Assessing socio-ecological factors on caesarean section and vaginal delivery: an extended perspective among women of South-Punjab, Pakistan

Abstract Research was conducted employing the extended socio-ecological model (ESEM) to examine factors associated with cesarean sections (CSs) and vaginal deliveries (VDs) among the women in our study population. Using the ESEM to determine South-Punjab and Pakistani women’s mode of delivery predictors. The cross-sectional study with a sample size of 908 patients was conducted through private and public obstetrics and gynecology departments in South Punjab, Pakistan, from 12 June 2022 to 29 May 2023. The Chi-square analysis compared baseline variables, delivery outcomes and delivery methods. Logistic regression analysis is used to determine predictive factors. The study revealed that 75.66% of women had CS, while 24.34% had VD. Education level, age, residential area and fetal presentation all had significant associations with mode of delivery. Logistic regression analysis suggested that gynecologist recommendation, belief in CS safety, abnormal fetal presentation, maternal anemia and meconium aspiration syndrome were all significant predictors of CS. The ESEM model concluded that age, fatigue and women’s preference for CS due to its reliability for her and her fetus were predictive factors for mode of delivery choices among South-Punjab Pakistani women.


Introduction
Childbirth is a significant event in a woman's life, and the method of delivery, whether CS or VD, has major consequences for the mother's and newborn baby's health outcomes [1][2][3].The decision regarding the method of delivery is impacted by an abundant number of factors [4,5], which include aspects of medicine, culture, society, the economy and the environment [6].The debate over CS versus VD has captured the world's attention [7].The prevalence of these delivery methods varies significantly across countries due to the various factors present in every region [8].The complex interplay of cultural norms, medical practices, healthcare policies and individual preferences that influence delivery modes has been illuminated by extensive international research [9].
In Punjab, Pakistan, research was conducted on the socio-ecological factors that have a significant influence on CS and VD, with worthwhile outcomes [10].
Several factors were associated with the mode of delivery identified in studies conducted in various countries.Maternal age consistently emerged as a significant predictor, with increased maternal and fetal risks associated with advanced maternal age.Socioeconomic status and educational level are the foundations for and influences on delivery preferences.Women from higher socioeconomic backgrounds, who frequently have better access to healthcare resources, may choose elective CS based on perceived benefits.Women with lower socioeconomic status, on the other hand, may face barriers to healthcare access, leading to a higher rate of emergency CS [11][12][13].
Globally, the prevalence of CS has risen significantly in recent decades [7,14].While CS can be a life-saving procedure in certain scenarios, it is associated with higher maternal risks and lower fetal risk when adjusted for elective and emergency [15].Many countries, however, have reported CS rates far above this threshold, raising concerns about overuse and unnecessary medical interventions [16].The CS rate in Pakistan is also increasing.This increase's causes are complex and need more investigation.CS rates are continuously higher in upper-class Pakistanis (35.3% vs. 5.5%).Fetal distress has elevated the chance of CS from 2% to 7%.In countries with higher incomes, pregnant mothers desire this surgery without medical difficulties to avoid VD.However, in Pakistan, the situation is the polar opposite, with doctors' decisions taking precedence over women's opinions [7,17].
Many factors that contribute to this growth need to be investigated.Decision-making is influenced by cultural beliefs, societal norms and women's preferences for CS, which are affected by convenience and safety.Defensive medicine and financial incentives may potentially increase CS rates.Prenatal care, birth attendants and healthcare inequities can worsen the problem.This study used an extended socio-ecological model (ESEM) to determine South-Punjab, Pakistani women's mode of delivery predictors.

Materials and methods
The investigation was done in different hospitals to assess delivery procedure parameters.Private and public obstetrics and gynecology departments in South-Punjab, Pakistan, conducted the study from 12 June 2022 to 9 July 2023.A total of 1500 women were invited to take part in the survey, but 592 declined.In total, 908 women willingly took part in this survey.The Yamane formula determines the sample size with a 0.05 error margin.A representative sample was chosen using multi-stage probability sampling (Table 1).In the final step, data were collected from women who met the criteria of interest using systematic sampling within multi-stage sampling.The study included all women between the ages of 14 and 49 who had at least one baby after 31-43 weeks of pregnancy, either via VD or through CS.Following collection, the data were statistically examined using R (R Foundation for Statistical Computing, Vienna, Austria) and SPSS version 23 (SPSS Inc., Chicago, IL).The "mean standard deviation (SD)" was determined for continuous variables, whereas the "number (percent)" was evaluated for categorical variables.A Chi-square analysis was used to examine the relationship between mode of delivery and rising maternal risk factors.Only the predictors found significant based on the bivariate Chi-square test analysis were included in the binary logistic regression (LR) analysis using the "forward LR" method.The significance is obtained when the associated p value satisfies p value .05.The best predictors were estimated using odds ratios and a 95% confidence interval.
Furthermore, the majority of respondents (74%) were uneducated.However, the majorities of respondents in private hospitals were willing to participate and comprehended the study, while only a few in public hospitals were hesitant to provide information.Pakistan does not have a universal health insurance system.The Prime Minister's Health Initiative and Sehat Sahulat Program provide health insurance to vulnerable populations like low-income families and specific age groups [18].In contrast, the private system caters to those who can afford better amenities and care.The private system includes private hospitals, clinics and specialty centers, and it often relies on health insurance.Health insurance plans help individuals manage medical costs and provide access to a network of private healthcare facilities.Patients in South-Punjab hospitals come from various socioeconomic backgrounds, with the public sector serving the economically disadvantaged and the private sector catering to the middle and affluent classes.
Using a socio-ecological model (Table 2) with an extended approach, the potential determinants involved in the method of delivery were divided into five levels, including demographic characteristics, socioeconomic characteristics, interpersonal and social characteristics, organizational levels and biological levels.The information was gathered using a self-structured questionnaire.The authors provided detailed guidance to the women in understanding the biological terms used in the questionnaire.
In our study, we identified factors after the birth of a child, like fetal distress, through various indicators, including abnormal cardiotocography (CTG) readings, fetal bradycardia (an abnormally low heart rate) and meconium-stained amniotic fluid (MEC liquor).Enough capacity for VD pain was measured through questionnaires or interviews, where women were asked about their willingness and confidence to undergo VD based on their pain tolerance.Reliable procedures for mother and fetus were examined to determine whether women perceive cesarean section (CS) as a safe and dependable obstetric procedure for both themselves and their babies.Fetus with intrauterine growth restriction IUG refers to a condition where the baby has a birth weight of less than 2500 g, indicating a low birth weight.We obtained this information from the newborns' birth records and classified them accordingly.

Results
The mode of delivery was used as the response variable in this study.The question was posed by inquiring about the women's preferred technique of delivery.There are two options: a CS or a VD.Women in this study underwent CS in 75.66% of cases and delivered vaginally in 24.34% of cases.The relationship between mode of delivery and demographic maternal risk factors is shown in Table 3.When compared to women who had VD, the mean age of women with CS was consistently higher (29.19 years) as compared to women with VD (24.24 years) in our study sample.
A considerable proportion of the women (38.87%) had completed primary education, among whom (30.06%) preferred CS as their mode of delivery (MOD).In the sample, the majority of women (65.53%) resided in urban areas, and intriguingly, 50.88% of them opted for CS.The Chi-square results reveal that there is a link between education, age, residential area and mode of delivery.Table 3, section 1, shows the interpersonal elements that influence the MOD.The prevalence of CSs due to maternal demand is low since the majority of women had a 57.04% capacity to tolerate VD discomfort, with only 40.19% having a CS due to a complication during the delivery process.In spite of the fact that 86.77% of women received CS, only 20.81% thought it was a safe and reliable obstetric technique.However, CS is not preferred by the husband and his family in the event that the expectant mother is carrying a male baby.
In Table 3, section 2 reveals that the majority of the women (89.86%) among all respondents were housewives, and that the majority of them (73.23%) had CS, but that it is not a significant factor of CS (p value ¼ .108).The technique of delivery influences the husband's willingness to pay for a CS, as determined by a Chi-square test.Hospital level has a significant association with birth method, which is one of the most intriguing findings.MOD is influenced by organizational considerations, as shown in section 3.In Table 3, section 4, it is shown that all biological parameters have a high relationship with the manner of delivery, which is unsurprising.Fetal distress is frequently a warning of negative consequences and the need for an emergency CS.A fetus weighing less than 2500 g is classified as a low-birth-weight fetus.The prevalence of low birth weight in newborn babies is a major cause of neonatal morbidity and mortality.High birth weight, on the other hand, is risky.The technique of delivery has a strong influence on an infant's weight.IUGR are seen as easy to deliver via normal delivery, while overweight fetuses are thought to be difficult to deliver via normal delivery.The mode of delivery is linked to an abnormal fetal presentation.There were 396 fetuses with aberrant presentation, 277 (69.94%) of which were delivered by CS and 119 (13.10) via vaginal delivery (VD).The technique of delivery is also linked to maternal anemia.Five hundred and sixty-nine women out of the total sample size had maternal anemia, with 447 (78.58) having a CS and 122 (21.44) having a VD.Previous CS is also a significant factor (p value .001)among associated factors of CS.Meconium aspiration syndrome is hazardous to the newborn, necessitating an emergency CS.Table 3 illustrates that intestinal blockage is strongly linked to the technique of birth.
The regression modeling process includes all factors with a statistically significant relationship to the dependent variable.The results of the final estimated LR model are presented in Table 4.The "forward LR" method was used to apply a binary LR model.MOD can be influenced by a variety of circumstances, including age, hospital type, gynecologist recommendation and all biological characteristics.Women who have been advised by their doctor to have a CS are 1.560 times more likely to want one.Women who believe CS is a safe and dependable obstetric surgery are 5.514 times more likely to get one.Women who had a fetus with abnormal presentation had a 3.767 times higher risk of delivering the infant via CS in comparison with women who did not carry a fetus with abnormal presentation.Women who had maternal anemia during pregnancy also had a 5.096 times higher chance of CS.Another intriguing finding is that women with meconium aspiration syndrome are 11.246 times more likely than their counterparts to have CS as shown also in Figure 1.

Discussion
The goal of this study was to use an ESEM approach to report the predictive factors of choosing the mode of delivery among women in South-Punjab, Pakistan.The current study's CS rate was 75.66%, which was much higher than the figure published in earlier Pakistani studies (68%), comparable to the rate reported in an Iranian study (54%), Turkey (48%) and China (46%) [19][20][21].The WHO has recommended that the CS rate be kept with the range of 5-15%, but the rate found in this study defied this advice [10].
In this study, maternal age was a significant predictor of the mode of delivery.It is associated with an increased risk of requiring a CS.This finding is consistent with previous studies conducted in different countries.Maternal and fetal risk rises with a woman's age, which may influence her decision to choose CS.It is essential to educate women about the risks and benefits of various delivery methods, especially as the worldwide trend of postponing childbirth grows [22,23].
Socioeconomic status and level of education also affected delivery preferences.Women from higher socioeconomic backgrounds who have better access to healthcare resources may opt for elective CS due to perceived benefits.On the other hand, women with a lower socioeconomic status may face barriers to healthcare access, leading to a higher rate of emergency CS.These findings highlight the role of socioeconomic disparities in determining the choice of delivery methods.Addressing these disparities and improving access to quality maternal healthcare are crucial for promoting equitable and evidence-based delivery practices [24].
Interpersonal, social and organizational factors influence delivery, according to the study.The ability of women to tolerate VD pain as well as their perceptions of the safety and reliability of CS were found to influence their delivery method choice.CS was also more likely when husbands and families preferred it for male babies.These findings suggest delivery preferences are influenced by social and cultural norms.Targeted interventions and education campaigns are needed to promote informed decision-making and reduce unnecessary CS.An increased risk of CS is associated with maternal age [25].
The mode of delivery is also influenced by organizational factors like hospital level and doctor recommendations.CS was more frequently performed on women giving birth in public hospitals than in private ones.This finding might be a result of the distinctions between public and private healthcare systems in terms of policies and practices.The impact of medical professionals' recommendations on the selection of delivery method also emphasizes the significance of healthcare providers' knowledge of and adherence to evidence-based recommendations.Educating healthcare professionals about the advantages and disadvantages of various delivery systems can encourage a more balanced approach to decision-making [8].
The mode of delivery was strongly correlated with biological factors such as fetal distress, an IUGR, abnormal presentations, maternal anemia and meconium aspiration syndrome.These results are in line with what currently known about the CS's medical indications.To protect the mother and child in the event of these complications, emergency CS may be required [26].To prevent unnecessary interventions, it is crucial to distinguish between elective CS with clear medical indications and CS that are not medically indicated [27].
However, doctor-advised women are 1.560 times more likely to want a CS.CS is 5.514 times more likely to be performed on women who think it is safe.Compared to women who did not carry a fetus with an aberrant presentation, those who did had a 3.767 times greater likelihood of delivering the infant via CS.Pregnant women with maternal anemia had a 5.096fold increased risk of CS.Meconium aspiration syndrome increases the risk of CS by 11.246 times.
It is worth noting that the majority of respondents in this study were uneducated, which may have influenced their understanding and decision making regarding the mode of delivery.Health literacy and education play a crucial role in empowering women to make informed choices regarding their reproductive health.Promoting health education programs and improving access to accurate and unbiased information about delivery options can help women [28][29][30][31].
Each research project had its own set of restrictions.Due to lack of time and money, pregnant women were conscripted from a few hospitals for this study.As a result, these findings may not be applicable to all pregnant women in Pakistan.This study, on the other hand, has the potential to add to the field of research and provides an important basis for academics learning about the factors that influence childbirth delivery decisions in Pakistan.Furthermore, because the data in this study were compiled by asking or requesting the pregnant women themselves, clinicians' perspectives, government restrictions and family restriction data were limited.Moreover, the majority of the study participants were illiterate, and it is possible that respondent women were unaware of the medical reasons for their cesarean deliveries.However, they fully explained all justifications for their delivery methods.They usually arrive at the hospital because an untrained staff member fails to deliver the baby vaginally in a life-threatening situation, in which case only an emergency CS is a viable option.Furthermore, owing to a lack of funds, information, advice and facilities, most women in impoverished countries do not visit prenatal services.As a result, pregnancies with significant problems are treated as emergency cases, and CS is regarded as a crucial and life-saving obstetric surgery.Furthermore, due to a lack of nutritional advice from antenatal clinics, a higher percentage of pregnant women develop anemia during pregnancy or birth.It is also a good idea to consider this level in future studies.

Conclusions
The ESEM model revealed that age, perceivable ability to tolerate pain via VD, and women's preference for CS due to its reliability for her and her fetus were predictive factors for the mode of delivery choices among South-Punjab Pakistani women.Biological factors such as aberrant breech presentation, fetal distress, and maternal anemia, lack of activity, meconium aspiration syndrome, gynecologist advice and private/public hospitals were more influential predictors of MOD among Pakistani women.Except for two clinical drivers, IUGR and appropriate nutrition, all of the clinical drivers described in the study were significant using the LR model.Furthermore, other characteristics such as the husband's career, the women's location (rural/urban), the mother's employment status, and the husband's and his family's preference for CS are not linked to the mode of delivery.The outcomes of this study will offer vigor to the antecedents for further research on women's choice of delivery.approval for publication.Sheikh Muhammad Sikandar: editing, proofreading, data interpretation, writing and final approval for publication.Alpha Kargbo: editing, proofreading, data interpretation, writing and final approval for publication.All authors contributed to interpreting data, drafting the manuscript and critically revising the manuscript for intellectual content; all authors approved of the published version.

Figure 1 .
Figure 1.Odd ratio with 95% confidence intervals of biological, demographic, organizational, interpersonal and social factors representation.

Table 2 .
Existing and extended SEM model.

Table 3 .
Characteristics, interpersonal, socio-economic, organizational and biological factors for MOD among women of South-Punjab, Pakistan (n ¼ 908).

Table 4 .
LR estimates for variables associated with method of delivery among South-Punjab women (sample size 908).