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Preference for cesarean section in young nulligravid women in eight OECD countries and implications for… Stoll, Kathrin H; Hauck, Yvonne L; Downe, Soo; Payne, Deborah; Hall, Wendy A Sep 12, 2017

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RESEARCH Open AccessPreference for cesarean section in younght OECD countriesConclusion: Education sessions delivered online, through social media, and face-to-face using drama and stories tolds to beStoll et al. Reproductive Health  (2017) 14:116 DOI 10.1186/s12978-017-0354-xBritish Columbia, 2206 E Mall, Vancouver, BC V6T 1Z9, CanadaFull list of author information is available at the end of the article* Correspondence: kstoll@alumni.ubc.ca1School of Population & Public Health & Division of Midwifery, University ofof control. The most efficacious designs and content for such education for young women and girls remaintested in future studies.Keywords: Cesarean, Women, Fear, Knowledge, Learning needs, Surveyby peers (young women who have recently had babies) or celebrities could be designed to maximize young women’scapacity to understand the physiology of labor and birth, and the range of methods available to support them incoping with labor pain and to minimize invasive procedures, therefore reducing fear of pain, bodily damage, and lossincreased.and implications for reproductive healtheducationKathrin H. Stoll1*, Yvonne L. Hauck2, Soo Downe3, Deborah Payne4, Wendy A. Hall5 and International ChildbirthAttitudes- Prior to Pregnancy (ICAPP) Study TeamAbstractBackground: Efforts to reduce unnecessary Cesarean sections (CS) in high and middle income countries have focusedon changing hospital cultures and policies, care provider attitudes and behaviors, and increasing women’s knowledgeabout the benefits of vaginal birth. These strategies have been largely ineffective. Despite evidence that women havewell-developed preferences for mode of delivery prior to conceiving their first child, few studies and no interventionshave targeted the next generation of maternity care consumers. The objectives of the study were to identify howmany women prefer Cesarean section in a hypothetical healthy pregnancy, why they prefer CS and whether womenreport knowledge gaps about pregnancy and childbirth that can inform educational interventions.Methods: Data was collected via an online survey at colleges and universities in 8 OECD countries (Australia, Canada,Chile, England, Germany, Iceland, New Zealand, United States) in 2014/2015. Childless young men and womenbetween 18 and 40 years of age who planned to have at least one child in the future were eligible to participate. Thecurrent analysis is focused on the attitudes of women (n = 3616); rates of CS preference across countries are compared,using a standardized cohort of women aged 18–25 years, who were born in the survey country and did not studyhealth sciences (n = 1390).Results: One in ten young women in our study preferred CS, ranging from 7.6% in Iceland to 18.4% in Australia. Fearof uncontrollable labor pain and fear of physical damage were primary reasons for preferring a CS. Both fear ofchildbirth and preferences for CS declined as the level of confidence in women’s knowledge of pregnancy and birthnulligravid women in eig© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.women would prefer CS, ranging from 7.6% in IcelandStoll et al. Reproductive Health  (2017) 14:116 Page 2 of 9to 18.4% in Australia. Fear of labour pain and fear ofphysical damage were the most common reasons whyyoung women prefer CS. In addition to childbirth fear,young women who preferred CS reported several know-ledge gaps and misperceptions about childbirth that canbe addressed through education. While findings fromthe current study can inform educational programming,the best way to deliver education about pregnancy andbirth to young women (and men) remains to be tested.BackgroundGlobally, an estimated 6.2 million unnecessary cesareansections (CS) are performed each year, at an approxi-mate cost of 2.3 billion US dollars [1]. Data from 194countries indicates that a CS rate above 19% is associ-ated with higher maternal and neonatal mortality [2]. Inanother study of 159 countries, no decreases in maternalor infant mortality were observed with CS rates above10% [3]. These findings indicate that a CS rate between10 and 19% is optimal; however, all OECD countriesexceed the lower limit of this range, and almost all ex-ceed the higher limit [4].Differences in CS rates across countries have been attrib-uted to a range of factors, including case mix, financialincentives, fear of malpractice litigation, differences in theavailability and training of midwives and nurses, access toout-of-hospital birth options, and the proportion of womenwho access private maternity care [5–7]. Many strategieshave been tested to reduce the number of unnecessarycesarean sections. These include active management ofPlain English SummaryCesarean section rates in most high and middle-incomecountries are higher than recommended and continue toincrease. Many strategies have been tested, to reducerates of Cesarean sections, such as educating cliniciansand patients about the benefits of vaginal birth, and therisks of unnecessary Cesarean sections, and ensuringthat physicians seek a second opinion before proceedingwith surgery. Most of these strategies are not linked tosizable reductions in Cesarean section rates.In this paper we argue that interventions aimed atreducing the Cesarean section rate should begin beforewomen and men become parents, because attitudes to-wards birth are developed in advance of pregnancy andmight be influenced by modifiable factors such as child-birth fear and lack of knowledge of pregnancy and birth.We studied young women from 8 OECD countries, tobetter understand how many would prefer a Cesareansection in a healthy pregnancy, why and whether prefer-ences vary across countries. We found that 1 in 10labor [8] continuous labor support [9], mode of deliverydecision-aids and information for pregnant women [10, 11]and mandatory second opinions [12]. These and otherstrategies have been largely ineffective [8, 13].Recently, psychological indications for cesarean sectionhave gained recognition. In particular, fear of childbirthis linked to a preference for CS during pregnancy and/orgiving birth via CS, even in the absence of medical indi-cations [14–17]. For example, Ryding et al. [18] surveyedover 6000 childbearing women across 6 European coun-tries; they found that 16.7% of first time mothers and31.7% of multiparas with severe fear of childbirth had aCS without medical indications (compared to 4.6% and17.5% of women without severe fear of birth). The linkbetween childbirth fear and preferences for CS overvaginal births has also been observed among youngwomen from Canada and the United States (US) whoplan to become pregnant [19, 20].Given the iatrogenic morbidities and increased costassociated with unnecessary CS [1], the limited effective-ness of strategies aimed at care providers, pregnantwomen and institutional structures, and evidence ofwell-developed birth preferences expressed by youngwomen prior to pregnancy, the objectives of this studywere to examine 1) preferences for Cesarean section in ahypothetical healthy pregnancy among young womenfrom 8 OECD countries, 2) reasons for this preferenceand 3) knowledge gaps and misperceptions about preg-nancy and birth among young women that can informeducational strategies.MethodsWe recruited childless women and men between theages of 18–40 years from different OECD countries.Data were collected via online survey at ten universitiesand colleges in eight countries between 2014 and 2015.At each institution, an invitation to the survey was eithersent to all students at the university or a subsample ofstudents. For example, at Curtin University in WesternAustralia the survey invitation was sent to 8000 domes-tic students, which constitutes 15% of the total studentbody. At the University of Iceland the invitation was sentto all enrolled students (N = 9805). In Germany, twouniversities participated. At Hannover Medical Schoolall 3130 students were invited and at the University ofBamberg all 12,800 students received the invitation. Stu-dents were directed to the consent form once theyclicked on the survey link. The consent form describedthe purpose of study, how anonymity would be pre-served and the consent process, i.e. by starting the sur-vey students consented to participate in the study. Ethicsapproval for the study was granted by the Behavioral Re-search Ethics Board at the University of British Columbia,Canada (H14–00033) and by institutional review boards atall participating universities and colleges, with the exceptionof the University of Northern British Columbia (UNBC).Data collection at UNBC was covered by the original ethicsapproval.Students completed an online questionnaire with 5sections: 1) Socio-demographic questions, 2) birth prefer-ences and reasons for preferences, 3) attitudes towardsbirth, 4) vicarious experiences with childbirth and sourcesof information that shaped students’ attitudes towardspregnancy and birth, 4) psychological profile (depression,anxiety, stress and childbirth fear) and 5) learning needs/knowledge gaps about pregnancy and childbirth (see Table1 for sample items). Depression, anxiety and stress weremeasured with the 21-item short form of the DASS scale(7 items per construct) [21]. Internal consistency reliabilityof the DASS-21 ranged from 0.91 among Canadianwomen in our study to 0.95 among women from the UK.Subscale alphas ranged from 0.83–0.89 for the stresssubscale, 0.68–0.83 for the anxiety subscale and 0.87–0.92construction and psychometric testing of the DASS-21 andChildbirth Fear Prior to Pregnancy (CFPP) scale are de-scribed elsewhere [22].Students were asked if they would prefer a vaginal birthor Cesarean birth, assuming the pregnancy is low-risk andthey could choose the type of birth for their baby. Afterstudents marked their preference for either a Cesareanbirth or vaginal birth, they were directed to a list of rea-sons for their choice. These pre-defined response optionswere based on a thematic analysis of open-ended com-ments about mode of delivery preferences of 3680 Canad-ian students who completed the first version of the surveyin 2006 [23].We report rates of CS preference for all women whoresponded to the survey and met the eligibility criteria,i.e., they were 40 years of age or younger, not pregnantat the time of data collection, and expressed a desire toplreumr bagiisioliedicel ceyok alt sndfel taarStoll et al. Reproductive Health  (2017) 14:116 Page 3 of 9for the depression subscale. Fear of childbirth was mea-sured with a 10-item scale that was developed for thecross-country study, the Childbirth Fear Prior to PregnancyScale. The scale assesses childbirth fear along threedomains: 1) Fear of pain and being out of control (5 items),2) fear of complications (3 items) and 3) fear of physicaldamage (2 items). The six response options ranged fromstrongly disagree to strongly agree, with higher scores indi-cating increased fear. Internal consistency reliability of thescale ranged from 0.85 among women in the US to 0.89among women from NZ and Iceland. Subscale alphasranged from 0.83–0.87 for subscale 1, 0.74–0.83 for sub-scale 2 and 0.89–0.94 for subscale 3. The total scale scoreswere highly correlated with an established measure ofchildbirth fear across samples, supporting the construct val-idity/ convergent validity of the scale. Details about the re-cruitment, forward backward translation of surveys, scaleTable 1 Survey sections and sample itemsSurvey section SamSocio-demographic profile: age, field of study, country of origin WeBirth preferences and reasons for preferences: Preferred mode ofdeliveryPreferred prenatal care providerPreferred place of birthAssyoua vincAttitudes towards birth: Attitudes towards obstetric technologyand interventions, students’ level of confidence in knowledge ofpregnancy and birthI bemeI feExperiences with childbirth and sources of information thatshaped students’ attitudes towards pregnancy and birthHavDo(ticPsychological profile: DASS-21: Depression, Anxiety, StressCFPP scale: Childbirth fearI feI teI amI feI amI feLearning needs Please(tick ahave one or more children in the future. Because of veryheterogeneous response rates from men (ranging from35 who responded from the UK to 288 from Chile) weelected to focus our analysis on women only. Further, toaccount for differences in the age distribution, the num-ber of health sciences students at different universities,and the number of students born outside the surveycountry, we also report CS rates for a standardized co-hort of women aged 18–25, who were born in the surveycountry, and not enrolled in a health sciences program.To determine whether rates of CS preferences werelinked to country level rates we used Spearman’s rhocorrelational coefficient (rs).To examine whether childbirth fear was associatedwith preferences for CS, we entered the three childbirthfear domains of the CFPP scale in a logistic regressionmodel, with CS preference as the outcome (referencee itemsyou born in (survey country)?ing the pregnancy is low-risk and you could choose the type of birth foraby, would you prefer it to be:nal birth or a cesarean birth, i.e., a surgical birth of an infant through ann in the mother’s abdomen and uterus?ve it is a woman’s right to have a Cesarean birth, even if there are noal indications.onfident about my level of knowledge around pregnancy and birthyou ever been present for a real (human birth)?u feel that your attitudes towards pregnancy/birth were/are shaped byll that apply): visual media, written media, family, friends, school, other.cared without any good reason.ed to over-react to situations.earful of birth.hat I will not be able to handle the pain of childbirth.fraid that my body will never be the same again after birth.complications during labor and birthtell us what topics you would be most interested in learning aboutll that apply): See Table 5 for a list of response options.lows: Australia: 13.2%; Germany: 8.2%; Iceland: 12.0%Stoll et al. Reproductive Health  (2017) 14:116 Page 4 of 9and USA: 13.5%. A total of 4569 students started thesurvey, met eligibility criteria and answered the ‘mode ofdelivery preference’ question. After excluding 942 menwho responded to the survey and 11 who did not pro-vide data or preferred not to state their gender, the finalsample size for this analysis of female respondents was3616: 562 responses from Australia (15.5%), 202 fromCanada (5.6%), 377 from the USA (10.4%), 313 from theUnited Kingdom (8.7%), 850 from Germany (23.5%), 478from Iceland (13.2%), 484 from Chile (13.4%) and 350from New Zealand (9.7%). Age, field of study, and coun-try of origin differed significantly across countries(p < 0.001 for all comparisons).Overall, 10.8% of study participants expressed a prefer-ence for CS in a healthy future pregnancy, ranging from8.9% of students from in Canada to 16.0% in Australia.When restricting our analysis to the standardized cohortof 18–25 year-old women who were born in the surveycountry and did not study health sciences (n = 1390), wefound that proportions of women expressing a preferencefor CS were still highest in Australia (18.4%). Proportionswere lowest in Iceland (7.6%) (see Table 2). Proportions ofyoung women in our study preferring CS were signifi-category: preference for vaginal birth). We controlled fordifferences in the socio-demographic (age, field of study,country of origin) and psychological profile of students(scores on the Depression Anxiety Stress-21 subscales).We performed this analysis for the full sample and foreach country separately, to determine whether resultswere replicable across samples.To determine whether childbirth fear and CS prefer-ences in our population might be associated withwomen’s confidence in their knowledge of pregnancyand birth, we examined CFPP scores and CS preferencesfor students who reported different levels of agreementwith the statement: ‘I feel confident in my level of know-ledge of pregnancy and birth’. The six response optionsfor this item ranged from strongly disagree to stronglyagree. Finally, for young women with CS preferencesand elevated fear of childbirth (i.e. scores above the 75thpercentile), we identified pregnancy and childbirth topicsthat students wanted to learn more about. P values arepresented, to identify significant differences in know-ledge gaps/learning needs for women who were fearfulof birth and those who preferred a CS.ResultsA total of 6571 students started the survey. Responserates in countries where it was known how many stu-dents received the invitation to participate were as fol-cantly higher in countries with higher national CS rates(rs = 0.04, p = 0.03); however, this association was weakand no longer significant when restricting the analysis tothe standardized cohort (rs = 0.01; p = 0.67).The most common reasons expressed by youngwomen for preferring a CS in a healthy future pregnancywere fear of labor pain and avoiding damage to thebody/ to maintain vaginal integrity (see Table 3). Thesereasons were reported by 77.8% and 62.5% of youngwomen who preferred a CS. One in four also reportedthe ability to plan the time of birth and the convenienceof a scheduled CS as reasons for their preferences. Asmaller proportion of women (18.1%) expressed a prefer-ence for a CS because they believe CS is better/saferand/or healthier for the mother.Results of the logistic regression analysis across thewhole sample of women indicated that health sciencesstudents had significantly lower odds of preferring CSand students with higher scores on the childbirth fearsubdomains that measure fear of physical changes andfear of pain/fear of being out of control had significantlyincreased odds of preferring CS (see Table 4). When per-forming the same regression analysis for each countryseparately, we found that fear of complications was notsignificantly linked to CS preferences in any of the coun-tries. Fear of pain/being out of control was significantlylinked to preferences for CS in a healthy future preg-nancy in 5 countries (Australia, NZ, the UK, Germany,and Iceland), controlling for differences in students’socio-demographic and psychological profiles. Fear ofphysical damage was significantly higher among studentswho preferred CS in 5 countries (Australia, Canada,Chile, Germany, and Iceland).We found a dose–response relationship between child-birth fear scores and CS preferences: 3.3% of studentswho scored in the 0-24th percentile on the CFPP scalepreferred a CS, 5.1% who scored in the 25th to 49th per-centile, 11.3% who scored in the 50th to 74th percentileand 22.9% of students scoring in the top quartile pre-ferred a CS. We also detected a dose- response relation-ship between confidence in students’ level of knowledgeabout pregnancy and birth and childbirth fear scoresand CS preferences (see Figs. 1 and 2). As confidence inknowledge increased, preferences for CS and childbirthfear decreased.When asked whether students would like to learnmore about pregnancy and childbirth, most said yes(71.1%) or ‘I don’t know’ (13.2%). The topics that mostof the young women wanted to learn about were: pro-motion of a healthy pregnancy (88.0%); the process oflabor and birth (84.4%); risks and benefits of commoninterventions and technologies used during pregnancy,labor and birth (82.8%); the process of pregnancy(81.0%), and what could go wrong during pregnancy,labor and birth (74.4%). Young women with elevatedchildbirth fear were significantly more likely to identifyhome – which is the highest rate in the Scandinaviancountries [28]. These figures suggest a specific culturalbias towards physiological labor and birth.The Australian sample included women from the stateof Western Australia (WA), where, in 2013, 98.4% ofwomen had a hospital birth [29]. Healthcare in Australiainvolves a two- tiered system of services with public andprivate sector hospitals. In WA, choices for maternityTable 2 Proportion of women who prefer CS in a low risk pregnancy and national CS ratesN All Australia NZ UK USA Canada Chile Germany IcelandPreferences for CS in low riskpregnancy- all women3616 10.8 16.0 10.3 10.2 10.1 8.9 11.8 9.1 9.2Preferences for CS in low riskpregnancy- standardized cohorta1390 11.7 18.4 14.4 11.9 10.0 14.7 12.8 10.1 7.6National CS rateb NA NA 32.4 25.9 26.2 32.2 27.3 56.0 32.9 15.5awomen aged 18–25 who do not study health sciences and were born in the survey countryb cional de Derechos Humanos, Chile. Situación de los Derechos Humanos en Chile,Stoll et al. Reproductive Health  (2017) 14:116 Page 5 of 9all topics as important, with the exception of learningabout how to promote a healthy pregnancy (see Table 5).A higher proportion of students who expressed a prefer-ence for CS in the context of a healthy future pregnancyreported interest in learning about what could go wrongduring pregnancy, labor, and birth, compared to studentswho preferred a vaginal birth (see Table 5). Significantlylower proportions were also interested in learning abouthow to include their partners in the childbirth experi-ence or learning about out-of-hospital birth options.DiscussionThe overall rate of CS preference in the context of ahealthy pregnancy was 10.8%; this finding is congruentwith the proportion of nulliparous women around theworld who prefer a CS during pregnancy [24] but ismuch higher than global estimates of CS on maternalrequest [25]. In 2013 the CS rate for the countries thatwere included in this study ranged from 15.5% in Icelandto 56% in Chile [4, 26]. In our study we found thatIcelandic students were least likely to express a prefer-ences for CS whereas Australian students had the high-est rate of CS preference (standardized cohort), with adifference of over 10%. A brief description of the mater-nity care systems in Iceland and Australia illustratespotential reasons for these differences. In Iceland, thehealth care system is publicly funded, and almost allwomen receive prenatal and intrapartum care from mid-wives [27]. Icelandic midwives are autonomous providerswho are trained to support physiologic labor and birth,OECD 2013 data for all countries except Chile; Chilean data is from Instituto NaInforme Anual 2016and they offer eligible women the option to give birth athome. Just over 2% of babies in Iceland are born atTable 3 Reasons for CS preference among women from 8countries (n = 392)Please indicate why you prefer Cesarean birth (CB) n (%)Fear of labor pain 305 (77.8)To avoid damage to my body/to maintain vaginal integrity 245 (62.5)Ability to plan the time of birth 103 (26.3)Convenience of scheduled Cesarean birth 102 (26.0)Cesarean birth is better/safer/healthier for the mother 71 (18.1)Other 20 (5.1)care include private obstetric care, public hospital care,and midwifery continuity of care through group prac-tices or homebirth with a privately practicing midwife ora publically funded program. WA had the highest(40.3%) proportion of private hospital births in Australiain 2013 [30] and the highest CS rate (34.3%) comparedto all states and territories [29]. An increase in pre-laborCS for WA women attending private hospitals has beenattributed to the increase in CS rates for nulliparouswomen [31].The relatively low proportion of Chilean participantsexpressing CS preferences compared to actual CS ratescontradict assumptions that birth preferences amongTable 4 Association between childbirth fear domains and CSpreferences, controlling for socio-demographic and psychologicalprofile (n = 2988)B Standard error OR 95% CISocio-demographic profileAge 0.03 0.02 1.03 1.00–1.06Born in survey country: 0.13 0.17 1.14 0.82–1.58Yes (Ref: No)Health sciences student:Yes (Ref: No)−0.33 0.14 0.72 0.55–0.95Psychological profileDepression 0.02 0.02 1.02 0.98–1.06Anxiety 0.02 0.03 1.02 0.97–1.07Stress −0.01 0.02 0.99 0.95–1.03Childbirth fear profileFear of complications −0.02 0.02 0.98 0.94–1.03Fear of physical changes 0.17 0.03 1.19 1.12–1.25Fear of pain and beingout of control0.12 0.02 1.12 1.09–1.16el cStoll et al. Reproductive Health  (2017) 14:116 Page 6 of 9young women would mimic rates of obstetric interven-tions at the country level. A study of birth preferences of180 Chilean women attending public and private ante-natal clinics in Santiago showed that 9.4% preferred CS[32]. The authors concluded that Chilean women’s pref-erences are not a significant contributor to the high ratesof CS in the country. The preferences of young Chileanwomen contemplating pregnancy and birth in our studyconcur with their conclusion.We found two main factors that were linked to CSpreferences among young women who contemplatepregnancy: fear of uncontrollable pain and fear of phys-ical damage. Epidural analgesia (EA) is very effective atrelieving labor pain [33] and might seem like an obvioussolution for women with fear of pain. However, evidencefrom a systematic review of trials comparing EA withother pain relief options or no pain relief during laborshowed an increased risk of instrumental vaginal birth,maternal hypotension, and cesarean section for fetaldistress for women who received EA. No significant dif-ferences in maternal satisfaction with pain relief werenoted between the two groups [33]. These findings drawinto question EA as a solution to childbirth fear in gen-eral and fear of pain in particular, especially when con-sidering that women who experienced an emergency CSor instrumental birth are significantly more likely to ratethe experience as negative or traumatic compared towomen who had a non-instrumental vaginal birth [34].Fig. 1 CS preferences, stratified by level of agreement with statement: I feWomen with a previous negative or upsetting birthexperience are significantly more likely to experienceFig. 2 Childbirth fear scores, stratified by level of agreement with statement: I ffear of birth in a subsequent pregnancy [17, 35, 36]. Inother words, while the promise of EA might reduce an-ticipatory fear of labor pain, EA is not associated withincreased satisfaction with pain relief and is linked tointerventions that might increase childbirth fear in thelonger term.The link between fear of physical damage and CS prefer-ences has been documented for US, Israeli, and Canadianstudents who contemplate pregnancy [19, 20, 37]. Forexample, college students from the US (n = 752) whopreferred CS were significantly more likely to expresselevated concerns about body changes following child-birth, compared to students who preferred a vaginal birth[19]. Similarly, fear of body changes and a preference forCS to prevent physical damage were significantly associ-ated with childbirth fear among Israeli women who hadnever given birth [37].Minimal work has examined women’s fears of beingout of control during labor and birth. However, some re-search suggests that this fear might be embedded in in-ternalized gender norms and constructions of vaginalbirth as messy and uncontrollable. Martin [38] con-ducted in-depth interviews with 26 women in the UnitedStates within 3 months of giving birth. She found thatwomen worried about being kind, polite, nice, and self-less during labor and birth. These internalized gendernorms seemed to exert external control over women andtheir bodies during childbirth. In a qualitative study withonfident in my level of knowledge of pregnancy and birth (n = 3389)33 women and 9 maternity care providers from NewZealand, CS was constructed as a routine procedure thateel confident in my level of knowledge of pregnancy and birth (n = 3360)is less messy than vaginal birth. Some respondents feltthat birth was more controlled, sterile, clean, and con-tained when having a CS and less embarrassing than avaginal birth [39]. These findings concur with the resultsfrom the current study that show that fear of pain andbeing out of control strongly correlate with students’ CSpreferences.A need for educationIn many countries, midwives and public health nursesprovide preconception care and education to womenand men prior to pregnancy. In some countries, likeGermany, education about childbirth can start as earlyas age 8. In Germany, 4 hours of midwifery-led instruc-tion about midwifery care, pregnancy, birth, and new-born care was well received by students in grades 3 and4 and associated with increased knowledge of pregnancyand birth and decreased childbirth worries [40]. WeOne in five young women who preferred CS for a fu-ture pregnancy and birth believed that it is healthier, bet-ter, and/or safer for the mother compared to vaginalbirth and 83% of students wanted to learn more aboutthe advantages and disadvantages of common obstetricinterventions. These findings indicate that studentswould benefit from a better understanding of the posi-tive outcomes of vaginal birth compared to CS, such asfaster recovery time [42], decreased risk of placental dis-orders in future pregnancies [43], decreased risk ofsevere maternal morbidity and anesthetic complications[44, 45], and decreased risk of readmission to hospital(for wound complications and infection) [46], as well ashealth benefits for infants, such as reduced likelihood ofdeveloping chronic diseases like asthma or obesity dur-ing childhood [47]. Women who have a vaginal birth arealso more likely to hold their infants immediately afterthe birth and have skin-to-skin contact with their new-reoreercStoll et al. Reproductive Health  (2017) 14:116 Page 7 of 9argue that education about childbirth should be deliv-ered to the next generation of maternity care consumers,commencing as early as primary and secondary school.College and university students would benefit from edu-cational content that addresses fear of physical damageand fear of pain, and all of the topics listed in Table 5.Specifically, young women need to know that a range ofeffective pain relief options are available to them, andthat their bodies will recover faster from a vaginal birth,that mode of delivery is not linked to decreases in sexualfunctioning or enjoyment [41] and that exercise duringthe postpartum period can strengthen pelvic floor andcore muscles. The content could be presented in work-shop format and facilitated by midwifery or obstetric/family practice trainees.Table 5 Learning needs of young women who plan to become p75th percentile on the CFPP scale and students who prefer CSFullsample%CFPP sc>75th p%The process of pregnancy 81.0 86.9Promotion of a healthy pregnancy (nutrition, life stylefactors etc.)88.0 91.6The process of labor and birth 84.4 90.4Available reproductive health services 59.1 69.2What could go wrong during pregnancy, labor andbirth74.4 85.6How to include both partners in the childbirthexperience72.0 76.4The anatomy and physiology of the femalereproductive system43.7 56.8Risks and benefits of common interventions andtechnologies used during pregnancy, labor and birth82.8 88.9How the female body is equipped for childbirth 64.7 76.7Birth at home or at birthing centres 55.8 58.5borns, and are significantly more likely to breastfeed at 3and 6 months compared to mothers who had a CS [48].Women who preferred CS for a future pregnancy didnot report many learning gaps, but were significantlymore likely to want to know more about what can gowrong during pregnancy, labour, and birth. When edu-cating young women about birth, it is important toemphasize the overall low risk of serious adverse out-comes and to frame this information in terms of thehigh likelihood of having a healthy pregnancy andnormal birth because the way clinical information ispresented can affect risk perception and health caredecision-making [49].Education sessions delivered online, through socialmedia, and face-to-face using drama and stories told bygnant, reported for full sample, students who scored above thesentileCFPP scores≤75th percentile%p Preferencefor CS %Preference forvaginal birth %P82.4 0.02 82.6 80.8 0.5389.9 0.23 84.7 88.3 0.1185.4 0.002 84.3 84.4 0.9758.6 <0.001 58.3 59.2 0.8273.4 <0.001 80.6 73.7 0.0273.6 0.22 64.5 72.7 0.0241.6 <0.001 45.9 43.4 0.5583.7 0.002 83.0 82.8 0.9563.4 <0.001 66.4 64.5 0.6057.6 0.73 39.7 57.2 <0.001peers (young women who have recently had babies) orLimitationsConclusionsStoll et al. Reproductive Health  (2017) 14:116 Page 8 of 9Young women who contemplate pregnancy are likely tobenefit from the knowledge that pregnancy and birth aregenerally normal and natural processes, their bodies arecapable of growing and giving birth to a healthy baby,and complications are rare. Moreover, even when com-plications do occur, pregnancy care is designed to enablecare providers to screen for and address such problemsif they arise. Introducing young college-age women tothe benefits of spontaneous vaginal birth with no or aminimum of interventions, and to the potential harmsas well as the benefits of routine use of technologicaland pharmacological interventions is also likely to im-prove their capacity for effective decision making, andfor feelings of control, when they do eventually becomepregnant.Data presented are based on convenience samples fromuniversity students from eight countries; response rateswere low, and do not reflect population sizes. For thesereasons findings cannot be generalized to all youngwomen from the countries that were included in ourstudy. Nonetheless, we were able to replicate key find-ings across countries, demonstrate dose–response rela-tionships and use a standardized cohort for cross-country comparisons, to minimize bias. In this study weassessed young women’s confidence about their know-ledge of pregnancy and birth. While increased confi-dence was linked to decreased fear and preferences forCS it is unclear whether confident students actually hadmore accurate information about pregnancy and birth.celebrities increase young women’s capacities to under-stand the physiology of labor and birth, and the range ofmethods available to support them in coping with laborpain and minimizing invasive procedures. Such sessionscould potentially reduce fear of pain, bodily damage, andloss of control. The most efficacious designs and contentfor education for young women and girls requires testingin future studies. The learning needs and knowledgegaps of young men should be explored in future studies,using a larger and more representative sample. Researchwith Swedish couples indicated that the attitudes of men(specifically prenatal childbirth fear) were strongly linkedto decisions about mode of delivery [50], and it is im-portant to include men in any future studies that testeducational interventions.AbbreviationsCS: Cesarean section; OECD: Organisation for Economic Co-operation andDevelopmentAcknowledgmentsWe would like to thank all of our international team members, whocollected data at their respective institutions and provided feedbackthroughout the publication process: Mechthild Gross from MedizinischeHochschule Hannover in Germany, Michelle Sadler from Universidad de Chilein Chile, Gillian Thomson from University of Central Lancashire in England,Joana Streffing from Medizinische Hochschule Hannover, Anne Malott andPatricia McNiven from McMaster University in Canada, Judith McAra-Couperfrom Auckland University of Technology in New Zealand, Emma Swift fromthe University of Iceland and Joyce Edmonds from Boston College in theUnited States. We are also grateful to the young men and women who tookthe time to respond to the survey.FundingThe study was supported by an internal grant from Curtin University in WesternAustralia. The first author received salary support from the Canadian Institutes ofHealth Research and the Michael Smith Foundation for Health Research.Availability of data and materialsThe dataset that was generated and analysed during the current study is notpublicly available due to different data access policies at institutions thatparticipated from different countries.Authors’ contributionsKS coordinated the cross-country-study, conducted the analysis and draftedthe first version of the manuscript. YH, WH and KS applied for internal fund-ing for the study. YH, WD, SD and DP collected data at their institutions,made substantial contributions to the interpretation of the data and criticallyreviewed and revised the manuscript. All authors read and approved thefinal manuscript.Ethics approval and consent to participateThe study was approved by the Behavioral Research Ethics Board at theUniversity of British Columbia, Canada (H14–00033) and at each participatinginstitution, with the exception of the University of Northern British Columbia(because this institution was covered by the original ethics approval).Students reviewed the study consent form on page 1 of the online survey;submitting a response implied consent to participate in the study.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Population & Public Health & Division of Midwifery, University ofBritish Columbia, 2206 E Mall, Vancouver, BC V6T 1Z9, Canada. 2School ofNursing, Midwifery and Paramedicine, Curtin University and King EdwardMemorial Hospital, Perth, WA, Australia. 3School of Community Health andMidwifery, University of Central Lancashire, Preston, UK. 4Centre for Midwifery& Women’s Health Research & Disability, Diversity & Gender Cluster, PCRC,School of Clinical Sciences, Auckland University of Technology, Auckland,New Zealand. 5School of Nursing, University of British Columbia, Vancouver,BC, Canada.Received: 13 April 2017 Accepted: 26 July 2017References1. 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