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The Journal of Perinatal Education logoLink to The Journal of Perinatal Education
. 2015;24(2):93–101. doi: 10.1891/1058-1243.24.2.93

Childbirth Education Prior to Pregnancy? Survey Findings of Childbirth Preferences and Attitudes Among Young Women

Joyce K Edmonds, Taylor Cwiertniewicz, Kathrin Stoll
PMCID: PMC4744342  PMID: 26957892

ABSTRACT

The childbirth preferences and attitudes of young women prior to pregnancy (N = 758) were explored in a cross-sectional survey. Sources of influential childbirth information and self-reported childbirth learning needs were described. Young women’s attitudes about childbirth, including the degree of confidence in coping with a vaginal birth, whether birth is considered a natural event, and expectations of labor pain were associated with their mode of birth preference. Conversations with friends and family were the most influential source of childbirth information. Gaps in knowledge about pregnancy and birth were identified. An improved understanding of women’s preferences and attitudinal profiles can inform the structure and content of educational strategies that aim to help the next generation of maternity care consumers participate in informed decision making.

Keywords: childbirth, preference, attitudes, cesarean birth, childbirth education, young women


Surgical obstetric interventions are now a routine part of the childbirth experience in the United States. The rate of cesarean surgeries, for instance, has increased more than 50%, from 20.7% in 1996 to 32.8% in 2011 (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013); and primary cesarean surgeries among nulliparous women are primarily responsible (Zhang et al., 2010). The current prevalence of cesarean surgery contributes to excess perinatal morbidity and mortality as well as significantly higher health-care costs compared to vaginal births (Clark et al., 2008; Gibbons et al., 2010; NIH State of the Science Conference, 2006). Clinical indications and demographic characteristics, many of which are immutable, have not fully accounted for the extent of the prevalence in cesarean surgery rates. One potentially modifiable factor involves women’s preferences for elective interventions in the absence of medical indications. Although the impact of maternal request on cesarean surgery rates is widely contested (McCourt et al., 2007), the childbirth preferences of women, as discussed in the literature on autonomy and shared decision making, are thought to play an important role in obstetric decision-making processes both prenatally and during labor (Dugas et al., 2012; Gee & Corry, 2012; Quiroz, Blomquist, Macmillan, McCullough, & Handa, 2011). Furthermore, the importance of listening to women’s preferences has been affirmed by professional guidelines and the general public and is inherent in national public health goals to improve maternal health (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2014; Goldberg, 2009; Haines, Rubertsson, Pallant, & Hildingsson, 2012; U.S. Department of Health and Human Services, 2011). However, what is known about women’s childbirth preferences has primarily been elicited during pregnancy or in the postpartum period. Few studies have examined the childbirth preferences and underlying attitudes of young women in the United States prior to their first pregnancy, when childbirth education has the potential to inform and influence future maternity care decisions.

This study was conducted with traditional (full time, <24 years of age, reside on campus) college-aged students, who were nearing the age at which childbirth is most likely to occur. The average age of first birth in the United States is 25.6 years, and the highest birth rates occur in women 25–29 years of age (Martin et al., 2013). The four study aims of this cross-sectional, descriptive study were to (a) describe childbirth preferences and attitudes, (b) assess the relationship between childbirth attitudes and mode of birth preference, (c) determine sources of influential information about childbirth, and (d) determine the self-reported childbirth-related learning needs. Attitudes were conceptualized as the degree to which young women had a favorable or unfavorable evaluation or appraisal of the behavior or subject matter in question (Ajzen, 1991). And, simply stated, expressed preferences were equated with choice.

METHODS

Quantitative and qualitative data from a self-administered, Web-based survey hosted by Qualtrics from March 13, 2013 to April 30, 2013 were collected. This study was publicized via posters, flyers, and e-mail messages that included the survey link. Students were given information on the purpose of the survey, with an emphasis on confidentiality and anonymity. Respondents consented to participate by clicking the “agree” button at the end of the informed consent. To maintain respondent anonymity, a separate survey, accessible only via the study survey, was used to collect the e-mail addresses of respondents who opted to register for the study incentive—an iPad. The Boston College Institutional Review Board approved the study.

The survey instrument consisted of 4 sections and 70 questions. Section 1 included questions about sociodemographic and reproductive goals. Section 2 inquired about childbirth preferences (mode of birth, pain relief, provider type, place of birth, and breastfeeding). Open-ended questions sought explanations to stated childbirth preferences. Respondents were asked to comment, for example, on why they preferred vaginal birth or cesarean surgery. Section 3 comprised items to assess childbirth attitudes, including confidence in and fear of vaginal birth. Respondents were asked whether they agreed or disagreed with a series of 27 statements. The items were combined into the Childbirth Attitudes Scale (CAS) with five Likert scale response options anchored from 1 (strongly disagree) to 5 (strongly agree). The CAS was developed in a previous study among university students and was shown to have a high internal consistency (Cronbach’s alpha = 0.88). A more detailed description of the survey and scale development is published elsewhere (Stoll et al., 2009). Questions in Section 3 also inquired about sources of influential information shaping respondents reported attitudes toward childbirth. In the last section, respondents were asked to assess their need for information on seven predetermined topic areas and to identify additional topics to include in an educational workshop.

Sample and Setting

This study was conducted at a private university located in an urban area of the northeastern United States. There were 897 students who arrived at the survey welcome page, who viewed the consent information, and who agreed to participate. Enrolled students who were not pregnant at the time of the survey and who had no children were eligible to participate. Students who were not planning on having children in the future or who did not answer the question about birthing mode preference were excluded from the analyses. The final analytical sample consisted of 758 students, representing approximately 16% of the total eligible population (female undergraduate students). Although there was minimum participant dropout over the course of the survey, the sample size did vary somewhat by question. The denominators used to calculate percentages are noted in the data tables.

Data Analysis

Descriptive statistics were calculated for all variables. To simplify the analysis, responses to the CAS were reduced into three categories (comprising the responses “agree,” “neutral,” “disagree”). Chi square was used to test and evaluate the associations with each of the CAS items and mode of birth preference. A summative CAS scale was created, and a one-way analysis of variance (ANOVA) was calculated to compare the mean scores with mode of birth preference. Ranking (1 = most influential to 6 = least influential) of information sources that influenced respondents’ attitudes toward childbirth were weighted based on frequency of response per rank. Multiplicity adjustments were not made because of the exploratory nature of this study. A p value of <0.05 was considered statistically significant. SPSS for Mac version 20 (IBM) was used for all analysis. A simple content analysis was conducted on respondents’ written comments to the open-ended question inquiring about reasons for mode of birth preferences. Both authors cut and sorted the comments manually to identify repetitions, similarities, and differences. Exemplar quotes were pulled out. Meta themes were identified; the themes were then coded and the frequencies calculated.

RESULTS

Sample Characteristics

The age of respondents ranged from 18 to 24 years with a mean age of 20 (SD = 1.34) years. Most young women anticipated having two or more children either between 25–29 or 30–34 years of age. A broad range of academic disciplines was represented, including the arts and sciences (55.1%), nursing (21.2%), education (12.3%), and business/management (10.9%). Respondents reported their relationship status as either single (57.9%), in a committed relationship (30.5%), or dating (11.6%). Most respondents identified their race and ethnicity as non-Hispanic White. See Table 1.

TABLE 1. Characteristics of Survey Respondents (N = 758).

Characteristic n (%)
Age (years)
18–21 626 (82.6)
22–24 132 (17.4)
Race
Asian 77 (10.2)
Black or African American 32 (4.2)
White 564 (74.4)
Multiracial 51 (6.7)
Other 19 (2.5)
Unknown/decline 15 (2)
Hispanic, Latina, or Spanish origin
Yes 86 (11.3)
No 664 (87.6)
Unknown/decline 8 (1.0)
Relationship status
Committed relationship 231 (30.5)
Dating 88 (11.6)
Single 439 (57.9)
Intended number of children
<2 27 (3.6)
2 288 (38.0)
>2 443 (58.4)
Intended age of having first child (years)
20–24 13 (1.7)
25–29 447 (59.0)
30–34 292 (38.5)
35–39 6 (0.8)

Childbirth Preferences

Table 2 presents respondents’ childbirth preferences (mode of birth, provider type, place of birth, pain relief, and breastfeeding intention). Vaginal birth was preferred by 86.3% of respondents, and 13.7% reported a preference for cesarean surgery. Many respondents (45.3%) preferred an obstetrician for their maternity care provider, whereas 33.1% reported not knowing enough to make a decision about the type of childbirth provider. A large majority (93%) indicated that they would choose a hospital as their place of birth. A mixed pattern of responses to preferences about pain relief during childbirth was provided. More than half of respondents (57.7%) preferred “the minimum quantity of drugs to keep the pain manageable,” whereas 31.7% chose the “the most pain-free labor that drugs can give me,” and 9.6% chose “to have a completely drug-free labor.” Most respondents (69.7%) reported an intention to breastfeed.

TABLE 2. Childbirth Preferences (N = 758).

Preference n (%)
Childbirth provider
Family physician 55 (7.3)
Midwife 66 (8.7)
Obstetrician 343 (45.3)
I don’t know enough to make a decision. 251 (33.1)
I am indifferent. 39 (5.1)
Other 4 (0.5)
Place of birth
Hospital 705 (93.0)
Birth center 36 (4.7)
Home 11 (1.5)
Other 6 (0.8)
Pain relief during labor and birth
The most pain-free labor that drugs can give me 238 (31.7)
The minimum quantity of drugs to keep the pain manageable 433 (57.7)
Willing to put up with quite a lot of pain to have a completely drug-free labor 72 (9.6)
Other 7 (0.9)
Birthing mode
Vaginal 654 (86.3)
Cesarean 104 (13.7)
Breastfeeding intention
Yes 528 (69.7)
Maybe 200 (26.4)
No 27 (3.6)

Note. Missing values: pain relief (8), breastfeeding intention (3).

Analysis of the reasons for mode of birth preferences revealed three themes for vaginal birth and two themes for cesarean surgery (themes described by at least 10% of respondents are reported here; see Tables 3 and 4 for additional themes). Among the 539 respondents who provided a reason for their vaginal birth preference, 70% considered it to be the “traditional,” “natural,” or “normal” route, and 40% wanted to avoid major surgery and the associated pain, scarring, and recovery time. Another reason for preferring vaginal birth was the perception that this mode is safer and healthier (cited by 16.6% of students). The most frequently reported reasons, among the 84 respondents who provided a reason for their cesarean surgery preference, were fear of vaginal birth and the desire to avoid labor pain (45.2%), followed by a desire to avoid changes to the body that young women associate with vaginal birth (19%).

TABLE 3. Reasons for Preferring Vaginal Birth (n = 539).

Theme n (%) Exemplar Quotes
Vaginal births as a traditional or natural way to give birth 336 (65.9)
  • “I believe it is the traditional way to have a child.”

  • “Our bodies are made for the birthing process.”

  • “. . . I would rather feel the natural process of childbirth . . . ”

Avoidance of major surgery (e.g., pain, scarring, and recovery time) 215 (39.8) “A C-section is a major surgery that would be much more painful and harder to recover from than a vaginal birth.”
Vaginal births as a healthier and safer way to give birth 90 (16.6) “Healthier for both mom and baby”
Other
Family history of vaginal births 12 (2.2) “My family has always had vaginal deliveries.”
To avoid future cesarean surgeries 8 (1.5) “I’ve heard that C-sections complicate future births; once you have a C-section, all births must be C-sections.”

Note. The percentages do not add up to 100% because more than one theme was assigned to respondents who offered more than one reason for their preference.

TABLE 4. Reasons for Preferring Cesarean Surgery (n = 84).

Theme n (%) Exemplar Quotes
Fear of vaginal birth and avoidance of pain 38 (45.2) “There is less pain involved in the [cesarean] delivery.”
To avoid changes to the body 16 (19.0) “Honestly, I don’t want my body to really change.”
Other
Family history of cesarean surgeries 5 (6.0) “My mother had it [cesarean delivery] for both myself and my sister.”
Cesarean surgeries are safer 4 (4.8) “I believe this [cesarean delivery] is safer and poses less risks to child and to the mother than a vaginal delivery.”
Too small/petite for a vaginal birth 3 (3.6) “I’m only 5′10 with a very small frame. I think that a C section would be a better option, given my size.”

Note. The percentages do not add up to 100% because more than one theme was assigned to respondents who offered more than one reason for their preference.

Childbirth Attitudes

Table 5 presents a selection of items from the CAS, stratified by mode of birth preference. The mean score on the CAS was 60.10 (SD = 6.5) with scores ranging from 44 to 77 out of a possible 81. Higher scores on the scale indicate greater agreement or more positive attitudes toward childbirth and specifically vaginal birth. The mean score for young women preferring a vaginal birth was 61.30 (SD = 5.7) compared with 52.36 (SD = 5.9) for women preferring cesarean surgery. The one-way ANOVA reached significance, F (1, 742) = 206.07, p < .01, with scores significantly lower among respondents preferring cesarean surgery compared to those preferring a vaginal birth. Reliability analysis revealed a Cronbach’s alpha of 0.79.

TABLE 5. Selected Childbirth Attitude Scale Item Percentages Stratified by Mode of Delivery Preference (n = 734).

Childbirth Attitude Statement Mode of Delivery Preference
Response Total Vaginal Cesarean p
I believe I will have enough confidence to give birth vaginally. Disagree 9.7 3.6 49 <.001
Neutral 11.7 9.7 24.5
Agree 78.6 86.6 26.5
Childbirth is a good healthy pain. Disagree 17.7 12.7 50.0 <.001
Neutral 29.0 29.9 23.5
Agree 53.3 57.4 26.5
I am worried that labor pain will be very intense. Disagree 3.4 3.6 2.0 .053
Neutral 7.6 8.5 2.0
Agree 89.0 87.9 95.9
I think I will be able to handle the pain of childbirth. Disagree 13.2 9.3 38.8 <.001
Neutral 23.8 23.1 28.6
Agree 62.9 67.6 32.7
I am fearful of the labor process. Disagree 19.0 20.5 9.2 <.001
Neutral 16.6 18.1 7.1
Agree 64.4 61.4 83.7
I would prefer to avoid the pain of childbirth by having a cesarean delivery. Disagree 68.5 78.9 1.0 <.001
Neutral 17.8 17.8 18.4
Agree 13.6 3.3 80.6
Labor pain is a necessary part of the labor process Disagree 16.2 12.7 38.8 <.001
Neutral 25.6 25.0 29.6
Agree 58.2 62.3 31.6
I feel that my body is able to successfully birth a child. Disagree 4.5 3.1 13.3 <.001
Neutral 14.3 11.8 30.6
Agree 81.2 85.1 56.1
A woman’s body recovers faster from a cesarean birth compared to a vaginal birth. Disagree 47.7 48.9 39.8 <.001
Neutral 47.5 47.8 45.9
Agree 4.8 3.3 14.3
Childbirth is inherently risky. Disagree 14.5 15.1 10.2 .128
Neutral 17.9 18.6 13.3
Agree 67.6 66.2 76.5
The surgical procedure involved in a cesarean section does not worry me. Disagree 65.5 68.7 44.9 < .001
Neutral 12.5 12.3 14.3
Agree 21.9 19.0 40.8
I believe that the process of pregnancy and birth is a transforming experience for women. Disagree 3.8 3.5 6.1 .003
Neutral 12.9 11.5 22.4
Agree 83.2 85.1 71.4
I don’t think I would be embarrassed by a vaginal birth. Disagree 12.7 9.7 31.6 <.001
Neutral 13.9 13.1 19.4
Agree 73.4 77.2 49.0
Childbirth is a normal process. Disagree 0.7 0.2 4.1 <.001
Neutral 3.8 3.3 7.1
Agree 95.5 96.5 88.8

Note. Data are in column %, items reverse scored.

Overall, the young women surveyed agreed that childbirth is a normal process (95.5%), that childbirth is a transformational experience (83.2%), and that their bodies are able to successfully birth a child (81.2%). Most young women were worried about the intensity of labor pain (89%). Their perception of the pain, their confidence in their ability to handle the pain, and their fear of the labor process all significantly varied by their birthing preference. Young women who preferred vaginal birth were more likely to select responses that reflect confidence in their ability to manage childbirth and an acceptance of labor pain than women who preferred cesarean surgery. In contrast, the response pattern of young women who preferred cesarean surgery reflects lower self-efficacy in the ability to cope with vaginal birth, fear of labor pain, and acceptance of surgical birth. For instance, 67.6% of women who preferred a vaginal birth agree that they would “be able to handle the pain of childbirth” versus 32.7% who preferred cesarean surgery. There were no significant differences by mode of birth preference in women’s attitudes toward the role of technology in childbirth and perceptions of the risk inherent in childbirth.

Sources of Information and Influence

The mean ranks of influential childbirth information sources ranged from 1.9 (most influential) to 5.5 (least influential) among the 702 respondents who ranked. Conversations with friends and relatives were ranked as the most influential source of information with a mean score of 1.9 (SD = 1.3), followed by watching television or movies (M = 3.6, SD = 1.8). Health education classes in primary or secondary school (M = 4.2, SD = 1.8), browsing the Internet (M = 4.3, SD = 1.5), and reading books (M = 4.4, SD = 1.5) had similar rankings. Obtaining information from health-care providers (M = 4.6, SD = 1.5) and witnessing a live birth (M = 5.5, SD = 2.3) were ranked as the least influential sources of information about childbirth. It is noteworthy that a post hoc analysis among the 153 (21%) students who reported witnessing a live birth revealed that witnessing a live birth was the most influential source of childbirth information, followed by conversations with friends and family.

Learning Needs

Nearly half (45.3%) of students reported a lack of confidence in their level of knowledge about pregnancy and childbirth, and 56.1% desired more information. The process of labor and birth and the risks and benefits of common obstetric interventions were prioritized as learning needs among those desiring more information. Preparation and involvement of partners, postpartum health, infertility, pregnancy, mental health, breastfeeding, and pregnancy prevention were among the most common responses to the open-ended question requesting additional topics to include in an educational workshop.

LIMITATIONS

A major limitation of this study is that it is derived from a voluntary, nonrandom sample of college students at one private university in the northeast United States, which may limit generalization of our results to other populations. Because of self-selection bias, student respondents may have a greater interest in childbirth than nonrespondents. Responses from populations of young women who are not traditional college students are also likely to differ. Further, the degree to which women’s childbirth preferences expressed prior to pregnancy are consistent with actual decisions made during labor and birth is unknown. Preferences are known to be sensitive to context and depend on the changing goals, cognitive constraints, and experiences of the decision maker (Warren, McGraw, & Van Boven, 2011). Despite these limitations, the results provide useful information about childbirth preferences and attitudes of young women prior to pregnancy and childbirth that, in combination with previous findings, can be used to generate hypotheses for future research and inform childbirth education strategies.

DISCUSSION

Most young women in this study report a preference for vaginal birth attended by a physician in a hospital. However, the proportion of young women who prefer surgical birth and a completely pain-free labor signals a predisposition toward surgical and medical interventions in childbirth or a greater willingness to accept interventions in the absence of specific obstetric indications. Approximately 14% of student respondents preferred cesarean surgery, absent of any known clinical indications. This rate is comparable to the 13% reported by Lampman and Phelps (1997) in a seminal study of 102 college students in Alaska, and the 12.5% reported by Gallagher, Bell, Waddell, Benoît, and Côte (2012) in a sample of 140 young Canadian women. The rate is higher than the 9% reported by Stoll et al. (2009) in a study of 3,680 college students in British Columbia. The similarity in cesarean surgery preference rates with the Lampman sample, despite a 15-year gap, suggests that preferences for cesarean surgery may be stable among young adults in the United States.

Our data suggest that fear of vaginal birth and a desire to avoid labor pain are the main reasons for electing cesarean surgery, corroborating the results of Cleeton (2001), DeJoy (2010), and Stoll and colleagues (Stoll et al., 2009; Stoll, Hall, Janssen, Carty, 2014). Although some young women associate vaginal birth with labor pain, they may not be considering the acute and potentially chronic postpartum pain associated with major abdominal surgery (Declercq, Cunningham, Johnson, & Sakala, 2008). Of women who preferred cesarean surgery, 14.3% agreed that recovery is faster for a cesarean compared to a vaginal birth, and close to 50% of overall respondents were neutral, suggesting a gap in knowledge. Awareness of the longer recovery times and postpartum pain associated with cesarean surgery might reduce young women’s expressed preferences for this surgical route of birth. Information about abdominal scarring might also deter cesarean preferences. Specific strategies to help reduce fear of childbirth and address concerns about labor pain, such as mindfulness-based childbirth education (Byrne, Hauck, Fisher, Bayes, & Schutze, 2014), are needed.

Regarding the choice of a maternity care provider, young women reported considerable uncertainty or lack of knowledge about provider options, revealing a potential opportunity to influence future decisions. Selecting a maternity care provider is one of the first choices a woman will make after confirming a pregnancy for the first time. Choice of care provider is associated to both preferences for interventions (Fairbrother, Stoll, Carty, & Schummers, 2012) and actual rates of interventions received (Janssen et al., 2009). Low-risk women who choose to see physicians during pregnancy have more obstetric interventions compared to women who are cared for by midwives (Janssen et al., 2009). In a study of 3,680 Canadian university students, a preference for obstetricians was linked to a higher likelihood of preferring cesarean surgery over vaginal birth and for wanting epidural anesthesia for relief of labor pain (Fairbrother et al., 2012). The next generation of maternity care consumers might benefit from knowing about different models of maternity care and the association between obstetric intervention rates and maternity provider type. In this survey, only 8.1% had a preference for a midwife, compared to 30% of young women in a Canadian study of maternity care provider preferences among university students (Fairbrother et al., 2012). Public opinion toward midwives and support for midwifery in the two countries could account for the observed difference. Future cross-cultural comparisons are warranted.

Another significant finding from this study was the relationship between young women’s attitudes toward childbirth and their mode of birth preferences. According to the theory of planned behavior, attitudes together with social norms shape intentions, which in turn predict behavior (Ajzen, 1991). Our study found a significant association between childbirth attitudes and women’s mode of birth preference, congruent with the theory’s link between attitudes and behavioral intentions. We found that young women’s attitudinal profiles about childbirth differ according to their preference of birthing mode. Further research is needed to determine the salience of young women’s attitudes toward childbirth and the degree to which their attitudes are modifiable and predict actual outcomes. Existing evidence does indicate that actual use of obstetric interventions, chosen or accepted, is partially determined by women’s attitudes about birth (Green & Baston, 2007; Haines et al., 2012).

Conversations with friends and relatives were cited as the main influence shaping young women’s attitudes about the labor and birth process, substantiating results from previous studies (Carter et al., 2010; Munro, Kornelsen, & Hutton, 2009). This finding suggests that the primary communication channels through which childbirth information is conveyed to young women lay outside the formal health-care system. For this reason, interventions that seek to positively influence childbirth attitudes in young women may be most successful if they consider the informal social norms that are often transmitted through the birth stories of family and friends (Munro et al., 2009).

Although health-care providers were ranked as one of the least influential sources of information about childbirth, they retain a professional responsibility to provide preconception health counseling to all women of reproductive age (American College of Obstetricians and Gynecologists, 2005). A Healthy People 2020 objective seeks to increase the proportion of childbearing women who discussed preconception health with a health-care worker prior to pregnancy (U.S. Department of Health and Human Services, 2011). Current preconception counseling recommendations suggest that only women with a prior cesarean be counseled about mode of birth options (Jack et al., 2008). Preconception counseling for all women should involve assessment of childbirth preferences and include education about the risks and benefits of common obstetric interventions, including cesarean surgery.

IMPLICATIONS FOR PRACTICE

A summary of recommendations for childbirth educators, derived from the study results, is provided in Table 6. Our study findings suggest that young women have knowledge deficits and want to learn more about childbirth. We suggest that educational content focus on the physiology and normality of vaginal birth, and on medical indications, risks, and benefits associated with different obstetric interventions, to help women critically evaluate their birth preferences and the risks and benefits of their choices. Young women should be made aware that use of cesarean surgery is best reserved for women who have a clinical need for the procedure because cesareans have consequences for future pregnancies (Lee & D’Alton, 2008) and are associated with significant postpartum pain and functional impairment (Declercq et al., 2008). A decision-making tool to elicit women’s preferred birthing method is a promising intervention that could be readily adopted to facilitate informed decision making (Milne et al., 2009).

TABLE 6. Suggestions for Childbirth Education for Young Women Prior to Pregnancy.

  • Deliver childbirth education well in advance of the first pregnancy and birth.

  • Increase awareness of consequences of cesarean surgery (e.g., longer recovery time, postpartum pain, abdominal scarring).

  • Address fear of childbirth and concerns about labor pain.

  • Provide information on different models of maternity care including the association between obstetric interventions and type of maternity provider.

  • Consider the influence of birth stories transmitted from family and friends.

  • Focus on the physiology and normality of vaginal birth and on medical indications, risks, and benefits associated with different obstetric interventions.

  • Reinforce the notion that a low-interventionist labor followed by a vaginal birth is the healthiest and best option for most childbearing women.

Findings from this study and a similar Canadian study (Fairbrother, Stoll, Schummers, & Carty,2013) suggest that attitudes toward obstetric interventions, including cesarean surgery, precede pregnancy. For this reason, we recommend that childbirth education be delivered well in advance of a young woman’s first birth, when views on maternity care are being established and there is potential to reinforce the notion that a low-interventionist labor, followed by a vaginal birth, is the healthiest and best option for most childbearing women. Although a Cochrane review found that the effects of general prenatal education are unknown and that specific educational strategies for reducing cesarean surgery rates was ineffective (Gagon & Sandall, 2007), no studies have evaluated the delivery of childbirth education prior to pregnancy. Further research is needed to assess the impact of specific childbirth education prior to pregnancy.

CONCLUSION

Our study provides an assessment of the prevalence of birth preferences and attitudes among a contemporary cohort of young women prior to their first birth in the United States. Findings support a relationship between childbirth attitudes and preferred mode of birth among young women, and identify conversations with friends and family as the most important influence on childbirth attitudes. Data from this study can be used to design the structure and content of educational strategies that aim to promote informed decision making about use of obstetric interventions in young women.

Biographies

JOYCE K. EDMONDS is an assistant professor at Boston College, William Connell School of Nursing. She is a certified public health nurse with experience in domestic and global maternal and child health programs.

TAYLOR CWIERTNIEWICZ was an undergraduate research fellow at Boston College, William Connell School of Nursing and is currently a graduate student at University of California Irvine.

KATHRIN STOLL has degrees in psychology and sociology and completed an interdisciplinary doctor of philosophy degree (epidemiology, midwifery, nursing) in 2012. Her program of research is focused on optimizing maternal and newborn health by identifying clinical, psychosocial, geographic, and systemic factors that are associated with adverse perinatal outcomes.

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