Cesarean Section (CS) is an important surgical procedure to save women’s and/or babies’ lives (1). According to WHO, the ideal rate for CS has been considered to be between 10% and 15% (2). Iran and Turkey (47.9% and 47.5%, respectively) have the highest rates of the CS in Asia (3). Other countries with the highest CS rates are Brazil (55.6%) and Dominican Republic (56.4%) in Latin America and the Caribbean (3). In Iran, the rate is even higher in private hospitals (72-89%) (4-7); and most of the cases have no medical indications in many settings (8).
CS can be life-saving when medically indicated; however, this procedure can also lead to short- and long-term risks for mother and infant (9, 10). Studies has identified that unnecessary CSs can create several complications with no benefits to both mother and baby (3, 11-14). CS can be associated with significant short-term risks such as asphyxia, if the uterus is hypo perfused due to anesthesia, uterine rupture, abnormal placentation, ectopic pregnancy, scalpel lacerations, and neonatal respiratory morbidities (11). A study showed that babies born by CS has different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology (10). Other short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity, increased risk of infection and lower likelihood of breast-feeding (10, 12, 13, 15). Moreover, urinary catheterization is associated with post CS bacteriuria and has been reported to be as high as 11% (16). Increasing rates of CS is associated to increased maternal and perinatal morbidities (17). According to an observational study conducted by WHO in nine Asian countries, women who underwent unplanned CS before or during labor or had assisted (operative) vaginal delivery were more likely to experience morbidity than those who had spontaneous vaginal delivery (18).
Previous studies have showed a list of probable reasons for high rate of CS including several economic, organizational, social and cultural issues (19, 20).The underlying factors of continuing high rates of CS have been studied in a mixed method review in Iran (21).This review reported that preferences for CS were often associated with all ‘women’s factors’, ‘health professional factors’, and ‘health organization, facility, or system factors’(21). The review showed that most of the women had fear of pain during labor and childbirth (22-24), had concerns about genital modifications after vaginal delivery(22, 24-26), believed that CS was safer for baby(27-30), and believed that CS was convenient for women and their families (29). Other studies show that women can play a major role in decision-making process about their birth (24, 31, 32).
In view of this unprecedented rise of CS in Iran, different interventions have been designed to reduce this trend (33-36). In Iran, many efforts have been made during last years to reduce CS rate. For instance, in 2014, Iran has been conducted a “health sector evolution policy” to improve public health; and increasing the rate of normal vaginal delivery (NVD) was one the most important objectives of this policy (37). Several strategies have been conducted through this policy such as freeing NVDs in all public hospitals, developing mother-friendly hospitals, developing standard protocols of birth and preparation classes for women, improving privacy and infrastructure of labor, promoting standards in birth facilities, promoting water birth, determining financial incentives to doctors to encourage them to do NVDs in public hospitals (38). There was a reduction in CS rate after implementing the policy; however the rate is still significantly higher than the rate recommended by WHO (38).
The WHO recommended that non-clinical interventions can be effective to reduce unnecessary CSs. The recommendations are grouped according to the target of intervention: (a) interventions targeted at women, (b) interventions targeted at health-care professionals; and (c) interventions targeted at health organizations, facilities or systems (39). According to this guideline, an important target for interventions is women. Previous experiences also makes it explicit that, in order to further reduce the rate of CS, it is necessary not only to address health system, health facility, and health professional factors, but also change women’s choice behaviors (38).
Implementing psycho-education interventions for women has been recommended by WHO in order to reduce unnecessary CS (40, 41). A Cochrane systematic review conducted by Chen et al (2018) on non-clinical interventions for reducing unnecessary CS reported that psycho-education interventions were effective in reducing unnecessary CSs (42). The educational interventions included psycho-education on fear of childbirth (43), intensive group therapy (cognitive behavioral therapy and childbirth psycho-therapy) (44), psycho-education by telephone (45), role-play education versus standard education using lectures (46), and nurse-led applied relaxation training program (43).
Motivational interviewing (MI) is a patient-centered counseling approach that has been proved to be influential in choosing suitable health behaviors (47); and is specifically aimed to improve motivation to change among individuals not ready to change unhealthy behavior (48). Research on MI has demonstrated positive effects of helping patients clarify goals, explore obstacles to treatment, and make commitments to change (48). MI is a relatively new cognitive–behavioral technique that aims to elevate internal motivation to identify and change behaviors that may be placing them at risk of developing health problems or may be preventing optimal management of a chronic condition.
In Information-Motivation-Behavioural skills (IMB) model, individuals should be informed, motivated and behaviorally skilled to change behaviour (49). The IMB model is a generalizable, and simple model to guide thinking about complex health behaviours. The IMB constructs, and how they pertain to patient adherence, are outlined as follows: 1) Information is the basic knowledge about a medical condition that might include how the disease develops, its expected course and effective strategies for its management; 2) Motivation encompasses personal attitudes towards the adherence behaviour, perceived social support for such behaviour, and the patients' subjective norm or perception of how others with this medical condition might behave; and 3) Behavioural skills include ensuring that the patient has the specific behavioural tools or strategies necessary to perform the adherence behaviour such as enlisting social support and other self-regulation strategies. The IMB model has been widely used in changing behavior for health problems (50-53).
In the modern age of information and communication, mobile applications play an important role in delivering educational contents nowadays. Educational interventions should be delivered at any time to anyone with extra support upon to request wherever and whenever it is needed (54); and mobile applications can easily make this access to people. This route provides simple, user friendly, downloadable, and non-expensive interventions to various ranges of individuals. Motivational messages, monitoring, and behaviour change tools can be modified for delivery via mobile phones (55). This type of interventions have been reported to be effective in several behavior change studies including smoking cessation (56), adherence to prescribed medication (57), blood pressure management; and delivering interventions(58) .
The aim of this study was to compare the effect of "motivational interviewing" and "information, motivation and behavioral skills” with face-to-face and mobile application in brief psychological interventions on women’s self-efficacy, intention to choose mode of delivery, and the mode of delivery among pregnant women.