Psychological predictors of cesarean delivery on maternal request in upper middle – income settings and the mitigating role of prenatal psychological education: a multicenter longitudinal study

Dongqiong Luo¹Yanhong Li²Juan Li³Xin Li^4*Tianjiao Liu⁴Lu Zhang¹Lan Huang³Hongyan Ma¹Biao Huang⁵Aijie Xie⁴

• ¹People's Hospital of Xinjin District Chengdu, Chengdu, China
• ²The Affiliated Hospital of Yunnan University, Kunming, China
• ³Chengdu Medical College, Chengdu, China
• ⁴Chengdu Women and Children's Central Hospital, Chengdu, China
• ⁵Chongqing Health Center for Women and Children, Chongqing, China

Objective: This study aimed to investigate, in an upper middle – income country context, the impact of maternal psychological status and prenatal psychological education on the cesarean delivery on maternal request among primiparous women. Methods: This prospective longitudinal study included 948 primiparous women who delivered at five hospitals between June 2023 and June 2024. Women with medical indications for cesarean section, multiparity, or incomplete data were excluded. Maternal anxiety and depression were assessed in the first, second, and third trimesters using the Self-Rating Anxiety Scale and Self-Rating Depression Scale. Childbirth fear was evaluated in the third trimester using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). Multivariate logistic regression was used to examine factors associated with cesarean delivery on maternal request. Results: Among the 948 participants, 543 (57.3%) had vaginal deliveries, while 405 (42.7%) underwent cesarean delivery on maternal request. Third-trimester anxiety, depression, and W-DEQ scores were significantly higher in the cesarean group (P < 0.001 for all). Multivariate analysis revealed that conception via assisted reproductive technology (ART) (OR = 2.12, 95% CI: 1.17–3.43), the presence of pregnancy-related illness (OR = 1.43, 95% CI: 1.09–2.08), and higher W-DEQ scores (OR = 1.08, 95% CI: 1.02–1.16) were independent risk factors for cesarean delivery on maternal request. Receipt of prenatal psychological education was associated with a 35% reduction in this risk (OR = 0.65, 95% CI: 0.38–0.91). Conclusion: Maternal psychological distress and fear of childbirth are significant contributors to the decision for cesarean delivery on maternal request among primiparous women. In an upper middle – income country context, prenatal psychological education may serve as an effective intervention to reduce childbirth fear and promote informed, evidence-based delivery decisions. Integrating routine mental health screening and targeted education into antenatal care could help curb the rising trend of unnecessary cesarean deliveries.