Perspectives of Obstetricians and Midwives on the Preference for Caesarean Deliveries: A Qualitative Exploration in Andhra Pradesh, India

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Although the c-sections are life-saving when medically necessary, their overuse is a cause of concern for maternal health outcomes and increased health expenditure. The present study aims to understand the perceptions of obstetricians and midwives on the rising trend of preference for caesarean sections in the selected districts of Andhra Pradesh. Materials and Methods A Qualitative research method was adopted to carry out this study among four districts of Andhra Pradesh; two with high C-section rates (Visakhapatnam, Krishna) and two with low C-section rates (Anantapur, Chittoor). Sixteen in-depth interviews were conducted with eight obstetricians and eight midwives selected through purposive sampling. Interviews were recorded digitally and transcribed verbatim, and Braun & Clarke’s thematic analysis framework was employed to generate the themes and sub-themes. Results Thematic analysis of the obtained data revealed four major themes influencing the preference for caesarean sections which included; Sociocultural and psychological determinants, including tokophobia, family pressures, and beliefs about auspicious dates of birth; followed by Maternal and lifestyle determinants, including sedentary behaviours that affect physiological capacity for vaginal delivery and mothers' decisions based on convenience. In addition, Healthcare system factors, including time, medico-legal considerations, staffing issues, and Medical indications for C-sections, including high-risk pregnancy and labour complications. These results suggest that the decision to conduct c-sections was influenced not only by medical indications but also by societal, systemic, and individual-level factors. Conclusion The study highlights that while medical indications are a valid basis for conducting c-sections, a substantial proportion of c-sections are happening due to the influence of non-clinical factors such as socio-cultural beliefs, maternal preferences, systemic challenges and provider convenience. The findings emphasize the need for a comprehensive regulatory framework, with standard clinical protocols, periodic audits, and maternal education, to reduce unnecessary c-sections in Andhra Pradesh. Perceptions caesarean section healthcare system non-medical indications birth preferences Figures Figure 1 Figure 2 Introduction Caesarean section is a life-saving surgical procedure; however, its effectiveness in reducing mortalities remains uncertain in cases where it is not indicated medically [ 2 ]. Globally, it is projected that the caesarean section rates will increase to 28% by 2030. Nevertheless, the very high and rapidly growing rate of caesarean sections (CS) during the past 20 years has become a concern worldwide [ 1 ]. In addition, excessively high rates of caesarean deliveries have detrimental effects on women's health, economic efficiency, and family and national well-being [ 3 ]. The NFHS-5 report states that 88% of deliveries in India are conducted in hospital institutions. Caesarean rates in India have increased from 17% in 2015-16 to 21% of total deliveries in 2019-21, with significant regional variations.[ 5 ] The overall prevalence of C-section deliveries in India is significantly higher than the typical range of 10 to 15 per cent in many states, according to the NFHS-5 survey. [ 5 ]. With 96.5% of institutional deliveries in Andhra Pradesh, the state has the third highest rate of c-section deliveries in India, with 42.4% of deliveries by c-section and 57.6% by normal vaginal deliveries. Surprisingly, c-sections comprised 63% of all deliveries in private healthcare establishments, while only 26% occurred in government healthcare institutions in Andhra Pradesh. Between the National Family Health Survey's two consecutive rounds, the percentage of caesarean deliveries rose from 40.1–42.4%. The percentage of deliveries by caesarean section in private facilities has increased significantly, rising from 57% in NFHS-4 to 63% in NFHS-5. [ 4 ] Fear of labour pains, perineal tears, and history of repeated pregnancy loss are some of the causes of non-medically indicated CS [ 6 ]. WHO in 2021 reported that a CS rate of more than 10 per cent is linked to more surgical complications and disabilities, and has no evidence to decrease the associated mortalities. [ 7 ]. Short-term complications of any CS are bleeding, infection, anaesthesia complications, and additional antibiotics and analgesics. As the rate of CS rises, complications of a long-term in nature, such as adhesions, injury to abdominal viscera, infertility, and pathologic placentation like placenta previa and scar ectopic pregnancy, have risen in numbers. Infants born by caesarean section are also at a higher risk of acute disease complications like transient tachypnoea and require admission into neonatal units. Additionally, certain types of hormonal, physical, and immune development changes may take place, including decreased intestinal gut microbiome diversity, atopy, asthma, and allergies [ 8 – 9 ]. This significant rise in C-section rates could be attributed to the lack of utilisation of a standardised, internationally accepted classification system for monitoring CS rates across states and medical units.[ 10 ] Apart from the acceptance and utilisation of these standardised tools, various other factors play a crucial role. The rise in CS rates is often driven by subjective preferences from both patients and healthcare providers [ 11 – 12 ]. Literature suggests that women often do not fully comprehend the associated risks, benefits, or long-term implications before undergoing CS.[ 12 ] The overuse of CS is driven by a complex interplay of maternal, health system, and healthcare provider-level factors. These include women's preference for CS, healthcare providers' attitudes toward normal delivery, associated financial incentives, institutional protocols, and overall systemic inefficiencies. While anecdotal evidence from various stakeholders highlights these issues, there is a dearth of literature on the perspectives of obstetricians and midwives. Understanding their attitudes and decision-making processes is crucial for developing targeted interventions to optimize CS use. The perceptions and personal experience of health providers and midwives often influence the decision regarding the mode of delivery. [ 13 ] Given these gaps, this study aims to explore the perceptions of obstetricians and midwives regarding the rising preference for cesarean deliveries in selected districts of Andhra Pradesh. By gaining insights into their attitudes, motivations, and decision-making frameworks, this research seeks to inform policies and interventions aimed at ensuring rational and evidence-based use of cesarean sections while improving maternal and neonatal health outcomes. Given this gap, this study would aim to explore perceptions on the preference of caesarean section by Obstetric specialists and midwives attending the deliveries in selected districts of Andhra Pradesh. Materials and Methods Study design and setting: The study adopted a phenomenological approach to understand the experience of obstetricians and midwives regarding higher C-section rates in selected districts of Andhra Pradesh. The study was conducted in four districts of Andhra Pradesh, in which Visakhapatnam, Krishna have high CS rates, and Anantapur, Chittoor have low CS rates. Study participants and sampling: Purposive sampling was employed to choose obstetricians and midwives actively engaged in their professions across four districts of Andhra Pradesh. The study comprised midwives and obstetricians who worked in the study districts. The study excluded midwives and obstetricians who refused to engage in the in-depth interviews (IDIs). Eight midwives and eight obstetricians were interviewed to learn more about their opinions regarding the preference for caesarean delivery. Inclusion Criteria: Obstetricians and Midwives who are currently practising in their respective professions in any of the four selected districts of Andhra Pradesh. Obstetricians working both in Public and Private hospitals are included in the study. Participants who are willing to participate in in-depth interviews and provide informed consent are included. Exclusion Criteria: Obstetricians and Midwives who are not currently practising and practising outside other than selected four districts of Andhra Pradesh. Obstetricians and Midwives who refused to participate in the study. Data collection tool and technique: Qualitative being an emergent design, we followed the same approach; thus, an open-ended guide was developed, which was later used for a pilot survey at Krishna District in one of the public health hospitals to ensure its consistency and clarity in understanding. A validated semi-structured questionnaire was used as the IDI guide. The discussions were facilitated in the local language (Telugu) to ensure effective communication. A total of sixteen IDIs were conducted, eight each for obstetricians and midwives. Before conducting the IDIs, the interviewer discussed the terms and conditions and sought informed consent from all participants for recording the discussions. The first author conducted the interview and audio recorded all IDIs. Audiotapes were transcribed and translated verbatim from Telugu to English, and then entered into a Microsoft Word document. IDIs were conducted at the hospitals where they are currently working to ensure the convenience of the study participants. The period of data collection was December 2024 – April 2025. Ethical consideration: Ethical clearance for the study was obtained from the Institutional Ethics Committee of the School of Public Health, SRMIST, Chennai on 29th May 2024 (Ref No: 00111/IEC/2024). Permission to conduct the In-depth interviews (IDIs) in all the selected districts was obtained from the Additional Director [MCH], O/o CH&FW, Andhra Pradesh. By following the declaration of Helsinki, the purpose of the research was explained clearly to all the study participants and informed consent was obtained from all of them. The participants include obstetricians and midwives, and the participants' confidentiality, anonymity, dignity, and integrity were guaranteed. Also, the participants were informed that they are free to leave the interview at any time if they wish to do so. Each IDI lasted approximately 45 minutes. Analysis method A thematic analysis was undertaken following the framework given by Braun & Clarke. [ 14 ] The transcripts were manually coded, using codes developed inductively. Thematic framework analysis was used to identify the various themes exploring the perceptions of CS among the Obstetricians and midwives. Results The study participants were Obstetricians and midwives working in the selected districts. Of the total 16 interviews, 8 were ObGs and 8 were midwives. The Obstetricians interviewed had an average experience of 22 years, of which 5 are working at government hospitals and 3 are working at private hospitals. The qualification of all of them were either a Diploma in Gynaecology and Obstetrics (DGO) or MS Obstetrics and Gynaecology. The midwives interviewed had an average experience of 14 years, and all are working at the government hospitals only. The qualification of midwives was GNM or BSc Nursing with a specialisation in Nurse Practitioner in Midwifery, an 18-month course offered by the Government of Andhra Pradesh. In the analysis of the obtained qualitative data, four major themes emerged regarding perceptions about CS among the obstetricians and midwives: Sociocultural and psychological factors, Maternal & lifestyle factors, Healthcare System Factors and Medical indications for CS. Mind map of the perspectives of Obstetricians and midwives on the factors leading to CS The Fig. 1 is a mind map of the various contributing factors for the increase in CS deliveries, as reported by obstetricians and midwives. The figure classifies these contributory factors into thematic areas of unawareness and fear, medical professionals' preference, sociocultural reasons, constraints in healthcare, and maternal requests, each of them further subdivided into specific sub-themes. In addition, both obstetricians and midwives reported the same concerns, like family pressure, cultural beliefs, and poor infrastructure, but with different emphasis according to their professional roles and experience. The figure describes the determinants for decisions regarding CS, with non-clinical determinants like social influences, misinformation, and medico-legal factors strongly influencing these decisions in addition to the genuine medical indications. 1. Sociocultural and Psychological Factors Our analysis revealed that multiple sociocultural and psychological factors strongly influence the preference for CS deliveries in Andhra Pradesh. These factors often exceed purely medical concerns, creating a series of influences on maternal birth decisions. 1.1 Fear and Lack of Awareness Fear of labour pain emerged as a predominant psychological factor driving CS preferences. Healthcare providers frequently reported encountering tokophobia among expecting mothers. As one midwife explained, "Fear of childbirth mostly many of the mothers will say I cannot bear that pains during the labour so I will go for C-section better with one stretch or they will give anaesthesia so that we will be feeling no pains like that is the reason they will say when we ask for the mothers." (M2) Another midwife observed that misinformation about the birthing process exacerbated these fears: "If they cannot bear the pains, they are tokophobia. If their pains, they thought that C-section is easy procedure. They will cut it. With general birth means they will put hands. They will irritate them. If C-section means they will cut in abdomen, they think like that." (M7) The influence of negative birth experiences, whether personal or shared by others, was frequently cited as contributing to a cycle of fear. As one midwife noted, "Nowadays everyone has come to know that there is an increased intensity of pain like during the normal births when they are facing and even the experiences of their parents or their peers, they will be saying like there will be pain which may not be bearable." (M5) 1.2 Family and Social Pressure Our findings indicate that familial pressure plays a significant role in driving CS preferences. Obstetricians frequently reported being unable to convince families about the benefits of vaginal delivery when faced with determined opposition. One obstetrician shared, "There is more pressure from birth companions, whatever the birth companion tell them they listen to it. If birth companion has a negative opinion that impacts the mother. Sometimes if they wait for Normal delivery here there are 2 disadvantages: one thing is if we tell them to wait for NVD then they will leave to another hospital for C-Section." (O1) Cultural and religious beliefs, particularly the preference for auspicious birth dates (muhurthams), were consistently mentioned as driving scheduled CSs. Several healthcare providers emphasized the prevalence of this practice: "Yes, one more thing to add, if there is any new moon day [Amavasya] or any bad days, they fear that during those days birth may happen, and they plan for C-section beforehand. They follow the muhurthams for birth and plan for C-section. From my opinion, if we explain the risk to illiterates, they will listen, but the so-called educated people won't listen to it." (O1) The influence of social media and peer networks in spreading misconceptions was also highlighted. As one midwife stated, "Online media is affecting a lot. Because of the online stories given by the previously delivered mothers, there are many misconceptions about normal delivery." (M1) Interestingly, CS in private hospitals were perceived as a status symbol by some patients. One obstetrician noted, "They'll undergo C-section in private hospitals and think it is a prestige issue to get an operation from a corporate hospital." (O7) These findings demonstrate how deeply established sociocultural influences intersect with psychological concerns to generate significant desires for CS deliveries, which are often independent of medical necessity. These non-medical factors present considerable challenges for healthcare providers who want to promote evidence-based birth choices. 2. Maternal and Lifestyle Factors Analysis of healthcare provider perspectives revealed significant maternal and lifestyle factors contributing to the increasing rates of CS deliveries in Andhra Pradesh. These factors include both physical health considerations associated with modern lifestyles and maternal preferences motivated by convenience and fear. 2.1 Sedentary Lifestyle and Physical Health Healthcare providers consistently identified modern sedentary lifestyles as a substantial contributor to the physiological challenges that lead to CS deliveries. Obstetricians observed that reduced physical activity during pregnancy has negatively affected women's capacity for vaginal delivery. As one obstetrician stated, "There is no physical activity for the antenatals and so there is no strength to the pelvic muscles and they are sensitive to little pain. Moreover, there is more pressure from husbands and birth companions, they say that their daughters can't tolerate pain and tell that they don't wait for NVD, so they demand for C-section." (O1) The contrast between historical practices and contemporary lifestyles was frequently mentioned. Another obstetrician elaborated, "Another thing is that in ancient days there was balance in consumption of food and physical activity. They think that pregnancy is precious and they will not allow for any physical activity, only eating, sitting, sleeping. Due to this foetus weight increases. It's not that pelvic size increases with the increase of baby weight and so there is an increase in CPD, that's another cause." (O2) This observation was echoed by other practitioners who noted the intersection between changing lifestyles and increased complications: "Olden days there was physical exercise for pregnant women, now we are not seeing that, use of sedentary life, pain intolerance to mothers, and parents also don't want their daughters to suffer with labour pains so they are choosing C-section." (O5) 2.2 Maternal Preferences and Demand The study identified strong maternal preferences and demands influencing CS rates. Healthcare providers reported that patient demand for CS has become a significant driver in delivery decisions, often independent of medical necessity. One obstetrician openly acknowledged this reality: "Definitely yes, many times we are doing C-section because of their demand. If we don't do a C-section for them, then they move on to another hospital, which causes a decrease in our census. For this reason, we are doing a C-section as per their request to reach our target. For some of them, if we educate, they listen to it, but many of them demand only a C-section. In some cases, both maternal and fetal conditions are well, but they prefer only C-section." (O3) Previous negative birth experiences were frequently cited as a factor in maternal demand for CSs. As another obstetrician explained, "They say for previous birth, I suffered 3 days with pains, baby didn't cry after birth, baby was kept in NICU, and they fear that it happens again, so they prefer C-section." (O4) The convenience of combining CS with tubectomy emerged as another significant factor driving maternal preference. The same obstetrician noted, "Nowadays, the trend is if the mother is multigravida with previous NVD, they go for C-section given tubectomy. They say that they can't come for a tubectomy again if we do a normal birth, so they demand a C-section. They think that both tubectomy and C-section are the same. This is all due to a lack of awareness." (O4) Women who conceived after fertility treatments were identified as particularly inclined toward elective CSs: "Infertility, precious pregnancies, I mean to say, after treatment, they conceive, so they don't want to take any risk. Even though obstetricians give assurance, family members will not take a chance on that." (O8) These findings show that maternal preferences and lifestyle factors have changed substantially, which has contributed significantly to the rise in CS deliveries. The factors, like sedentary lifestyles affecting physical capability and the growing maternal demand for surgical delivery, make it challenging for healthcare providers to support evidence-based birth practices. 3. Healthcare System Factors The study identified several healthcare system and professional factors that contribute significantly to the increasing rates of CS in Andhra Pradesh. These factors include medical professionals' preferences, systemic constraints, and infrastructure limitations that collectively influence delivery decisions. 3.1 Medical Professionals' Preferences The analysis of the qualitative data revealed that time constraints and scheduling preferences of the healthcare providers play a substantial role in the decision to perform CS. This was particularly evident in the statements of midwives who observed patterns in CS scheduling. As one midwife noted, "C-sections are being done during the OP timings only. After that, OP timings, the C-sections won't be there, no births will be there." (M3) Another midwife elaborated on this reality: "Sometimes doctors' timing, they may be available till 4 o'clock. That time they may can't wait. If any meconium stain or any such things, they won't wait." (M8) The pervasive fear of medico-legal consequences emerged as a significant factor influencing obstetricians' decisions. Several providers explicitly mentioned the anxiety associated with potential negative outcomes and public outrage. One obstetrician expressed this concern directly: "The main reason, the most important reason, is the fear of attacks from the public. That is my honest opinion as an obstetrician. Having a lot of stress, as you see when we counsel for the normal delivery, anything can go wrong, which cannot be corrected immediately. Even to detect distress and you take the patient for a C-section, there is a minimum shifting time. This will be at least half an hour, in that we may lose the baby because of a cord around the neck complication identified in the last minute, and when such a thing happens, nobody is there to support us and there are so many issues with patients attacking doctors." (O8) Another obstetrician highlighted the changing patient expectations: "Public awareness is different nowadays. Adverse response is taken differently, so that is also a factor. Increased awareness and medico-legal aspects and adverse events is being taken in the wrong direction only. So all these things cause stress and lead specialists to choose C-section." (O4) The study also revealed concerns about the diminishing confidence and skills among junior obstetricians in managing vaginal deliveries. This generational shift in obstetric practice was identified as a contributing factor to rising CS rates. As one experienced obstetrician observed, "The present junior obstetricians are not confident in conducting normal deliveries. They are less equipped to conduct a normal delivery, and they are not able to assist correctly. They believe that learning how to do a C-section is enough, but the decision to do a C-section or a normal delivery you have to have a good, sound knowledge of the pelvis and all the other protocols. Because of that, they are having low confidence, and because of panic, they very quickly and prematurely decide to conduct a C-section." (O4) 3.2 Infrastructure and Staffing Issues Infrastructure limitations and staffing challenges were identified as significant systemic factors contributing to the preference for CS, particularly in smaller and first-referral healthcare facilities. The lack of 24/7 operating theatre services in smaller hospitals emerged as a critical constraint. As one obstetrician explained, "In CHC, if we notice any small risk for the mother, we fear to leave the woman for NVD. In an emergency, if we refer the woman for a C-section, there will be a delay of time. In that situation, we fear foetal consequences as in CHC, we have no facility for 24* 7 OT services." (O1) Staffing shortages and personnel distribution were also identified as contributing factors. Another obstetrician noted, "My one more input is - in CHCS, Area Hospitals, if there are 2 gynaecologists, 2 anaesthetists, and with trained staff, then we can reduce the C-Section rate. One person can't provide 24* 7 services because this is another reason for the rise in C-Section rate." (O4) The quality of staff training, particularly in labor monitoring, was highlighted as a concern affecting the confidence and capability to manage vaginal deliveries. One obstetrician stated, "Staff nurses have no skills in monitoring mother and baby. If the staff nurses are skillful, we can facilitate many normal births. They need in-service trainings. Earlier, there were many trainings, but nowadays they are not conducting any training programs. Not that every staff nurse is the same, whatever I am facing, I am telling." (O7) The availability of insurance schemes covering CS was identified as a structural factor increasing their accessibility and appeal. One obstetrician mentioned, "In AP, we have NTR Vaidyaseva (State Sponsored Health Insurance Scheme), in that also, they are paying for deliveries for C-section as well as normal deliveries. So, under that, they are getting a corporate-type facility in NTR Vaidyaseva. So definitely, patients will prefer that also." (O7) These findings emphasise the different factors, like healthcare professionals' preferences, risk management strategies, and systemic constraints, that contribute to the increasing rates of CS deliveries in Andhra Pradesh. 4. Medical Indications for C-Sections The study identified several legitimate medical indications that necessitate CS deliveries. Healthcare providers emphasized that, alongside non-medical factors driving CS rates, specific medical conditions continue to form the essential clinical basis for surgical interventions. 4.1 High-Risk Pregnancies Healthcare providers consistently identified certain high-risk conditions as valid indications for CS. These conditions present significant risks to maternal and foetal health that warrant surgical intervention. One midwife provided a comprehensive overview of these indications: "Medical indications like pre-eclampsia, eclampsia, fibroids, CPD, prolonged labor, fetal distress, and infections lead to emergency C-sections." (M1) Another midwife specifically highlighted concerns for conducting normal deliveries when mother have certain infectious diseases : "High-risk pregnancies like hypertension during pregnancy, diabetes, any infections like herpes simplex and any HIV, VDRL positive, I think most of these, when they come, maybe due to fear or maybe due to some fear of infection, most of them are being posted for the C-sections." (M5) The study revealed that healthcare providers approach high-risk conditions with heightened caution, often opting for CS to minimize potential complications. As one midwife observed: "In government sector, I feel so many factors is contributing to C-section. Firstly, any precious labor, with any treatment, the mother conceived. If not progressed in a normal time limit, they won't take a chance for trial. Okay. And they will directly report it to C-section." (M8) 4.2 Labor-Related Complications Complications arising during labor emerged as another significant category of medical indications for CS. Healthcare providers detailed several intrapartum conditions that necessitate surgical intervention. Prolonged labor and fetal distress were frequently cited as critical indications. One midwife stated: "Prolonged labor, premature rupture of membranes, and lack of confidence among staff also lead to emergency C-sections." (M3) Cephalopelvic disproportion (CPD) was identified as a significant physical barrier to natural birth. One obstetrician explained the connection between contemporary lifestyle factors and CPD: "Another thing is that in ancient days there was balance in consumption of food and physical activity. They think that pregnancy is precious and they will not allow for any physical activity, only eating, sitting, sleeping. Due to this foetus weight increases. It's not that pelvic size increases with the increase of baby weight and so there is an increase in CPD, that's another cause." (O2) The study also revealed that healthcare providers experience increased anxiety when managing labor complications, particularly in facilities with limited resources. This anxiety frequently leads to decisions favoring CSs. As one obstetrician explained: "In CHC, if we notice any small risk for the mother, we fear to leave the woman for NVD. In an emergency, if we refer the woman for C-section there will be some delay of time. At that situation, we fear foetal consequences." (O1) Healthcare providers emphasized that their clinical judgment regarding these complications is increasingly influenced by risk aversion and concern for potential negative outcomes. One midwife noted: "If anything happens, trial and error, trial and error. If anything goes wrong, why should we take that much risk? So, better to have a C-section like that they are planning." (M8) These findings demonstrate that while numerous non-medical factors contribute to rising CS rates, legitimate medical indications continue to form an essential basis for surgical intervention. The data indicate that healthcare providers are expected to make clinical judgments while balancing the risk management strategies, particularly when managing high-risk pregnancies and labor complications. Framework prepared after analysis using inductive codes The Fig. 2 shows the developed framework which consolidates overall findings from the study, which illustrates factors influencing the decision to perform a CS. At its core, sociocultural and psychological factors, maternal and lifestyle factors, healthcare system factors, and medical indications play a key role. Here, the sociocultural factors refer to the societal norms of fixing the dates and time for delivery, fear of labour pain, etc impact a mother's preference for CS deliveries. Similarly, maternal and lifestyle factors like advanced maternal age, prior CSs, and body mass index have also influenced the decision, either by way of medical suggestion or personal convenience. Healthcare system factors are institutional policies, time constraints, provider convenience, and medico-legal factors. These have shown greater influence on the healthcare provider's style in prescribing a caesarean delivery. Lastly, some medical conditions, such as foetal distress, hypertensive disease, obstructed labour, or multiple gestations, required caesarean delivery to ensure safe maternal and neonatal health outcomes. Discussion This study explored the perceptions of Obstetricians and Midwives towards the mode of delivery, especially CSs, and the factors driving the high prevalence of caesarean deliveries in Andhra Pradesh. The findings highlight sociocultural, psychological, Maternal and lifestyle factors, Health care system factors, and Medical indications that influence preferences for normal delivery or CSs. The results highlight unique reasons, concerns, and situational factors influencing these choices, consistent with the larger body of research on similar areas of maternal health and delivery procedures. The findings of this study highlight fear of labour pain (tokophobia) and lack of awareness as key psychological factors for opting for CS deliveries. This corresponds to the study, which reported an increased in the rate of CSs due to women’s fear of pain during vaginal deliveries and their lack of knowledge of the various modes of delivery in China[ 17 ]. Likewise, an Iranian study indicated that women’ and their families’ cultural and personal beliefs had a considerable bearing on the preference for CS[ 18 ]. Similarly, family members, especially those present during delivery, exert considerable pressure about preference for CSs. This supports earlier studies, which pointed out the strong role played by family and other caregivers in the decision by women to undergo a CS [ 19 , 20 ]. Obstetricians and midwives mentioned the influence of cultural and religious practices, such as the selection of favourable birth dates (muhurthams) for the performance of scheduled CSs. This is in agreement with recent findings, which pointed out that cultural practices and social expectations are significant determinants of CS preferences.[ 21 , 22 ]. Another key finding of the present study is that undergoing CSs in private hospitals is sometimes viewed as a status symbol, in agreement with a finding from a Telangana study, where in some parts of the state, CSs are viewed as markers of wealth and modernity [ 21 ]. Additionally, the dissemination of misinformation on social media and social networks was highlighted, in association with overall social and cultural determinants as recorded in available literature [ 23 ]. The study also identified significant lifestyle and maternal determinants of the increasing rates of CS delivery. Health professionals consistently attributed modern sedentary lifestyles to physiological challenges leading to CS delivery. The observation is in line with earlier research findings showing the normalization process of caesarean delivery in the clinical and social contexts due to changing lifestyles and perceptions [ 24 , 25 ]. The study also revealed strong maternal requests and preferences underlying the CS rates, which are likely to occur irrespective of clinical necessity. This finding is supported by a previous study that indicated there was a practice to oblige requests by patients for CS delivery among Indian private sector practitioners because of consumer-provider relationship dynamics [ 24 ]. The study also found that obstetricians believed that women who conceived after fertility treatments were likely to choose CSs, a finding supported by a previous analysis that showed that use of assisted reproductive technologies was associated with increased requests for CS delivery in the United States [ 26 ]. Past negative birth experience is a significant influence on maternal requests for CS, and the results were in line with findings of studies carried out in Nigeria, where obstetricians were more likely to grant CS requests due to past negative labor experience[ 27 ]. The convenience of carrying out a tubectomy simultaneously with CS was also found to be one of the key drivers in this study, and something that has not yet been fully explored in existing academic literature. The analysis of the study found that Obstetricians and midwives also felt that various healthcare system factors contribute to excessive CS rates, such as medical professionals' preferences, time constraints, and scheduling considerations. These results are consistent with previous findings identifying that physicians with higher CS rates in their prior practice were more likely to deliver by CS in subsequent cases, indicating the influence of provider-specific factors such as experience and convenience factors[ 28 ]. The pervasive fear of medico-legal consequences emerged as one of the key drivers of the decision-making among obstetricians, consistent with findings from a series of studies. Literature across the world also indicated the same trend, as one study in Ireland noted the clinicians’ concerns about litigation [ 29 ], and another study revealed that experienced obstetricians in Argentina mentioned fear of litigation as a leading factor[ 30 ]. This study’s results also indicate that Obstetricians believe the diminishing confidence and skills juniors have in performing vaginal deliveries is one of the reasons CS rates continue to increase. This generational shift in obstetric practice is consistent with one that found in the United States, providers with less favorable attitudes towards vaginal delivery had higher associated CS rates[ 31 ]. Insufficient resources and a lack of staff were suggested to be the most important underlying systemic causes for the preference of CS, especially in lower-level health facilities. These findings are consistent with earlier research that reported public sector institutions do not have enough available staff such as midwives and obstetricians to adequately support the management of vaginal deliveries [ 21 , 32 ]. The shortage of staffing and the absence of operative theatre services around the clock at small hospitals emerged as major limitations, supporting previous studies that noted a lack of defined protocols and indicator systems to monitor the use of caesarean section procedures to control their rising frequency.[ 24 , 21 ]. Study findings also recognised the influence of insurance schemes that compensated for CSs as a structural factor increasing their accessibility, which aligns with the economic incentives driving the CS rates as documented in the earlier studies [ 24 , 25 ]. These studies have pointed out that in private healthcare facilities, financial incentives and the pressure to maintain high patient loads are significant drivers of CS preferences. This study found that obstetricians and midwives perceived several legitimate medical indications that necessitate CS deliveries, including high-risk pregnancies and labour-related complications. These findings are similar to those of previous studies, which found obstetricians and midwives prioritise medical indications such as previous CSs, hypertension, and fetal distress [ 19 , 33 ]. There was also an emphasis on high-risk conditions, such as pre-eclampsia, eclampsia, fibroids, and cephalopelvic disproportion (CPD) is consistent with clinical factors documented in the literature. [ 34 ]. Labour complications, including prolonged labour and fetal distress, are leading categories of medical indications for CSs, consistent with earlier studies on the influence of clinical factors such as gestational age, pelvic size, and maternal age on CS delivery[ 33 ]. Findings of this study indicate that healthcare providers have increased anxiety levels when dealing with labor complications, particularly in low-resource settings, which frequently leads to decisions with a preference for CSs. The perspectives from both obstetricians and midwives enable a complete understanding of the various determinants of CS preferences in Andhra Pradesh. The study reveals that although legitimate medical reasons constitute a critical foundation for the conduct of operations, non-medical determinants—such as sociocultural determinants, preference of the mother, limitations in the healthcare system, and the attitude of healthcare providers—are also accountable for the high rates of CS delivery. The apparent disparity in CS rates between private (63%) and public (26%) health facilities in Andhra Pradesh is consistent with research studies examining the healthcare system and economic incentive determinants [ 24 ]. The private health sector, as motivated by economic incentives and consumer-provider relationships dynamics, has shown significantly higher rates consistent with broader trends documented in prior literature [ 25 ]. This study also highlights the regional specificity of high CS in southern states like Andhra Pradesh, consistent with previous studies that highlighted that southern states like Telangana, Tamil Nadu and Andhra Pradesh have some of the highest CSs, driven predominantly by private sector and cultural preferences [ 21 , 25 ]. The findings from this study have the potential to guide specific interventions towards addressing the particular determinants of high CS rates in Andhra Pradesh. Policy makers to develop a comprehensive regulatory framework by duly including mandatory second opinions for elective CS, standardised care protocols to adhere along with auditing mechanism, financial incentives for conducting normal deliveries, and maternal education with emphasis on benefits of vaginal deliveries for reduction of unnecessary surgical interventions. Limitations of the study: As this was a qualitative study, the findings from this study may not feasible to be generalised to other regions of India. Though efforts were made to include obstetricians from both public and private facilities, all midwives who participated were from the government facilities as the private sector doesn’t have trained midwives. This could have potentially limited insights from private sector midwifery practices. There might be bias in the responses from the participants as they might have given only socially desirable responses, especially regarding non-medical factors influencing c-section decisions The study only included the perspectives of Obstetricians and midwives; inclusion of the perspectives of pregnant women and their families would have given a comprehensive understanding of the factors influencing CS preferences. Strengths of the study: Study locations, including districts with both high CS rates and low CS rates, provided insights into regional variations in perceptions. The inclusion of obstetricians from both public and private facilities captured significant variations in factors influencing the high CS rates. The inductive thematic analysis approach led to the emergence of themes naturally from the responses rather than categorising into predetermined categories. Conclusion This qualitative research emphasises that CS rates in Andhra Pradesh are being influenced by several factors, including sociocultural, psychological, maternal, health system, and medical factors such as fear of labor pain, cultural reasons, sedentary lifestyle, medico-legal issues, and systemic issues like staff shortages and diminished confidence among junior obstetricians. Though medical indications are crucial, high CS rates require a comprehensive response—raising public awareness, strengthening provider education, fortifying healthcare systems, and changing cultural norms—to advance evidence-based practice, decrease unnecessary interventions, and maximise maternal and child health outcomes while maintaining access to life-saving care. Abbreviations CS Caesarean Sections NFHS-5 National Family Health Survey − 5 IDI In-Depth Interview IEC Institutional Ethics Committee MCH Maternal and Child Health CHFW Commissionerate of Health and Family Welfare DGO Diploma in Gynaecology and Obstetrics NVD Normal Vaginal Delivery CPD Cephalopelvic Disproportion NICU Neonatal Intensive Care Unit CHC Community Health Centre AP Andhra Pradesh VDRL Venereal Disease Research Laboratory HIV Human Immunodeficiency Virus Declarations Ethics approval and consent to participate Ethical approval was obtained from the Institutional Ethics Committee of the School of Public Health, SRMIST, Chennai on 29 th May 2024 (Ref No: 00111/IEC/2024). By the Declaration of Helsinki, the researchers upheld the confidentiality and integrity of the study participants. Consent was obtained from all the participants by explaining the aims and objectives of the study. Consent for publication All the authors have gone through the final version of this manuscript and have given their consent for the publication Availability of data and material This research paper was prepared based on primary data collected during December 2024 - April 2025. The data can be obtained upon request, contingent upon approval from SRMIST, Chennai. Competing interests The authors declare no competing interests. Funding No financial support has been obtained from any sources for conducting this research Authors’ contribution NBG and BTM conceptualised and designed the study. NBG conducted a literature search, manuscript preparation, and data analysis. BTM, AKP, and JS completed Manuscript editing and manuscript review. All authors approved the final manuscript for submission. Acknowledgements Not applicable Authors' information Nagendra Babu Gavvala: Doctoral Scholar, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected] Benson Thomas M: Associate Professor, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected] Anuj Kumar Pandey: Assistant Professor, International Institute of Health Management Research (IIHMR), New Delhi, India. Email: [email protected] Janmejaya Samal: Associate Professor, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected] References Torloni MR, Bonet M, Betrán AP, Ribeiro-do-Valle CC, Widmer M. Quality of medicines for life-threatening pregnancy complications in low- and middle-income countries: A systematic review. PLoS ONE. 2020;15(7):e0236060. https://doi.org/10.1371/journal.pone.0236060 . Molina G, ∙ Weiser TG, ∙ Lipsitz SR, ∙ et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. 2015; 314:2263–2270 JAMA, Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. (2016). The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014. PLoS One, 11(2), e0148343. https://doi.org/10.1371/journal.pone.0148343 Dewianti NM, Palutturi S, Muis M, Karmaya IN. Development of application-based education model and prenatal yoga in reducing the occurrence of cesarean section (CS) delivery: Study protocol. J Educ Health Promotion. 2022;11:365. https://doi.org/10.4103/jehp.jehp_1770_21 . Pandey AK, Raushan MR, Gautam D, Neogi SB. Alarming Trends of Cesarean Section-Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India. J Med Internet Res. 2023;25:e41892. 10.2196/41892 . PMID: 36780228; PMCID: PMC9972201. Elnakib S, Abdel-Tawab N, Orbay D, Hassanein N. Medical and non-medical reasons for cesarean section delivery in Egypt: A hospital-based retrospective study. BMC Pregnancy Childbirth. 2019;19:411. https://doi.org/10.1186/s12884-019-2558-2 . World Health Organization. (2018). WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections. https://apps.who.int/iris/bitstream/handle/10665/275377/9789241550338-eng.pdf Sandall J, Tribe RM, Avery L, Mola G, Visser GHA, Homer CSE, Gibbons D, Smith V. Short-term and long-term effects of cesarean section on the health of women and children. Lancet. 2018;392(10155):1349–57. https://doi.org/10.1016/S0140-6736(18)31930-5 . Jameel K, Mannan A, Niaz GE, R., Hayat DE. Cesarean scar ectopic pregnancy: A diagnostic and management challenge. Cureus. 2021;13(10):e14463. https://doi.org/10.7759/cureus.14463 . . World Health Organization. (2015). WHO statement on caesarean section rates. https://www.who.int/publications/i/item/WHO-RHR-15.02 Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. 2023;6(5):e1274. https://doi.org/10.1002/hsr2.1274 . Lafta R, Habeeb H. Caesarean section: Time trend and risk factors. Basrah J Surg. 2020;26:27–31. https://doi.org/10.33762/bsurg.2020.167509 . Gunnervik C, Sydsjö G, Sydsjö A, Selling E, K., Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand. 2008;87(4):438–44. https://doi.org/10.1080/00016340801996724 . Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant. 2022;56:1391–412. https://doi.org/10.1007/s11135-021-01182-y . State Fact Sheet. Andhra Pradesh NFHS 5. Mumbai: International Institute for Population Sciences; 2020. Cavallaro FL, Cresswell JA, Ronsmans C. Obstetricians' opinions of the optimal caesarean rate: A global survey. PLoS ONE. 2016;11(3):e0152779. https://doi.org/10.1371/journal.pone.0152779 . Li M, Gu W, Li X, Wang X. (2018). The Reasons and Strategies of High Cesarean Section Rate from Chinese Obstetricians and Midwives Perspective in the Public Hospitals: An Interpretative Phenomenologic Analysis. 4(3). https://doi.org/10.23937/2469-5793/1510087 Hantoosh Zadeh S, Shariat M, Mousavi A, Sahebi L, Moradi R, Farrokhzad N. Obstetricians’ Views for Reasons Decision-Making for Cesarean Section in Iran. Acta Medica Iranica. 2024. https://doi.org/10.18502/acta.v62i3.17140 . Kumar P, Dhillon P. Household- and community-level determinants of low-risk Caesarean deliveries among women in India. J Biosoc Sci. 2021;53(1):55–70. https://doi.org/10.1017/S0021932020000024 . Mohan VN, Shirisha P, Vaidyanathan G, Muraleedharan VR. Variations in the prevalence of caesarean section deliveries in India between 2016 and 2021 – an analysis of Tamil Nadu and Chhattisgarh. BMC Pregnancy Childbirth. 2023;23:1–22. https://doi.org/10.1186/s12884-023-05928-4 . Jirra K, Br SM. Understanding The Reasons for High Rates of Caesarean Section Deliveries in Telangana, South India: An Explorative Study. Natl J Community Med. 2023;14(11):704–10. https://doi.org/10.55489/njcm.141120233324 . Kapasia N, Roy A, Rahaman MM, Ghosh S, Chouhan P. (2023). Prevalence and determinants ofcaesarean delivery at child birth order in India: Insights from national representative data. https://doi.org/10.21203/rs.3.rs-3199695/v1 Astepe BS, Ayaz R, Köleli I, Yücedağ M, Yılmaz Ö, Uzel K. Turkish obstetricians’ self-birth preferences, attitudes and practices towards caesarean section on maternal request and vaginal birth after caesarean section: a national online survey. J Obstet Gynaecol. 2022;42(6):2033–8. https://doi.org/10.1080/01443615.2022.2080531 . Peel A, Bhartia A, Spicer N, Gautham M. If I do 10–15 normal deliveries in a month I hardly ever sleep at home. A qualitative study of health providers’ reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India. BMC Pregnancy Childbirth. 2018;18(1):470. https://doi.org/10.1186/S12884-018-2095-4 . Malla VR. & S, R. (2022). Role of Private and Public Health Institution in Caesarean Delivery in the Districts of Andhra Pradesh, India. Social Science Research Network. https://doi.org/10.2139/ssrn.4067974 Masciullo L, Petruzziello L, Perrone G, Pecorini F, Remiddi C, Galoppi P, Brunelli R. Caesarean Section on Maternal Request: An Italian Comparative Study on Patients’ Characteristics, Pregnancy Outcomes and Guidelines Overview. Int J Environ Res Public Health. 2020;17(13):4665. https://doi.org/10.3390/IJERPH17134665 . Chigbu CO, Ezenyeaku C, Ezenkwele EP. Obstetricians’ attitudes to caesarean delivery on maternal request in Nigeria. J Obstet Gynaecol. 2010;30(8):813–7. https://doi.org/10.3109/01443615.2010.489165 . Burns LR, Geller SE, Wholey DR. The effect of physician factors on the cesarean section decision. Med Care. 1995;33(4):365–82. https://doi.org/10.1097/00005650-199504000-00004 . Panda S, Begley C, Daly D. Clinicians’ views of factors influencing decision-making for CS for first-time mothers—A qualitative descriptive study. PLoS ONE. 2022;17(12):e0279403. https://doi.org/10.1371/journal.pone.0279403 . Perrotta C. Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees. BMJ Open. 2022;12(1):e053419. https://doi.org/10.1136/bmjopen-2021-053419 . VanGompel EW, Main EK, Tancredi DJ, Melnikow J. Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study. BMC Pregnancy Childbirth. 2018;18(1):184. https://doi.org/10.1186/S12884-018-1756-7 . Pendleton AA, Dutta R, Shukla M, Jayaram A, Gadgil A, Hembram S, Roy N, Raykar NP. What to scale first? A cross-sectional analysis of factors affecting cesarean delivery rates at first referral units in Bihar, India. Global Health Action. 2023;16(1). https://doi.org/10.1080/16549716.2023.2202465 . Taganoviq B, Smith P, Lorber M, Hoxha I. The influence of emotional labor and emotional intelligence on cesarean section decision-making among midwives and obstetricians in Kosovo: A cross-sectional study using conjoint analysis. Eur J Midwifery. 2025;9:1–9. https://doi.org/10.18332/ejm/197168 . Carrera AM, Sternke EA, Rivera-Viñas JI. A Pilot Study of the Perceptions of Actively Practicing Obstetricians in Puerto Rico: Factors that Influence Decision Making in Cesarean Delivery. P R Health Sci J. 2017;36(1):17–23. http://prhsj.rcm.upr.edu/index.php/prhsj/article/view/1367 . Additional Declarations No competing interests reported. Supplementary Files IDIGuidelinesObstetriciansandMidwives.pdf Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 15 Sep, 2025 Reviews received at journal 10 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers invited by journal 28 Jul, 2025 Editor invited by journal 17 Jul, 2025 Editor assigned by journal 16 May, 2025 Submission checks completed at journal 16 May, 2025 First submitted to journal 16 May, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-6620120","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493687043,"identity":"b5fd45d6-acaf-49ed-8e0a-5cbd90a835a9","order_by":0,"name":"Nagendra Babu Gavvala","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Nagendra","middleName":"Babu","lastName":"Gavvala","suffix":""},{"id":493687045,"identity":"91493de2-25ae-407d-bafa-8e78e62aabde","order_by":1,"name":"Benson Thomas M","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACAxiDH0QkMEDJBMJaDBgkG8CKDUjQYnAAzsenHgjM2XsPf/i440+08fmzTzc8+POHgZ89x4Dh4Q7cWix7zqVJzjxjkLvtRrrZjcQ2oAt73hgwJJ7B47AbOWbMvG0gLWxsNxIbDEAiQC1teLTcf2P8GaRlc/8xthsJfwwY7AlqucFjIA3SsoEhDaiFDWiLBAEtlj05ZpIz24xzZ9wAaklsM+aROPOs4AA+LebsZ4w/fGyTy+0HOuzmjz9ycvztyRsf/sSjBQPwgIgDJGgYBaNgFIyCUYAFAACRolLITMd5dQAAAABJRU5ErkJggg==","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Benson","middleName":"Thomas","lastName":"M","suffix":""},{"id":493687047,"identity":"1eb0afa5-5bf3-4a0f-a5cc-a638e789d9ac","order_by":2,"name":"Anuj Kumar Pandey","email":"","orcid":"","institution":"International Institute of Health Management Research (IIHMR)","correspondingAuthor":false,"prefix":"","firstName":"Anuj","middleName":"Kumar","lastName":"Pandey","suffix":""},{"id":493687051,"identity":"4417ed0d-b7de-4467-8f5c-d9abd8ccf3cf","order_by":3,"name":"Janmejaya Samal","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Janmejaya","middleName":"","lastName":"Samal","suffix":""}],"badges":[],"createdAt":"2025-05-08 11:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6620120/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6620120/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08388-0","type":"published","date":"2025-11-28T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88128406,"identity":"824dfe62-87f0-488f-bbb5-715423b46102","added_by":"auto","created_at":"2025-08-01 17:56:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236032,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMind map of the perspectives of Obstetricians and midwives on the factors leading to CS\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6620120/v1/666bba5f4306ad42effebf82.png"},{"id":88128408,"identity":"73ddfbf8-085e-4051-b611-47972498087a","added_by":"auto","created_at":"2025-08-01 17:56:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180391,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFramework prepared after analysis using inductive codes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6620120/v1/3642c5061bc7b9adfd18aa81.jpeg"},{"id":97178775,"identity":"0c60e60c-ba95-4a65-ac01-eb210a64b186","added_by":"auto","created_at":"2025-12-01 16:13:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1268532,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6620120/v1/e9f55a68-5d85-418e-969c-9387b9a27fbb.pdf"},{"id":88128531,"identity":"e7f7c19e-6de2-4930-b9f4-684cb2ba79ed","added_by":"auto","created_at":"2025-08-01 18:04:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":76160,"visible":true,"origin":"","legend":"","description":"","filename":"IDIGuidelinesObstetriciansandMidwives.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6620120/v1/b8a0a12292ad4396b77fdf87.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perspectives of Obstetricians and Midwives on the Preference for Caesarean Deliveries: A Qualitative Exploration in Andhra Pradesh, India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCaesarean section is a life-saving surgical procedure; however, its effectiveness in reducing mortalities remains uncertain in cases where it is not indicated medically [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, it is projected that the caesarean section rates will increase to 28% by 2030. Nevertheless, the very high and rapidly growing rate of caesarean sections (CS) during the past 20 years has become a concern worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, excessively high rates of caesarean deliveries have detrimental effects on women's health, economic efficiency, and family and national well-being [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe NFHS-5 report states that 88% of deliveries in India are conducted in hospital institutions. Caesarean rates in India have increased from 17% in 2015-16 to 21% of total deliveries in 2019-21, with significant regional variations.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The overall prevalence of C-section deliveries in India is significantly higher than the typical range of 10 to 15 per cent in many states, according to the NFHS-5 survey. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With 96.5% of institutional deliveries in Andhra Pradesh, the state has the third highest rate of c-section deliveries in India, with 42.4% of deliveries by c-section and 57.6% by normal vaginal deliveries. Surprisingly, c-sections comprised 63% of all deliveries in private healthcare establishments, while only 26% occurred in government healthcare institutions in Andhra Pradesh. Between the National Family Health Survey's two consecutive rounds, the percentage of caesarean deliveries rose from 40.1\u0026ndash;42.4%. The percentage of deliveries by caesarean section in private facilities has increased significantly, rising from 57% in NFHS-4 to 63% in NFHS-5. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eFear of labour pains, perineal tears, and history of repeated pregnancy loss are some of the causes of non-medically indicated CS [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. WHO in 2021 reported that a CS rate of more than 10 per cent is linked to more surgical complications and disabilities, and has no evidence to decrease the associated mortalities. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Short-term complications of any CS are bleeding, infection, anaesthesia complications, and additional antibiotics and analgesics. As the rate of CS rises, complications of a long-term in nature, such as adhesions, injury to abdominal viscera, infertility, and pathologic placentation like placenta previa and scar ectopic pregnancy, have risen in numbers. Infants born by caesarean section are also at a higher risk of acute disease complications like transient tachypnoea and require admission into neonatal units. Additionally, certain types of hormonal, physical, and immune development changes may take place, including decreased intestinal gut microbiome diversity, atopy, asthma, and allergies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis significant rise in C-section rates could be attributed to the lack of utilisation of a standardised, internationally accepted classification system for monitoring CS rates across states and medical units.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Apart from the acceptance and utilisation of these standardised tools, various other factors play a crucial role. The rise in CS rates is often driven by subjective preferences from both patients and healthcare providers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Literature suggests that women often do not fully comprehend the associated risks, benefits, or long-term implications before undergoing CS.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe overuse of CS is driven by a complex interplay of maternal, health system, and healthcare provider-level factors. These include women's preference for CS, healthcare providers' attitudes toward normal delivery, associated financial incentives, institutional protocols, and overall systemic inefficiencies. While anecdotal evidence from various stakeholders highlights these issues, there is a dearth of literature on the perspectives of obstetricians and midwives. Understanding their attitudes and decision-making processes is crucial for developing targeted interventions to optimize CS use. The perceptions and personal experience of health providers and midwives often influence the decision regarding the mode of delivery. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eGiven these gaps, this study aims to explore the perceptions of obstetricians and midwives regarding the rising preference for cesarean deliveries in selected districts of Andhra Pradesh. By gaining insights into their attitudes, motivations, and decision-making frameworks, this research seeks to inform policies and interventions aimed at ensuring rational and evidence-based use of cesarean sections while improving maternal and neonatal health outcomes. Given this gap, this study would aim to explore perceptions on the preference of caesarean section by Obstetric specialists and midwives attending the deliveries in selected districts of Andhra Pradesh.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting:\u003c/h2\u003e\u003cp\u003eThe study adopted a phenomenological approach to understand the experience of obstetricians and midwives regarding higher C-section rates in selected districts of Andhra Pradesh. The study was conducted in four districts of Andhra Pradesh, in which Visakhapatnam, Krishna have high CS rates, and Anantapur, Chittoor have low CS rates.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy participants and sampling:\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was employed to choose obstetricians and midwives actively engaged in their professions across four districts of Andhra Pradesh. The study comprised midwives and obstetricians who worked in the study districts. The study excluded midwives and obstetricians who refused to engage in the in-depth interviews (IDIs). Eight midwives and eight obstetricians were interviewed to learn more about their opinions regarding the preference for caesarean delivery.\u003c/p\u003e\u003cp\u003eInclusion Criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eObstetricians and Midwives who are currently practising in their respective professions in any of the four selected districts of Andhra Pradesh.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eObstetricians working both in Public and Private hospitals are included in the study.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eParticipants who are willing to participate in in-depth interviews and provide informed consent are included.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eExclusion Criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eObstetricians and Midwives who are not currently practising and practising outside other than selected four districts of Andhra Pradesh.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eObstetricians and Midwives who refused to participate in the study.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eData collection tool and technique:\u003c/h3\u003e\n\u003cp\u003eQualitative being an emergent design, we followed the same approach; thus, an open-ended guide was developed, which was later used for a pilot survey at Krishna District in one of the public health hospitals to ensure its consistency and clarity in understanding. A validated semi-structured questionnaire was used as the IDI guide.\u003c/p\u003e\u003cp\u003e The discussions were facilitated in the local language (Telugu) to ensure effective communication. A total of sixteen IDIs were conducted, eight each for obstetricians and midwives. Before conducting the IDIs, the interviewer discussed the terms and conditions and sought informed consent from all participants for recording the discussions. The first author conducted the interview and audio recorded all\u0026ensp; IDIs. Audiotapes were transcribed and translated verbatim from Telugu to English, and then entered into a Microsoft Word document. IDIs were conducted at the hospitals where they are currently working to ensure the convenience of the study participants. The period of data collection was December 2024 \u0026ndash; April 2025.\u003c/p\u003e\n\u003ch3\u003eEthical consideration:\u003c/h3\u003e\n\u003cp\u003e Ethical clearance for the study was obtained from the Institutional Ethics Committee of the School of Public Health, SRMIST, Chennai on 29th May 2024 (Ref No: 00111/IEC/2024). Permission to conduct the In-depth interviews (IDIs) in all\u0026ensp; the selected districts was obtained from the Additional Director [MCH], O/o CH\u0026amp;FW, Andhra Pradesh. By following the declaration of Helsinki, the purpose of the research was explained clearly to all the study participants and informed consent was obtained from all of them.\u003c/p\u003e\u003cp\u003eThe participants include obstetricians and midwives, and the participants' confidentiality, anonymity, dignity, and integrity were guaranteed. Also, the participants were informed that they are free to leave the interview at any time if they wish to do so. Each IDI lasted approximately 45 minutes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAnalysis method\u003c/strong\u003e\u003cp\u003eA thematic analysis was undertaken following the framework given by Braun \u0026amp; Clarke. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The transcripts were manually coded, using codes developed inductively. Thematic framework analysis was used to identify the various themes exploring the perceptions of CS among the Obstetricians and midwives.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e The study participants were Obstetricians and midwives working in the selected districts. Of the total 16 interviews, 8 were ObGs and 8 were midwives. The Obstetricians interviewed had an average experience of 22 years, of which 5 are working at government hospitals and 3 are working at private hospitals. The qualification of all of them were either a Diploma in Gynaecology and Obstetrics (DGO) or MS Obstetrics and Gynaecology. The midwives interviewed had an average experience of 14 years, and all are working at the government hospitals only. The qualification of midwives was GNM or BSc Nursing with a specialisation in Nurse Practitioner in Midwifery, an 18-month course offered by the Government of Andhra Pradesh.\u003c/p\u003e\u003cp\u003eIn the analysis of the obtained qualitative data, four major themes emerged regarding perceptions about CS among the obstetricians and midwives: Sociocultural and psychological factors, Maternal \u0026amp; lifestyle factors, Healthcare System Factors and Medical indications for CS.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eMind map of the perspectives of Obstetricians and midwives on the factors leading to CS\u003c/h2\u003e\u003cp\u003eThe Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e is a mind map of the various contributing factors for the increase in CS deliveries, as reported by obstetricians and midwives. The figure classifies these contributory factors into thematic areas of unawareness and fear, medical professionals' preference, sociocultural reasons, constraints in healthcare, and maternal requests, each of them further subdivided into specific sub-themes. In addition, both obstetricians and midwives reported the same concerns, like family pressure, cultural beliefs, and poor infrastructure, but with different emphasis according to their professional roles and experience. The figure describes the determinants for decisions regarding CS, with non-clinical determinants like social influences, misinformation, and medico-legal factors strongly influencing these decisions in addition to the genuine medical indications.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e1. Sociocultural and Psychological Factors\u003c/h3\u003e\n\u003cp\u003eOur analysis revealed that multiple sociocultural and psychological factors strongly influence the preference for CS deliveries in Andhra Pradesh. These factors often exceed purely medical concerns, creating a series of influences on maternal birth decisions.\u003c/p\u003e\n\u003ch3\u003e1.1 Fear and Lack of Awareness\u003c/h3\u003e\n\u003cp\u003eFear of labour pain emerged as a predominant psychological factor driving CS preferences. Healthcare providers frequently reported encountering tokophobia among expecting mothers.\u003c/p\u003e\u003cp\u003eAs one midwife explained, \u003cem\u003e\"Fear of childbirth mostly many of the mothers will say I cannot bear that pains during the labour so I will go for C-section better with one stretch or they will give anaesthesia so that we will be feeling no pains like that is the reason they will say when we ask for the mothers.\"\u003c/em\u003e (M2)\u003c/p\u003e\u003cp\u003eAnother midwife observed that misinformation about the birthing process exacerbated these fears: \u003cem\u003e\"If they cannot bear the pains, they are tokophobia. If their pains, they thought that C-section is easy procedure. They will cut it. With general birth means they will put hands. They will irritate them. If C-section means they will cut in abdomen, they think like that.\"\u003c/em\u003e (M7)\u003c/p\u003e\u003cp\u003eThe influence of negative birth experiences, whether personal or shared by others, was frequently cited as contributing to a cycle of fear. As one midwife noted, \u003cem\u003e\"Nowadays everyone has come to know that there is an increased intensity of pain like during the normal births when they are facing and even the experiences of their parents or their peers, they will be saying like there will be pain which may not be bearable.\"\u003c/em\u003e (M5)\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Family and Social Pressure\u003c/h2\u003e\u003cp\u003eOur findings indicate that familial pressure plays a significant role in driving CS preferences. Obstetricians frequently reported being unable to convince families about the benefits of vaginal delivery when faced with determined opposition.\u003c/p\u003e\u003cp\u003eOne obstetrician shared, \u003cem\u003e\"There is more pressure from birth companions, whatever the birth companion tell them they listen to it. If birth companion has a negative opinion that impacts the mother. Sometimes if they wait for Normal delivery here there are 2 disadvantages: one thing is if we tell them to wait for NVD then they will leave to another hospital for C-Section.\"\u003c/em\u003e (O1)\u003c/p\u003e\u003cp\u003eCultural and religious beliefs, particularly the preference for auspicious birth dates (muhurthams), were consistently mentioned as driving scheduled CSs. Several healthcare providers emphasized the prevalence of this practice:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Yes, one more thing to add, if there is any new moon day [Amavasya] or any bad days, they fear that during those days birth may happen, and they plan for C-section beforehand. They follow the muhurthams for birth and plan for C-section. From my opinion, if we explain the risk to illiterates, they will listen, but the so-called educated people won't listen to it.\"\u003c/em\u003e (O1)\u003c/p\u003e\u003cp\u003eThe influence of social media and peer networks in spreading misconceptions was also highlighted. As one midwife stated, \u003cem\u003e\"Online media is affecting a lot. Because of the online stories given by the previously delivered mothers, there are many misconceptions about normal delivery.\"\u003c/em\u003e (M1)\u003c/p\u003e\u003cp\u003eInterestingly, CS in private hospitals were perceived as a status symbol by some patients. One obstetrician noted, \u003cem\u003e\"They'll undergo C-section in private hospitals and think it is a prestige issue to get an operation from a corporate hospital.\"\u003c/em\u003e (O7)\u003c/p\u003e\u003cp\u003eThese findings demonstrate how deeply established sociocultural influences intersect with psychological concerns to generate significant desires for CS deliveries, which are often independent of medical necessity. These non-medical factors present considerable challenges for healthcare providers who want to promote evidence-based birth choices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2. Maternal and Lifestyle Factors\u003c/h2\u003e\u003cp\u003eAnalysis of healthcare provider perspectives revealed significant maternal and lifestyle factors contributing to the increasing rates of CS deliveries in Andhra Pradesh. These factors include both physical health considerations associated with modern lifestyles and maternal preferences motivated by convenience and fear.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Sedentary Lifestyle and Physical Health\u003c/h2\u003e\u003cp\u003eHealthcare providers consistently identified modern sedentary lifestyles as a substantial contributor to the physiological challenges that lead to CS deliveries. Obstetricians observed that reduced physical activity during pregnancy has negatively affected women's capacity for vaginal delivery.\u003c/p\u003e\u003cp\u003eAs one obstetrician stated, \u003cem\u003e\"There is no physical activity for the antenatals and so there is no strength to the pelvic muscles and they are sensitive to little pain. Moreover, there is more pressure from husbands and birth companions, they say that their daughters can't tolerate pain and tell that they don't wait for NVD, so they demand for C-section.\"\u003c/em\u003e (O1)\u003c/p\u003e\u003cp\u003eThe contrast between historical practices and contemporary lifestyles was frequently mentioned. Another obstetrician elaborated, \u003cem\u003e\"Another thing is that in ancient days there was balance in consumption of food and physical activity. They think that pregnancy is precious and they will not allow for any physical activity, only eating, sitting, sleeping. Due to this foetus weight increases. It's not that pelvic size increases with the increase of baby weight and so there is an increase in CPD, that's another cause.\"\u003c/em\u003e (O2)\u003c/p\u003e\u003cp\u003eThis observation was echoed by other practitioners who noted the intersection between changing lifestyles and increased complications: \u003cem\u003e\"Olden days there was physical exercise for pregnant women, now we are not seeing that, use of sedentary life, pain intolerance to mothers, and parents also don't want their daughters to suffer with labour pains so they are choosing C-section.\"\u003c/em\u003e (O5)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Maternal Preferences and Demand\u003c/h2\u003e\u003cp\u003eThe study identified strong maternal preferences and demands influencing CS rates. Healthcare providers reported that patient demand for CS has become a significant driver in delivery decisions, often independent of medical necessity.\u003c/p\u003e\u003cp\u003eOne obstetrician openly acknowledged this reality: \u003cem\u003e\"Definitely yes, many times we are doing C-section because of their demand. If we don't do a C-section for them, then they move on to another hospital, which causes a decrease in our census. For this reason, we are doing a C-section as per their request to reach our target. For some of them, if we educate, they listen to it, but many of them demand only a C-section. In some cases, both maternal and fetal conditions are well, but they prefer only C-section.\"\u003c/em\u003e (O3)\u003c/p\u003e\u003cp\u003ePrevious negative birth experiences were frequently cited as a factor in maternal demand for CSs. As another obstetrician explained, \u003cem\u003e\"They say for previous birth, I suffered 3 days with pains, baby didn't cry after birth, baby was kept in NICU, and they fear that it happens again, so they prefer C-section.\"\u003c/em\u003e (O4)\u003c/p\u003e\u003cp\u003eThe convenience of combining CS with tubectomy emerged as another significant factor driving maternal preference. The same obstetrician noted, \u003cem\u003e\"Nowadays, the trend is if the mother is multigravida with previous NVD, they go for C-section given tubectomy. They say that they can't come for a tubectomy again if we do a normal birth, so they demand a C-section. They think that both tubectomy and C-section are the same. This is all due to a lack of awareness.\"\u003c/em\u003e (O4)\u003c/p\u003e\u003cp\u003eWomen who conceived after fertility treatments were identified as particularly inclined toward elective CSs: \u003cem\u003e\"Infertility, precious pregnancies, I mean to say, after treatment, they conceive, so they don't want to take any risk. Even though obstetricians give assurance, family members will not take a chance on that.\"\u003c/em\u003e (O8)\u003c/p\u003e\u003cp\u003eThese findings show that maternal preferences and lifestyle factors have changed substantially, which has contributed significantly to the rise in CS deliveries. The factors, like sedentary lifestyles affecting physical capability and the growing maternal demand for surgical delivery, make it challenging for healthcare providers to support evidence-based birth practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3. Healthcare System Factors\u003c/h2\u003e\u003cp\u003eThe study identified several healthcare system and professional factors that contribute significantly to the increasing rates of CS in Andhra Pradesh. These factors include medical professionals' preferences, systemic constraints, and infrastructure limitations that collectively influence delivery decisions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Medical Professionals' Preferences\u003c/h2\u003e\u003cp\u003eThe analysis of the qualitative data revealed that time constraints and scheduling preferences of the healthcare providers play a substantial role in the decision to perform CS. This was particularly evident in the statements of midwives who observed patterns in CS scheduling.\u003c/p\u003e\u003cp\u003eAs one midwife noted, \u003cem\u003e\"C-sections are being done during the OP timings only. After that, OP timings, the C-sections won't be there, no births will be there.\"\u003c/em\u003e (M3)\u003c/p\u003e\u003cp\u003eAnother midwife elaborated on this reality: \u003cem\u003e\"Sometimes doctors' timing, they may be available till 4 o'clock. That time they may can't wait. If any meconium stain or any such things, they won't wait.\"\u003c/em\u003e (M8)\u003c/p\u003e\u003cp\u003eThe pervasive fear of medico-legal consequences emerged as a significant factor influencing obstetricians' decisions. Several providers explicitly mentioned the anxiety associated with potential negative outcomes and public outrage.\u003c/p\u003e\u003cp\u003eOne obstetrician expressed this concern directly: \u003cem\u003e\"The main reason, the most important reason, is the fear of attacks from the public. That is my honest opinion as an obstetrician. Having a lot of stress, as you see when we counsel for the normal delivery, anything can go wrong, which cannot be corrected immediately. Even to detect distress and you take the patient for a C-section, there is a minimum shifting time. This will be at least half an hour, in that we may lose the baby because of a cord around the neck complication identified in the last minute, and when such a thing happens, nobody is there to support us and there are so many issues with patients attacking doctors.\"\u003c/em\u003e (O8)\u003c/p\u003e\u003cp\u003eAnother obstetrician highlighted the changing patient expectations: \u003cem\u003e\"Public awareness is different nowadays. Adverse response is taken differently, so that is also a factor. Increased awareness and medico-legal aspects and adverse events is being taken in the wrong direction only. So all these things cause stress and lead specialists to choose C-section.\"\u003c/em\u003e (O4)\u003c/p\u003e\u003cp\u003eThe study also revealed concerns about the diminishing confidence and skills among junior obstetricians in managing vaginal deliveries. This generational shift in obstetric practice was identified as a contributing factor to rising CS rates.\u003c/p\u003e\u003cp\u003eAs one experienced obstetrician observed, \u003cem\u003e\"The present junior obstetricians are not confident in conducting normal deliveries. They are less equipped to conduct a normal delivery, and they are not able to assist correctly. They believe that learning how to do a C-section is enough, but the decision to do a C-section or a normal delivery you have to have a good, sound knowledge of the pelvis and all the other protocols. Because of that, they are having low confidence, and because of panic, they very quickly and prematurely decide to conduct a C-section.\"\u003c/em\u003e (O4)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Infrastructure and Staffing Issues\u003c/h2\u003e\u003cp\u003eInfrastructure limitations and staffing challenges were identified as significant systemic factors contributing to the preference for CS, particularly in smaller and first-referral healthcare facilities.\u003c/p\u003e\u003cp\u003eThe lack of 24/7 operating theatre services in smaller hospitals emerged as a critical constraint. As one obstetrician explained, \u003cem\u003e\"In CHC, if we notice any small risk for the mother, we fear to leave the woman for NVD. In an emergency, if we refer the woman for a C-section, there will be a delay of time. In that situation, we fear foetal consequences as in CHC, we have no facility for 24*\u003c/em\u003e7 OT services.\" (O1)\u003c/p\u003e\u003cp\u003eStaffing shortages and personnel distribution were also identified as contributing factors. Another obstetrician noted, \u003cem\u003e\"My one more input is - in CHCS, Area Hospitals, if there are 2 gynaecologists, 2 anaesthetists, and with trained staff, then we can reduce the C-Section rate. One person can't provide 24*\u003c/em\u003e7 services because this is another reason for the rise in C-Section rate.\" (O4)\u003c/p\u003e\u003cp\u003eThe quality of staff training, particularly in labor monitoring, was highlighted as a concern affecting the confidence and capability to manage vaginal deliveries. One obstetrician stated, \u003cem\u003e\"Staff nurses have no skills in monitoring mother and baby. If the staff nurses are skillful, we can facilitate many normal births. They need in-service trainings. Earlier, there were many trainings, but nowadays they are not conducting any training programs. Not that every staff nurse is the same, whatever I am facing, I am telling.\"\u003c/em\u003e (O7)\u003c/p\u003e\u003cp\u003eThe availability of insurance schemes covering CS was identified as a structural factor increasing their accessibility and appeal. One obstetrician mentioned, \u003cem\u003e\"In AP, we have NTR Vaidyaseva (State Sponsored Health Insurance Scheme), in that also, they are paying for deliveries for C-section as well as normal deliveries. So, under that, they are getting a corporate-type facility in NTR Vaidyaseva. So definitely, patients will prefer that also.\"\u003c/em\u003e (O7)\u003c/p\u003e\u003cp\u003eThese findings emphasise the different factors, like healthcare professionals' preferences, risk management strategies, and systemic constraints, that contribute to the increasing rates of CS deliveries in Andhra Pradesh.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4. Medical Indications for C-Sections\u003c/h2\u003e\u003cp\u003eThe study identified several legitimate medical indications that necessitate CS deliveries. Healthcare providers emphasized that, alongside non-medical factors driving CS rates, specific medical conditions continue to form the essential clinical basis for surgical interventions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.1 High-Risk Pregnancies\u003c/h2\u003e\u003cp\u003eHealthcare providers consistently identified certain high-risk conditions as valid indications for CS. These conditions present significant risks to maternal and foetal health that warrant surgical intervention.\u003c/p\u003e\u003cp\u003eOne midwife provided a comprehensive overview of these indications: \u003cem\u003e\"Medical indications like pre-eclampsia, eclampsia, fibroids, CPD, prolonged labor, fetal distress, and infections lead to emergency C-sections.\" (M1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother midwife specifically highlighted concerns for conducting normal deliveries when mother have certain infectious diseases : \u003cem\u003e\"High-risk pregnancies like hypertension during pregnancy, diabetes, any infections like herpes simplex and any HIV, VDRL positive, I think most of these, when they come, maybe due to fear or maybe due to some fear of infection, most of them are being posted for the C-sections.\" (M5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe study revealed that healthcare providers approach high-risk conditions with heightened caution, often opting for CS to minimize potential complications. As one midwife observed: \u003cem\u003e\"In government sector, I feel so many factors is contributing to C-section. Firstly, any precious labor, with any treatment, the mother conceived. If not progressed in a normal time limit, they won't take a chance for trial. Okay. And they will directly report it to C-section.\" (M8)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Labor-Related Complications\u003c/h2\u003e\u003cp\u003eComplications arising during labor emerged as another significant category of medical indications for CS. Healthcare providers detailed several intrapartum conditions that necessitate surgical intervention.\u003c/p\u003e\u003cp\u003eProlonged labor and fetal distress were frequently cited as critical indications. One midwife stated: \u003cem\u003e\"Prolonged labor, premature rupture of membranes, and lack of confidence among staff also lead to emergency C-sections.\" (M3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCephalopelvic disproportion (CPD) was identified as a significant physical barrier to natural birth. One obstetrician explained the connection between contemporary lifestyle factors and CPD: \u003cem\u003e\"Another thing is that in ancient days there was balance in consumption of food and physical activity. They think that pregnancy is precious and they will not allow for any physical activity, only eating, sitting, sleeping. Due to this foetus weight increases. It's not that pelvic size increases with the increase of baby weight and so there is an increase in CPD, that's another cause.\" (O2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe study also revealed that healthcare providers experience increased anxiety when managing labor complications, particularly in facilities with limited resources. This anxiety frequently leads to decisions favoring CSs. As one obstetrician explained: \u003cem\u003e\"In CHC, if we notice any small risk for the mother, we fear to leave the woman for NVD. In an emergency, if we refer the woman for C-section there will be some delay of time. At that situation, we fear foetal consequences.\" (O1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealthcare providers emphasized that their clinical judgment regarding these complications is increasingly influenced by risk aversion and concern for potential negative outcomes. One midwife noted: \u003cem\u003e\"If anything happens, trial and error, trial and error. If anything goes wrong, why should we take that much risk? So, better to have a C-section like that they are planning.\" (M8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese findings demonstrate that while numerous non-medical factors contribute to rising CS rates, legitimate medical indications continue to form an essential basis for surgical intervention. The data indicate that healthcare providers are expected to make clinical judgments while balancing the risk management strategies, particularly when managing high-risk pregnancies and labor complications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eFramework prepared after analysis using inductive codes\u003c/h2\u003e\u003cp\u003eThe Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the developed framework which consolidates overall findings from the study, which illustrates factors influencing the decision to perform a CS. At its core, sociocultural and psychological factors, maternal and lifestyle factors, healthcare system factors, and medical indications play a key role. Here, the sociocultural factors refer to the societal norms of fixing the dates and time for delivery, fear of labour pain, etc impact a mother's preference for CS deliveries. Similarly, maternal and lifestyle factors like advanced maternal age, prior CSs, and body mass index have also influenced the decision, either by way of medical suggestion or personal convenience. Healthcare system factors are institutional policies, time constraints, provider convenience, and medico-legal factors. These have shown greater influence on the healthcare provider's style in prescribing a caesarean delivery. Lastly, some medical conditions, such as foetal distress, hypertensive disease, obstructed labour, or multiple gestations, required caesarean delivery to ensure safe maternal and neonatal health outcomes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the perceptions of Obstetricians and Midwives towards the mode of delivery, especially CSs, and the factors driving the high prevalence of caesarean deliveries in Andhra Pradesh. The findings highlight sociocultural, psychological, Maternal and lifestyle factors, Health care system factors, and Medical indications that influence preferences for normal delivery or CSs. The results highlight unique reasons, concerns, and situational factors influencing these choices, consistent with the larger body of research on similar areas of maternal health and delivery procedures.\u003c/p\u003e\u003cp\u003eThe findings of this study highlight fear of labour pain (tokophobia) and lack of awareness as key psychological factors for opting for CS deliveries. This corresponds to the study, which reported an increased in the rate of CSs due to women\u0026rsquo;s fear of pain during vaginal deliveries and their lack of knowledge of the various modes of delivery in China[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Likewise, an Iranian study indicated that women\u0026rsquo; and their families\u0026rsquo; cultural and personal beliefs had a considerable bearing on the preference for CS[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, family members, especially those present during delivery, exert considerable pressure about preference for CSs. This supports earlier studies, which pointed out the strong role played by family and other caregivers in the decision by women to undergo a CS [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Obstetricians and midwives mentioned the influence of cultural and religious practices, such as the selection of favourable birth dates (muhurthams) for the performance of scheduled CSs. This is in agreement with recent findings, which pointed out that cultural practices and social expectations are significant determinants of CS preferences.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Another key finding of the present study is that undergoing CSs in private hospitals is sometimes viewed as a status symbol, in agreement with a finding from a Telangana study, where in some parts of the state, CSs are viewed as markers of wealth and modernity [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, the dissemination of misinformation on social media and social networks was highlighted, in association with overall social and cultural determinants as recorded in available literature [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study also identified significant lifestyle and maternal determinants of the increasing rates of CS delivery. Health professionals consistently attributed modern sedentary lifestyles to physiological challenges leading to CS delivery. The observation is in line with earlier research findings showing the normalization process of caesarean delivery in the clinical and social contexts due to changing lifestyles and perceptions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The study also revealed strong maternal requests and preferences underlying the CS rates, which are likely to occur irrespective of clinical necessity. This finding is supported by a previous study that indicated there was a practice to oblige requests by patients for CS delivery among Indian private sector practitioners because of consumer-provider relationship dynamics [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The study also found that obstetricians believed that women who conceived after fertility treatments were likely to choose CSs, a finding supported by a previous analysis that showed that use of assisted reproductive technologies was associated with increased requests for CS delivery in the United States [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Past negative birth experience is a significant influence on maternal requests for CS, and the results were in line with findings of studies carried out in Nigeria, where obstetricians were more likely to grant CS requests due to past negative labor experience[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The convenience of carrying out a tubectomy simultaneously with CS was also found to be one of the key drivers in this study, and something that has not yet been fully explored in existing academic literature.\u003c/p\u003e\u003cp\u003eThe analysis of the study found that Obstetricians and midwives also felt that various healthcare system factors contribute to excessive CS rates, such as medical professionals' preferences, time constraints, and scheduling considerations. These results are consistent with previous findings identifying that physicians with higher CS rates in their prior practice were more likely to deliver by CS in subsequent cases, indicating the influence of provider-specific factors such as experience and convenience factors[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The pervasive fear of medico-legal consequences emerged as one of the key drivers of the decision-making among obstetricians, consistent with findings from a series of studies. Literature across the world also indicated the same trend, as one study in Ireland noted the clinicians\u0026rsquo; concerns about litigation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and another study revealed that experienced obstetricians in Argentina mentioned fear of litigation as a leading factor[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This study\u0026rsquo;s results also indicate that Obstetricians believe the diminishing confidence and skills juniors have in performing vaginal deliveries is one of the reasons CS rates continue to increase. This generational shift in obstetric practice is consistent with one that found in the United States, providers with less favorable attitudes towards vaginal delivery had higher associated CS rates[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Insufficient resources and a lack of staff were suggested to be the most important underlying systemic causes for the preference of CS, especially in lower-level health facilities. These findings are consistent with earlier research that reported public sector institutions do not have enough available staff such as midwives and obstetricians to adequately support the management of vaginal deliveries [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The shortage of staffing and the absence of operative theatre services around the clock at small hospitals emerged as major limitations, supporting previous studies that noted a lack of defined protocols and indicator systems to monitor the use of caesarean section procedures to control their rising frequency.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Study findings also recognised the influence of insurance schemes that compensated for CSs as a structural factor increasing their accessibility, which aligns with the economic incentives driving the CS rates as documented in the earlier studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These studies have pointed out that in private healthcare facilities, financial incentives and the pressure to maintain high patient loads are significant drivers of CS preferences.\u003c/p\u003e\u003cp\u003eThis study found that obstetricians and midwives perceived several legitimate medical indications that necessitate CS deliveries, including high-risk pregnancies and labour-related complications. These findings are similar to those of previous studies, which found obstetricians and midwives prioritise medical indications such as previous CSs, hypertension, and fetal distress [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. There was also an emphasis on high-risk conditions, such as pre-eclampsia, eclampsia, fibroids, and cephalopelvic disproportion (CPD) is consistent with clinical factors documented in the literature. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Labour complications, including prolonged labour and fetal distress, are leading categories of medical indications for CSs, consistent with earlier studies on the influence of clinical factors such as gestational age, pelvic size, and maternal age on CS delivery[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Findings of this study indicate that healthcare providers have increased anxiety levels when dealing with labor complications, particularly in low-resource settings, which frequently leads to decisions with a preference for CSs.\u003c/p\u003e\u003cp\u003eThe perspectives from both obstetricians and midwives enable a complete understanding of the various determinants of CS preferences in Andhra Pradesh. The study reveals that although legitimate medical reasons constitute a critical foundation for the conduct of operations, non-medical determinants\u0026mdash;such as sociocultural determinants, preference of the mother, limitations in the healthcare system, and the attitude of healthcare providers\u0026mdash;are also accountable for the high rates of CS delivery. The apparent disparity in CS rates between private (63%) and public (26%) health facilities in Andhra Pradesh is consistent with research studies examining the healthcare system and economic incentive determinants [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The private health sector, as motivated by economic incentives and consumer-provider relationships dynamics, has shown significantly higher rates consistent with broader trends documented in prior literature [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This study also highlights the regional specificity of high CS in southern states like Andhra Pradesh, consistent with previous studies that highlighted that southern states like Telangana, Tamil Nadu and Andhra Pradesh have some of the highest CSs, driven predominantly by private sector and cultural preferences [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The findings from this study have the potential to guide specific interventions towards addressing the particular determinants of high CS rates in Andhra Pradesh. Policy makers to develop a comprehensive regulatory framework by duly including mandatory second opinions for elective CS, standardised care protocols to adhere along with auditing mechanism, financial incentives for conducting normal deliveries, and maternal education with emphasis on benefits of vaginal deliveries for reduction of unnecessary surgical interventions.\u003c/p\u003e\u003cp\u003eLimitations of the study:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAs this was a qualitative study, the findings from this study may not feasible to be generalised to other regions of India.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThough efforts were made to include obstetricians from both public and private facilities, all midwives who participated were from the government facilities as the private sector doesn\u0026rsquo;t have trained midwives. This could have potentially limited insights from private sector midwifery practices.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThere might be bias in the responses from the participants as they might have given only socially desirable responses, especially regarding non-medical factors influencing c-section decisions\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe study only included the perspectives of Obstetricians and midwives; inclusion of the perspectives of pregnant women and their families would have given a comprehensive understanding of the factors influencing CS preferences.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStrengths of the study:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e Study locations, including districts with both high CS rates and low CS rates, provided insights into regional variations in perceptions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe inclusion of obstetricians from both public and private facilities captured significant variations in factors influencing the high CS rates.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe inductive thematic analysis approach led to the emergence of themes naturally from the responses rather than categorising into predetermined categories.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative research emphasises that CS rates in Andhra Pradesh are being influenced by several factors, including sociocultural, psychological, maternal, health system, and medical factors such as fear of labor pain, cultural reasons, sedentary lifestyle, medico-legal issues, and systemic issues like staff shortages and diminished confidence among junior obstetricians. Though medical indications are crucial, high CS rates require a comprehensive response\u0026mdash;raising public awareness, strengthening provider education, fortifying healthcare systems, and changing cultural norms\u0026mdash;to advance evidence-based practice, decrease unnecessary interventions, and maximise maternal and child health outcomes while maintaining access to life-saving care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCaesarean Sections\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNFHS-5\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Family Health Survey \u0026minus;\u0026thinsp;5\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIn-Depth Interview\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIEC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInstitutional Ethics Committee\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMaternal and Child Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHFW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommissionerate of Health and Family Welfare\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDGO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiploma in Gynaecology and Obstetrics\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNVD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNormal Vaginal Delivery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCephalopelvic Disproportion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity Health Centre\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAndhra Pradesh\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVDRL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVenereal Disease Research Laboratory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the\u0026nbsp;Institutional Ethics Committee of the School of Public Health, SRMIST, Chennai on 29\u003csup\u003eth\u003c/sup\u003e May 2024 (Ref No: 00111/IEC/2024).\u0026nbsp;By the Declaration of Helsinki, the researchers upheld the confidentiality and integrity of the study participants. \u0026nbsp;Consent was obtained from all the participants by explaining the aims and objectives of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors have gone through the final version of this manuscript and have given their consent for the publication\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research paper was prepared based on primary data collected during December 2024 - April 2025. \u0026nbsp;The data can be obtained upon request, contingent upon approval from SRMIST, Chennai.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo financial support has been obtained from any sources for conducting this research\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contribution\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNBG and BTM conceptualised and designed the study. NBG conducted a literature search, manuscript preparation, and data analysis. BTM, AKP, and JS completed Manuscript editing and manuscript review. \u0026nbsp;All authors approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; information\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNagendra Babu Gavvala: Doctoral Scholar, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected]\u003c/p\u003e\n\u003cp\u003eBenson Thomas M: Associate Professor, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected]\u003c/p\u003e\n\u003cp\u003eAnuj Kumar Pandey: Assistant Professor, International Institute of Health Management Research (IIHMR), New Delhi, India. Email: [email protected]\u003c/p\u003e\n\u003cp\u003eJanmejaya Samal: Associate Professor, School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTorloni MR, Bonet M, Betr\u0026aacute;n AP, Ribeiro-do-Valle CC, Widmer M. Quality of medicines for life-threatening pregnancy complications in low- and middle-income countries: A systematic review. PLoS ONE. 2020;15(7):e0236060. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0236060\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0236060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMolina G, ∙ Weiser TG, ∙ Lipsitz SR, ∙ et al. 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P R Health Sci J. 2017;36(1):17\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://prhsj.rcm.upr.edu/index.php/prhsj/article/view/1367\u003c/span\u003e\u003cspan address=\"http://prhsj.rcm.upr.edu/index.php/prhsj/article/view/1367\" targettype=\"URL\" 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":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Perceptions, caesarean section, healthcare system, non-medical indications, birth preferences","lastPublishedDoi":"10.21203/rs.3.rs-6620120/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6620120/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eCaesarean section rates in Andhra Pradesh increased to 42.4% in 2019-21, far above the WHO-recommended 10\u0026ndash;15% level. Although the c-sections are life-saving when medically necessary, their overuse is a cause of concern for maternal health outcomes and increased health expenditure. The present study aims to understand the perceptions of obstetricians and midwives on the rising trend of preference for caesarean sections in the selected districts of Andhra Pradesh.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003eA Qualitative research method was adopted to carry out this study among four districts of Andhra Pradesh; two with high C-section rates (Visakhapatnam, Krishna) and two with low C-section rates (Anantapur, Chittoor). Sixteen in-depth interviews were conducted with eight obstetricians and eight midwives selected through purposive sampling. Interviews were recorded digitally and transcribed verbatim, and Braun \u0026amp; Clarke\u0026rsquo;s thematic analysis framework was employed to generate the themes and sub-themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThematic analysis of the obtained data revealed four major themes influencing the preference for caesarean sections which included; Sociocultural and psychological determinants, including tokophobia, family pressures, and beliefs about auspicious dates of birth; followed by Maternal and lifestyle determinants, including sedentary behaviours that affect physiological capacity for vaginal delivery and mothers' decisions based on convenience. In addition, Healthcare system factors, including time, medico-legal considerations, staffing issues, and Medical indications for C-sections, including high-risk pregnancy and labour complications. These results suggest that the decision to conduct c-sections was influenced not only by medical indications but also by societal, systemic, and individual-level factors.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study highlights that while medical indications are a valid basis for conducting c-sections, a substantial proportion of c-sections are happening due to the influence of non-clinical factors such as socio-cultural beliefs, maternal preferences, systemic challenges and provider convenience. The findings emphasize the need for a comprehensive regulatory framework, with standard clinical protocols, periodic audits, and maternal education, to reduce unnecessary c-sections in Andhra Pradesh.\u003c/p\u003e","manuscriptTitle":"Perspectives of Obstetricians and Midwives on the Preference for Caesarean Deliveries: A Qualitative Exploration in Andhra Pradesh, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 17:48:16","doi":"10.21203/rs.3.rs-6620120/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-15T18:41:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T05:00:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-09T01:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240463000771381393445468299924692069867","date":"2025-07-31T02:37:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189641010059296244183357735866933824247","date":"2025-07-29T11:55:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-28T23:44:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-17T09:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-16T09:32:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-16T09:05:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-05-16T09:04:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac999bb2-4fee-4349-9b8c-97dc6b4b5882","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:07:43+00:00","versionOfRecord":{"articleIdentity":"rs-6620120","link":"https://doi.org/10.1186/s12884-025-08388-0","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-11-28 15:58:16","publishedOnDateReadable":"November 28th, 2025"},"versionCreatedAt":"2025-08-01 17:48:16","video":"","vorDoi":"10.1186/s12884-025-08388-0","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08388-0","workflowStages":[]},"version":"v1","identity":"rs-6620120","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6620120","identity":"rs-6620120","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}