests that high fear of childbirth is a primary driver for requesting elective cesarean sections (Elgzar et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; St\u0026oslash;rksen et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, our results present a contrasting dynamic. The fact that the VBAC group reported significantly more negative previous experiences suggests that their current fear may not be of vaginal birth itself, but rather a fear of repeating the previous traumatic cesarean experience. Studies by Nilsson et al. and Keedle et al. support this interpretation, indicating that women often view VBAC as an opportunity to overcome from a previous traumatic birth and regain a sense of control (Keedle et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Nilsson et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Thus, the preference for VBAC in this high-anxiety group can be interpreted as a coping mechanism to avoid a recurrence of past trauma\u003c/p\u003e \u003cp\u003eThe present study found that women whose husbands have a university degree were more than twice as likely to prefer VBAC, suggesting that partner-related social support and informed engagement may influence women\u0026rsquo;s mode of birth preferences; although few studies have examined spousal education specifically, the broader literature on VBAC decision-making highlights the importance of external support including partner and family encouragement as facilitators of VBAC choice (Cosmai et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Moreover, shared decision-making where women, their partners, and healthcare providers discuss options collaboratively has been shown to improve involvement in decisions about mode of birth and is associated with higher engagement in VBAC planning (Yussuph \u0026amp; Alwy Al-Beity, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Higher educational attainment of husbands may therefore be linked to greater health literacy, more effective participation in antenatal counselling, and better support of evidence-based birth options, all of which could contribute to a woman\u0026rsquo;s likelihood of preferring VBAC in the context of informed and collaborative decision-making.\u003c/p\u003e \u003cp\u003eIn the present study, childbirth self-efficacy emerged as a significant predictor of VBAC preference in both Model 1 and Model 2, indicating that higher levels of self-efficacy were independently associated with an increased likelihood of preferring VBAC. This finding aligns with recent evidence that maternal self-efficacy is a modifiable psychological construct that positively influences childbirth experiences and related outcomes; antenatal education interventions have been shown to significantly increase self-efficacy while concomitantly reducing fear of childbirth and increasing rates of vaginal delivery and lower cesarean rates in meta-analytic synthesis (Zaman et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). A large 2024 observational study also confirms that childbirth self-efficacy varies across groups (primiparas vs multiparas) and is inversely related to fear and labor pain intensity, suggesting that confidence in coping with labor may shape attitudes toward physiological birth options, including VBAC (Huang et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Taken together, these recent data support the interpretation that higher childbirth self-efficacy contributes to a greater likelihood of preferring VBAC, likely through mechanisms of increased confidence, reduced fear, and enhanced ability to engage in active coping and informed decision-making.\u003c/p\u003e \u003cp\u003eFinally, the ROC analysis underscores the discriminatory power of specific birth fears in predicting birth preference. The fear of pregnancy and childbirth problems sub-dimension demonstrated a significant discriminative ability with a relatively high sensitivity of 76% at the cut-off value of 15.50. This high sensitivity indicates that the scale is particularly effective in correctly identifying women who are inclined towards VBAC. In clinical practice, distinguishing women's birth preferences early in pregnancy is crucial for appropriate counseling. While most existing studies focus on cut-off points to diagnose 'tocophobia' for requesting cesarean (Lai et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Nilsson et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; St\u0026oslash;rksen et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), our study is one of the few to establish a cut-off value for predicting a preference for vaginal birth after cesarean.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the results. First, the cross-sectional design of the study prevents the establishment of causal relationships between psychological variables and birth preference. Second, the data were collected from a single center, which may limit the generalizability of the findings to other populations with different cultural or socioeconomic backgrounds.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings demonstrate a paradoxical yet significant association: women who prefer vaginal birth after cesarean exhibit higher specific birth fears, lower self-efficacy, and more negative previous birth experiences compared to those choosing a repeat cesarean. This suggests that for many women, the desire for VBAC is driven to overcome a past traumatic experience or to avoid repeated surgery, rather than by a lack of fear or high self-confidence.\u003c/p\u003e \u003cp\u003eIn clinical practice, health professionals should not interpret high levels of birth fear solely as a request for cesarean. Instead, the cut-off value identified in this study can be used as a screening tool to identify high-risk women who are nevertheless motivated for a trial of labor. These women require targeted antenatal counseling and enhanced psychological support to improve their self-efficacy and ensure a positive birth experience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the administration of Van Training and Research Hospital for their permission and support during the data collection process. We also express our sincere gratitude to all the women who voluntarily participated in this study and shared their valuable experiences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflıct of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author has no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupporting Information\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for the research was obtained from the Scientific Research and Publication Ethics Committee (Approval No: GOKAEK/2025-08-33).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI have declared that that none of the paper\u0026apos;s contents have been published or are under consideration else where.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;I have declared that all authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception/design: MCG, YS, SG, \u0026Uuml;Y\u003c/p\u003e\n\u003cp\u003eData collection/analysis: MCG YS, SG, \u0026Uuml;Y\u003c/p\u003e\n\u003cp\u003eDrafting of manuscript: MCG, YS\u003c/p\u003e\n\u003cp\u003eCritical revisions for important intellectual content: supervision; MCG, YS, SG, \u0026Uuml;Y\u003c/p\u003e\n\u003cp\u003eStatistical expertise: YS\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdministrative/ technical material support: MCG, YS, SG, MY\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBandura, A. 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H., \u0026amp; Alwy Al-Beity, F. M. (2023). Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania. \u003cem\u003ePLoS One\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(10), e0291809. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0291809\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0291809\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaman, A., Fadlalmola, H. A., Ibrahem, S. E., Ismail, F. H., Abedelwahed, H. H., Ali, A. M., Abdelgadim, N. H., Mustafa, A. M. A., Ahmed, I. H., Ahmed, N. M., Eltyeb, A. A., Gaafar, D. A., Alnassry, S. M., Adam, A. A., Yasin, N. S., Ali, R. A., Fadlalla, A. A., Eltayeb, A. E., \u0026amp; Saad, A. M. (2025). The role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes: A systematic review and meta-analysis. \u003cem\u003eEur J Midwifery\u003c/em\u003e, 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18332/ejm/200747\u003c/span\u003e\u003cspan address=\"10.18332/ejm/200747\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vaginal birth after cesarean, fear of childbirth, self-efficacy","lastPublishedDoi":"10.21203/rs.3.rs-8945877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8945877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to identify the psychological determinants of the preference for vaginal birth after cesarean versus cesarean after vaginal birth and to develop a prognostic nomogram. This cross-sectional study included 400 participans. Data were analyzed using multivariable logistic regression and ROC analysis. Contrary to expectations, the preferring vaginal birth after cesarean group reported significantly lower childbirth self-efficacy (p\u0026thinsp;=\u0026thinsp;0.045) and higher specific birth fears (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multivariable analysis identified husband\u0026rsquo;s education (OR: 2.32), negative previous birth experience, and fear of pregnancy and childbirth problems (OR: 0.84) as significant predictors of preferring vaginal birth after cesarean preference. ROC analysis demonstrated that the fear of pregnancy and childbirth problems had statistically significant discriminative ability in predicting birth preference (AUC\u0026thinsp;=\u0026thinsp;0.68, 95% CI: 0.63\u0026ndash;0.73, Sensitivity: 76%). A paradoxical association exists where women with higher fears and lower self-efficacy are more inclined to choose preferring vaginal birth after cesarean, which may reflect a motivation to avoid repeated surgery. High fear levels may indicate a strong motivation for a trial of labor rather than a request for cesarean.\u003c/p\u003e","manuscriptTitle":"Psychological Determinants of Preferring Vaginal Birth After Cesarean: Fear and Self-Efficacy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 14:33:44","doi":"10.21203/rs.3.rs-8945877/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"74e377bf-888f-4e62-9ad7-a67d14fbef7a","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-17T07:40:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 14:33:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8945877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8945877","identity":"rs-8945877","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}