Pelvic floor-related fears and preference for mode of delivery in primigravid women: a cross-sectional study

Pelvic floor-related fears and preference for mode of delivery in primigravid women: a cross-sectional study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 6 April 2026 V1 Latest version Share on Pelvic floor-related fears and preference for mode of delivery in primigravid women: a cross-sectional study Authors : Gamze KARABABA 0000-0002-0210-5135 , Yusuf BASKIRAN [email protected] , and Kazım UCKAN Authors Info & Affiliations https://doi.org/10.22541/au.177549700.09049465/v1 158 views 83 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To evaluate the relationship between specific pelvic floor–related fears and mode of delivery preference in primigravid women, and to determine the independent effect of these fears on cesarean preference. Design, Setting, Population: Cross-sectional group-comparative study conducted at a tertiary obstetrics center including 510 primigravid women at 32–35 weeks of gestation. Participants were classified into three groups based on delivery preference: vaginal, cesarean, and undecided Methods: Pelvic floor–related fears were assessed using a structured scale with four subscales. A total concern score (0–40) was calculated. Associations between delivery preference and fear scores were analyzed using appropriate statistical methods. Main Outcome Measures: Primary outcome was preference for cesarean delivery. The main exposure variable was the total concern score; subscale scores were evaluated secondarily. Results: The total concern score differed significantly across delivery preference groups (p=0.002) and was higher among women preferring cesarean delivery. Significant differences were observed for fears of urinary incontinence (p=0.001) and perineal deformity (p=0.015), while other subscales were not significant. ROC analysis showed limited discriminatory performance (AUC=0.586; p=0.003). In multivariate analysis, a total concern score ≥25.5 independently increased the likelihood of cesarean preference (OR=1.41; 95% CI: 1.01–2.08; p=0.048). Conclusions: Pelvic floor–related fears significantly influence delivery preferences in primigravid women, with the total concern score emerging as an independent predictor of cesarean preference. Addressing these fears during antenatal care may help reduce non-medically indicated cesarean rates. Funding: No funding was received for this study. INTRODUCTION Cesarean section rates have increased significantly on a global scale in recent years and have exceeded recommended limits in many countries(1) . According to current data, 21% of births worldwide are performed via cesarean section. If the current rate continues, the estimated cesarean section rate in 2030 will be 28.5%, with projections indicating that this rate could reach 60% or higher in some regions(2) . This increase is associated with heightened risks of maternal morbidity, infection, and bleeding, as well as placental complications in subsequent pregnancies; furthermore, potential adverse effects on neonatal outcomes are increasingly coming to the forefront(3,4) . It is acknowledged that the rise in cesarean section rates cannot be explained solely by obstetric indications, and that maternal preferences are becoming increasingly decisive(5) . This suggests that the choice of delivery method is shaped not only by clinical necessity but also by individual perceptions, expectations, and fears. While the relationship between fear of childbirth and the preference for cesarean section has been established in the literature, the impact of specific concerns regarding pelvic floor function on this preference has been examined only to a limited extent(6) . In particular, concerns regarding conditions such as perineal deformity, urinary incontinence, and sexual dysfunction are potential factors that could influence the perception of childbirth in primigravid women without prior obstetric experience(7–9) . However, these fears have generally been addressed separately and have not been evaluated together within a quantitative framework during pregnancy. Current measurement tools cover only specific aspects of these areas, and there is no standardized approach that comprehensively assesses the relationship between multidimensional fears related to the pelvic floor and the choice of delivery method. In this context, the systematic examination of specific fears related to pelvic floor function is important for better understanding maternal decision-making processes and identifying areas for intervention aimed at reducing non-medically indicated cesarean section rates. Turkey is one of the countries with the highest cesarean section rates among Organisation for Economic Co-operation and Development (OECD) member states, and it is believed that cesarean delivery on maternal request (CDMR) accounts for a significant portion of these high rates(10–12). In this context, in a population with high cesarean rates such as Turkey, the relationship between specific fears related to the pelvic floor and mode of delivery preference among primigravid women was evaluated, and the independent role of these fears in the tendency toward cesarean delivery was analyzed. Study Design and Participants This cross-sectional study was conducted among women in their 32nd to 35th week of pregnancy. The study population consisted of volunteer participants with singleton pregnancies who were undergoing antenatal care at the relevant center. All participants were selected from women experiencing their first pregnancy, aiming to minimize confounding effects related to differences in obstetric experience. Inclusion criteria • Being between 32 and 35 weeks of gestation • Being a primigravida • Singleton pregnancy • Voluntary participation in the study Exclusion criteria • Major fetal anomaly • Severe maternal systemic disease • Previous pelvic floor surgery • Presence of obstetric complications that may indicate a cesarean section (PAS spectrum, low-lying placenta, vasa previa, etc.) Data collection tool A structured questionnaire consisting of four subscales was used to assess specific fears related to the pelvic floor. While scales that separately assess areas such as tokophobia, sexual function, or urinary incontinence exist in the current literature, there is no single validated tool that measures these specific concerns regarding pelvic floor function during pregnancy together and directly within the context of birth preference. Therefore, a composite scoring system was developed based on four main areas considered clinically meaningful. The questionnaire includes the following subscales: 1. Fear of pelvic organ prolapse and vaginal laxity 2. Fear of sexual dysfunction 3. Fear of urinary incontinence 4. Fear of perineal deformity or permanent perineal damage Each subscale is rated on a scale from 0 (no fear) to 10 (maximum fear). The sum of the subdimensions is calculated as a “total concern score” ranging from 0 to 40, with a higher score indicating a greater level of fear. This composite score was developed to directly measure specific fears regarding pelvic floor function during pregnancy in a clinical context and was used as an exploratory measurement tool in the present study. Variables The dependent variable was participants’ preferred mode of delivery, classified into three categories: vaginal delivery, cesarean delivery, and undecided. Independent variables included the total concern score and subscale scores, as well as maternal body mass index (BMI), education level, household income category, place of residence (district/village), and type of health care financing (covered by social security or paid). Socioeconomic status, educational level, household income category, place of residence, and type of financing were assessed indirectly. Since all participants were primigravidas, the gravida and parity variables were considered constant and were not included in the analyses. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as n (%) for categorical variables and as mean ± standard deviation and median (minimum–maximum) for continuous variables. The normality of continuous variables was assessed using the Kolmogorov–Smirnov test and histograms. For variables showing a normal distribution, one-way analysis of variance (ANOVA) was used; for those not showing a normal distribution, the Kruskal–Wallis test was used. Bonferroni correction was applied in post-hoc analyses. The Pearson chi-square test or Fisher’s exact test was used to compare categorical variables. The performance of the total concern score in predicting cesarean delivery was evaluated using ROC curve analysis. Univariate and multivariate logistic regression analyses were performed to identify factors influencing cesarean delivery. A p-value of <0.05 was considered statistically significant. Results Participant characteristics and sociodemographic characteristics A total of 510 primigravid women were included in the study. While the age distribution of participants was predominantly concentrated in the younger age group, 37.6% were in the 18–25 age range, 34.3% in the 26–30 age range, 20.6% in the 31–35 age range, and 7.5% in the 36–40 age range. In terms of educational level, high school graduates (37.5%) constitute the largest group of participants, followed by middle school graduates (31.2%) and elementary school graduates (18.6%); university graduates account for 11.4%, and individuals with graduate-level education account for 1.4%. The participants’ average body mass index was determined to be 26.76 ± 4.01. In terms of place of residence, the vast majority of individuals live in a district (86.7%), while 13.3% reside in a village . Regarding household income, 58.2% of participants had an income between 1 and 2 times the minimum wage, 16.5% had an income more than 3 times the minimum wage, 16.3% had an income below the minimum wage, and 9.0% had an income between 2 and 3 times the minimum wage. When examining the type of financing, it was determined that the vast majority of individuals are covered by the Social Security Institution (SGK) (98.2%), while only 1.8% pay for services out-of-pocket. The average gestational age was calculated as 33.49 ± 1.11 weeks. When comparing sociodemographic and clinical variables by mode of delivery, a statistically significant difference was observed between groups in terms of age groups (p=0.032); the proportion of women aged 18–25 (46.7%) was found to be higher in the undetermined group compared to the other groups. No significant differences were found between the groups in terms of education level, BMI, place of residence, type of financing, and gestational age (p=0.121; p=0.401; p=0.387; p=0.180; p=0.501, respectively). In contrast, a significant association was found between household income and mode of delivery (p=0.009); specifically, the undecided group had a significantly higher proportion of higher income levels (72.2%). Significant differences were also found between the groups regarding the primary factors influencing birth preference (p<0.001); while the most common reason for preferring vaginal birth was method safety (54.7%), fear of childbirth (60.1%) was the primary factor among those preferring cesarean section. In the undecided group, fear of childbirth (48.9%) and other factors (20%) were observed (Table 1). Fear Scores and Birth Preference When examining the general statistics for the scale and subscales, it was observed that the mean total fear score was 23.79 ± 8.98 and the median value was 25.00 (min–max: 0.00–40.00). When the subscales were evaluated, the fear of pelvic prolapse/vaginal laxity had a mean of 5.62 ± 2.99 (median: 6.00; min–max: 0.00–10.00), fear of sexual dysfunction at 4.80 ± 2.98 (median: 5.00; min–max: 0.00–10.00), and fear of urinary incontinence at 6.83 ± 2.99 (median: 7.00; min-max: 0.00–10.00), and fear of perineal deformity was 6.54 ± 3.13 (median: 7.00; min-max: 0.00–10.00). When comparing scale and subscale scores by mode of delivery, a statistically significant difference was found between the groups in terms of total fear scores (p=0.002); post-hoc analysis revealed that this difference was between the vaginal delivery and cesarean section groups, with the cesarean section group having a higher total fear score (25.25 ± 8.97 vs. 22.38 ± 9.43). No significant differences were found between the groups regarding fear of pelvic prolapse/vaginal laxity and fear of sexual dysfunction (p=0.204 and p=0.067, respectively). In contrast, a significant difference was found between the groups regarding fear of urinary incontinence (p=0.001), and this difference was observed between the vaginal delivery and cesarean section groups; it is noteworthy that the fear level was higher in the cesarean section group (7.42±2.8 vs. 6.33±3.1). A significant difference was also found between the groups regarding fear of perineal deformity (p=0.015), and this difference was determined to be between the vaginal delivery and the undecided groups; the fear level was higher in the undecided group (7.26±2.69 vs. 6.18±3.26) (Table 2). Discriminatory performance analysis When examining the predictive value of the Total Concern Score in distinguishing cesarean delivery, the area under the curve (AUC) was found to be 0.586 (95% CI: 0.531–0.641) according to ROC analysis, and this value was determined to be statistically significant (p=0.003). At the determined cutoff point of ≥25.50, sensitivity was found to be 54.3% and specificity 55.9% (Table 3). Logistic regression analysis When factors influencing cesarean delivery were evaluated using univariate and multivariate logistic regression analyses, it was observed that the likelihood of cesarean delivery was significantly increased in individuals with a Total Concern Score ≥25.50 (OR=1.51; 95% CI: 1.03–2.19; p=0.031); this association persisted in the multivariate analysis (OR=1.41; 95% CI: 1.01–2.08; p=0.048) and was identified as an independent risk factor. Regarding maternal age, the 31–35 age group was found to carry a significantly higher risk of cesarean delivery compared to the 18–25 age group in both univariate (OR=1.72; 95% CI: 1.03–2.87; p=0.036) and multivariate analyses (OR=2.03; 95% CI: 1.15–3.59; p=0.014). Regarding educational level, univariate analysis showed that high school (OR=1.73; 95% CI: 1.09–3.03; p=0.046) and college graduates (OR=1.97; 95% CI: 1.05–4.09; p=0.049) were associated with cesarean delivery; however, these associations lost statistical significance in the multivariate analysis (p=0.078 and p=0.066, respectively). Similarly, although a significant association was observed for the 2–3 income group in univariate analysis (OR=1.97; 95% CI: 1.08–5.16; p=0.030), this relationship was not maintained in the multivariate model (p=0.087). No significant associations were found between BMI, place of residence, or type of financing and cesarean delivery. The overall fit of the model was modest, with a -2 log likelihood value of 605.047 and a coefficient of determination (R²) of 0.056 (Table 4). Discussion Main findings This study demonstrated that specific pelvic floor–related fears significantly influence delivery mode preference in primigravid women. The independent association between total concern score and cesarean preference indicates that delivery decisions are shaped not only by obstetric factors but also by concerns regarding postpartum bodily integrity. Subscale analysis showed that fears of urinary incontinence and perineal deformity were significantly associated with delivery preference, whereas fears related to pelvic organ prolapse and sexual dysfunction were not, suggesting a differential impact of pelvic floor components. Strengths and Limitations A major strength of this study is the inclusion of a homogeneous population of primigravid women within a narrow gestational age range, minimizing variability related to prior obstetric experience. The multidimensional assessment of pelvic floor–related fears using a composite scoring approach further strengthens the study. Additionally, multivariate analysis was performed to control for potential confounders. However, several limitations should be acknowledged. The cross-sectional design precludes causal inference. Self-reported data may introduce response bias. The use of a non-validated measurement tool represents a methodological limitation, and the single-center design may limit generalizability. Interpretation While the relationship between tokophobia and cesarean section preference is well-established in the literature, current evidence largely focuses on general fear of childbirth, and the impact of specific, multidimensional anxieties regarding pelvic floor function on birth preference has not been sufficiently characterized(13,14) . The present study offers a new perspective on this field by elucidating the role of more specific and somatic anxieties regarding pelvic floor function in birth preference. In particular, the prominence of fears related to urinary incontinence and perineal deformity suggests that women’s concerns regarding postpartum quality of life and bodily integrity play a significant role in the decision-making process. Understanding the psychosocial and perceptual factors influencing birth preference is of critical importance, particularly in countries like Turkey where cesarean section rates are high. Misconceptions, gaps, or exaggerated perceptions regarding pelvic floor function may position cesarean section as a safer or more protective option, particularly among women without prior obstetric experience. The association between vaginal birth and pelvic organ prolapse has long been established, and it has been shown that factors such as multiparity, operative vaginal delivery, and advanced maternal age may contribute to weakened pelvic floor support(15,16) . However, current evidence indicates that pelvic floor dysfunction is a multifactorial process and cannot be explained by mode of delivery alone(17) . Nevertheless, it has been reported that there is a widespread perception among women that vaginal delivery causes permanent and inevitable damage to the pelvic floor(18) . This perception is shaped primarily by fears related to conditions such as pelvic organ prolapse, urinary incontinence, and loss of perineal integrity, and may influence the choice of delivery method. Similarly, in our study, it was demonstrated that the total level of fear related to the pelvic floor is an independent determinant of cesarean section preference. These findings support the notion that perceptions regarding pelvic floor function are shaped not only by biological risks but also through individual interpretations and expectations, and play a significant role in the childbirth decision-making process. In particular, the literature has shown that changes in pelvic floor support following vaginal delivery may be associated with an increased risk of urinary incontinence. However, current evidence indicates that cesarean delivery does not completely eliminate this risk and that pelvic floor dysfunction arises from the interaction of numerous factors, including age, genetic predisposition, connective tissue characteristics, and lifestyle(19) . Nevertheless, there is a widespread perception among women that vaginal delivery poses a significant and inevitable risk for urinary incontinence, and this perception can be a major determinant in the choice of delivery method. Indeed, some studies have reported that the fear of developing urinary incontinence is one of the primary factors driving the preference for cesarean delivery(20) . Similarly, in the present study, it was found that the level of fear regarding urinary incontinence was significantly higher in the group opting for cesarean delivery, and this finding supports the notion that perceptions regarding pelvic floor function play a significant role in the decision-making process regarding delivery. The relationship between sexual dysfunction and mode of delivery has long been debated in the literature; in particular, it has been suggested that trauma to the pelvic floor muscles, neural structures, and perineal tissues that may occur during vaginal delivery could affect sexual function in the postpartum period(21) . However, current evidence indicates that this relationship is inconsistent and that sexual function is shaped not only by mode of delivery but also by the interaction of numerous variables such as hormonal changes, psychosocial factors, partner relationships, and individual perceptions(22) . In our study, it was found that fear of sexual dysfunction did not show a significant association with birth preference. This suggests that concerns regarding sexual function are not the sole determining factor, and that somatic and more directly perceivable risks—such as urinary incontinence and perineal integrity—may play a more prominent role in the choice of delivery method. Perineal integrity is of central importance for women’s body image and functional well-being in the postpartum period. Stretching, tearing, or surgical interventions (such as episiotomy) that may occur in the perineal tissues during vaginal delivery can lead to short- and long-term anatomical changes; this is associated in the literature with pelvic floor support and perineal structure(23) . However, the occurrence of perineal injury and its clinical manifestations are not limited solely to the mode of delivery; they are determined by the interaction of various factors, including obstetric interventions, fetal characteristics, and individual tissue properties. Nevertheless, there is a significant concern, particularly among women without prior childbirth experience, that permanent deformation may develop in the perineal region, and it is believed that this concern may influence childbirth preferences(24) . In the current study, the fact that fear of perineal deformity showed significant differences across childbirth preference groups and was particularly higher in the undecided group suggests that this concern may act as a factor increasing uncertainty in the decision-making process. This finding suggests that perceptions regarding perineal integrity may be related not only to expectations regarding physical outcomes but also to more complex cognitive processes such as concerns about loss of control and permanence. However, the low level of explanatory power in the ROC analysis (R²=0.056) indicates that the factors determining birth preference are not limited to pelvic floor fears alone . This finding reflects the complex and multidimensional nature of the processes shaping birth preferences, suggesting that cultural norms, health system dynamics, and individual experiences also play significant roles in this decision-making process. In this context, it is understood that fears related to the pelvic floor are not sufficient predictors on their own but should be evaluated as part of a broader psychosocial framework. Conclusion Pelvic floor–related fears are an independent determinant of delivery mode preference in primigravid women, highlighting the role of perception-driven factors beyond obstetric indications. Integrating structured antenatal counseling targeting these concerns may offer a modifiable strategy to reduce non-medically indicated cesarean rates. Author Contributions All authors contributed to all stages of the study, critically revised the manuscript, and approved the final version. Funding No financial support was received for this study. Ethics Statement Ethical approval was obtained for this study. (No:699 Date:07.11.2025) Conflicts of Interest The authors declare that they have no conflicts of interest. 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Keywords delivery: birth trauma delivery: breech delivery: caesarean section delivery: perineal care genitourinary medicine psychosexual medicine urogynaecology Authors Affiliations Gamze KARABABA 0000-0002-0210-5135 TC Saglik Bakanligi Silvan Dr Yusuf Azizoglu Devlet Hastanesi View all articles by this author Yusuf BASKIRAN [email protected] Liv Hospital View all articles by this author Kazım UCKAN Van Yuzuncu Yil Universitesi View all articles by this author Metrics & Citations Metrics Article Usage 158 views 83 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Gamze KARABABA, Yusuf BASKIRAN, Kazım UCKAN. Pelvic floor-related fears and preference for mode of delivery in primigravid women: a cross-sectional study. Authorea . 06 April 2026. DOI: https://doi.org/10.22541/au.177549700.09049465/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. 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