https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Pregnant Women's Perception and Attitude Towards Mode of Delivery in Erbil City- A Qualitative Study ABSTRACT INTRODUCTION Childbirth is regarded as one of the divine blessings to reproduce human beings on the earth and has persisted up to the pre- sent time. The objectives of childbirth con- trol policies are to have safe deliveries and healthy childbirth. Cesarean section (CS) was utilized to assist mothers with high-risk pregnancies in the last few decades [1]. Cesarean section is a lifesaving surgical in- tervention for women and newborns, though overutilization is a public health concern [2].The childbirth experience has always been a significant event in wom- en's lives, a special moment marked by the woman's conversion into her new role as a mother. In developed countries, women often decide on cesarean delivery due to their understanding of its role and safety and the increasing importance of the right to self-decision-making regarding mode of delivery [3].The World Health Or- ganization (WHO) reported that 35% of all deliveries worldwide are by mode of ce- sarean sections. Furthermore, these rates Background and objective: The childbirth experience has always been represented as a significant event in women’s lives. With the rising rates of cesarean sections in the Kurdi- stan region and lack of evidence, this study was conducted to explore women’s percep- tions and attitudes towards a mode of delivery. Method: An exploratory qualitative design with in‑depth interviews was used to collect data from 18 pregnant women. All in-depth interviews were tape-recorded, transcribed, and subsequently analyzed. Inductive content analysis methods were used to establish the meaning units, subthemes, and main themes. Result: From the analysis of depth-interview data of 18 pregnant women, 48 meaning units were obtained. These meaning units were collected into four themes and nine sub- themes. These themes were identified as perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak healthcare provider's role, and fear related to vaginal delivery. Conclusion: Results showed that women’s decision-making on the mode of delivery de- pended on their family and friends’ opinions. Health care providers had few roles in providing the necessary information about the advantages and disadvantages of delivery modes, childbirth, and decreasing their fear of vaginal delivery. Keywords: Pregnant women; Attitude; Perception; Knowledge; Mode of delivery Khadija Mirkhan Ahmed; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: khmirkhan@yahoo.com) Tiran Jamil Piro; Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Iraq. 11 Erbil Journal of Nursing & Midwifery Received: 23/11/2021 Accepted: 09/02/2022 Published: 30/05/2022 mailto:khmirkhan@yahoo.com https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article are estimated at 50% in Asia and 48% in China. However, according to WHO recom- mendation, this rate should be reduced to 5-15%. The safest and most common mode of childbirth is vaginal delivery, and in most cases, cesarean section is done on women with high-risk pregnancies [1].The cause of increased cesarean section rate and choos- ing cesarean section are influenced by many factors, including previous cesarean section, multiple gestations, malpresenta- tion, fetal distress, failure in labor progress, and mother’s medical conditions [5]. Now- adays, maternal request is the most com- mon non-medical reason that may increase the cesarean rate, despite the extra cost for families and medical costs for health facilities. According to Lewis's theory, pain and fear associated with CS could affect mothers' decisions because they think they will have less pain in cesarean delivery [6]. Unnecessarily high cesarean rates have ad- verse implications regarding women's health, health charge, and resources bene- fits at the personal, family, and social lev- els. Non-clinical factors have equally essen- tial factors as clinical factors when looking at the rapidly increasing cesarean section rate. Women who select cesarean delivery believe that vaginal delivery is a more pain- ful and dangerous procedure without con- sidering the negative outcome of unneces- sary operation intervention [2]. The high cesarean section rate and the role of wom- en's preference for mode of delivery are disputed. Assessing these preferences are complicated because they are influenced by family, knowledge about risks and bene- fits, and cultural and social factors [3]. Knowledge of pregnant women about de- livery comes from family exchanges and others’ experiences. Evidence confirms that hearing the experiences of others is an effective way to help women select the mode of delivery [7]. Optional CS inflict high costs on the healthcare system and lead to many complications for mothers. Identifying the intellectual and internal fac- tors that affect their preference for child- birth methods and educating primiparous mothers can reduce their anxiety and fear related to vaginal delivery and motivate them to choose a vaginal delivery method [7]. Women’s beliefs and perceptions re- garding CS play a significant role in se- lecting a birthing method. Women’s deci- sion making sometimes depends on cultur- al factorss, social support, and women's knowledge and attitude. Selecting a child- birth method does not depend on the ma- ternal and fetus condition identified by Sa- navi et al. [9]. The cesarean rate in 2012 in Iraq was 24.4% for all births, 25.4% in Iraqi Kurdistan, and 24.3% in Center/South of Iraq rates of cesarean, which were far above the WHO recommended rate of 10%. From 2008 to 2012, Iraq had a rapid upward trend in the cesarean rate, with much of this trend attributed to the Kurdi- stan Region [11]. Women's perceptions and attitudes regarding the mode of deliv- ery and factors associated with the pre- ferred delivery method were explored in the present study. Study design An exploratory qualitative design with in‑depth interviews was used to explore women’s perceptions and atti- tudes toward the mode of de- livery.Participants and setting This study was conducted from January to March 2021 at two Primary Health Care (PHC) centers (Nazdar Bamarny and Tayrawa) which provides antenatal care unit in Erbil city, Iraq. Eighteen pregnant women who attended the antenatal care unit without significant complications (no indication for cesarean section, no medical condition) were eligible for the study. The partici- pants were between fifteen to thirty-five weeks of gestation. Those who did 12 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Data analysis All in-depth interviews were tape-recorded, transcribed, and later ana- lyzed. Inductive content analysis methods were used to establish the themes. Data collection, transcription, and analysis were assumed on an iterative process. Starting transcriptions were in Kurdish, which was taken then back-translated to English be- fore coding. WHO recommended that the "onwards backward technique" for qualita- tive data transcription between two lan- guages be followed [2]. All transcribed da- ta were read carefully after gaining a gen- eral understanding of the information, highlighted the text that obtained the theme related to the questions, and cate- gorized into meaningful units that were subsequently coded manually by the re- searcher. Finally, the main themes and subthemes were determined according to extracted meaning units. The findings con- sist of four main themes and nine sub- themes. Table 1 presents an example of themes, subthemes, and meaning units. This study interviewed eighteen pregnant women aged 17 to 34 years old. The mean age at marriage of the total sample was 21.66 years old. Sixteen participants were housewives, one was employed, and one was a businesswoman. The participant’s education level was 6 in each level, and none of the participants was illiterate. After analyzing the qualitative content of interviews, 48 meaning units were ob- tained. The findings consist of four themes and nine subthemes. These themes were identified in the analysis of interviews ad- dressing perceptions and attitudes of women’s preferred mode of delivery. The main themes were perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak healthcare provid- ers role, and fear related to vaginal deliv- ery. not want to be interviewed or ended the interview were excluded from the study. The number of participants was deter- mined on the data saturation. Data collec- tionData was collected via semi-structured face-to-face interviews with pregnant women attending antenatal care visits in the primary health care center after com- pleting their antenatal care unit schedule. The duration of the interviews was be- tween 30 to 40 minutes. Interviews were conducted in the obstetrician or antenatal care unit staff room. Participants were asked questions relevant to the research objective ("What is your preferred mode of delivery? What are the advantage and dis- advantages of vaginal and cesarean deliv- ery? What is the factor affecting the choice of delivery? What are the sources of infor- mation? Do you take any education regard- ing VD and CS delivery during antenatal care unit checkups?"). After 18 interviews, the data did not lead to any new themes. The number of samples was adequate when data saturation was reached. Accord- ing to Hancock et al., the gold standard for qualitative research is data saturation [12]. Data saturation or sufficiency is reached when there are no new meaning units of information in the data, the point in coding when no new meaning units occur in the data [13]. Ethical considerationsThe Scien- tific and Ethical Committee of the College of Nursing Hawler Medical University ap- proved the study protocol. In addition, for- mal permission was granted by the Direc- torate of Health-Erbil/ Planning depart- ment to Nazdar Bamarne and Tayrawa health care centers in Erbil city for data col- lection. The required information was ex- plained, and informed oral consent was obtained from all participants. Confidenti- ality was assured about the participant’s identity and personal information. The data collected were stored in Microsoft word files and were password protected. 13 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 14 Erbil Journal of Nursing & Midwifery Table 1: Extracted themes and subthemes of women’s perception and attitude towards a mode of delivery. Themes Subthemes Meaning Units 1 Perceived advantages & disadvantages of a mode of delivery Perceived pros of vaginal delivery Fast recovery after VD Care of the baby Immediate breastfeeding Pain restricted after delivery Perceived cons of cesarean sec- tion More painful after delivery Tearing of abdomen, stitches, and scars on the abdomen. Side effects of anesthesia Restricted Physical activities Need care and rest after CS 2 Knowledge deficit Source of knowledge Family source Mother's experience Having no information about childbirth No information about characteris- tics of labor pain Inability to choose the mode of delivery due to lack of information about VD and CS No information about the ways to reduce VD pain. 3 Weak health care provider's role Inadequate information received from a healthcare provider None of the pregnant women re- ceived any information about VD and CS delivery during antenatal care unit checkups. Not allocated time for the moth- ers The physician does not have time to explain more to mothers in the clinic Mother feels the private hospital's doctors drown them to do an op- eration to finish the labor process as soon as possible. 4 Fear related to vaginal delivery Fear from vaginal delivery in prim- igravida women Fear from labor pain Do not tolerate pain Fear from vaginal episiotomy and wound stitches in multipara wom- en Having awful experience of VD episiotomy and stitches. https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article she is still in pain and has not recovered as before…" (Participant 8). B:Perceived cons of cesarean section Tearing of the abdomen, stitches, pain, re- stricted physical activity, wound healing, anesthesia side effects, and cesarean com- plications were some of the perceived cons of cesarean delivery mentioned by partici- pants. A 20 year old primiparous woman stated: "…In a normal delivery, if there is a stitch, it will heal soon, but in a cesarean section, the wound site will not heal soon, and mother cannot lift heavy things, and any duties cannot be done, the others said the wound scar is always itching and pain- ful…" (Participant 3). A 24 year old primi- gravida woman referred to this issue in this way: "… the side effect of cesarean after delivery will turn out, mothers after cesarean will faced anesthesia side effect, back pain, and many diseas- es..." (Participant 15). Another participant concerned about the care after delivery stated: "…I have seen that my sister and the brother's wife have so much pain after cesarean and just need someone to care and served them for a month…" (Participant 12). Theme II: Knowledge deficit The second them obtained from data anal- ysis was knowledge deficit. Source of infor- mation and limited knowledge regarding modes of delivery are two subthemes identified within this theme ( Table 1). A: Source of knowledge In response to the researcher's question regarding the source of information, all participants mentioned they had obtained information from the family’s [mother] ex- perience and word of advice from others. One of the woman pointed out: "… due to it is my first baby, I heard from others that vaginal delivery better than cesarean sec- tion, my mother and my family said that 15 Erbil Journal of Nursing & Midwifery Theme I: Perceived advantages and disad- vantages The first theme that emerged from data analysis was “perceived advantages and disadvantages of vaginal delivery and ce- sarean sections”. Within this, two main subthemes were identified, “perceived pros of VD” and “perceived cons of CS." Participants mentioned several advantages of vaginal delivery and disadvantages of cesarean section (Table 1). A:Perceived pros of vaginal delivery In this study, most of the participants men- tioned the reasons of choosing vaginal de- livery as a preferred mode of delivery in- cluded a fast recovery, can take care and have a healthy baby. A 25 year old primi- gravida woman said, "I prefer natural deliv- ery instead of the cesarean section because I feel that the baby will come at the right time and it's healthier for the baby. Also it's better for my body too, so I can get up and do exercise sooner, in natural delivery mother can take care and breastfeed soon- er…" (Participant 2). Another participant said: "I like to have vaginal delivery be- cause after delivery you can get up very soon, but cesarean section need to be in bed for a month, my sister in law had a ce- sarean section, and she was in bed for a month while I had a vaginal delivery and it was better than CS…" (Participant 18). An- other perceived pros of vaginal delivery mentioned by a participant were restricted pain in vaginal delivery. Women’s per- ceieved that pain is limited to the labor time in vaginal delivery. In contrast, cesar- ean section's pain will start after delivery. A 30 year old multigravida women de- clared that: "…The pain of normal delivery is only one day, and pain will be finished after the baby is born. However, the pain of cesarean delivery starts after the baby is born, my sister had a cesarean section, and https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article too…". Another woman said: "…I have tak- en this information from the persons around me that have been vaginal or cesar- ean delivery….". A 30 year old multipara woman with two prior vaginal deliveries states: "… I know that the vaginal delivery easier than cesarean I had two vaginal de- liveries, nobody has given me information about mode of delivery…". Two participants in this study referred to media and televi- sion as sources of information besides fam- ily sources. None of the participants men- tioned the healthcare provider as a source of information. B: Having no information about mode of delivery Women with high knowledge about mode delivery have more power to choose the preferred mode of delivery. Regarding the limited knowledge and many misconcep- tions about the mode of delivery, one par- ticipant said: "… this is my first child, and I don't know any better method of delivery, my friends told me that a cesarean section is a better way, but I do not know what the difference between vaginal and cesarean delivery is" (participant 4). C: No information about characteristics of labor pain The only disadvantage of vaginal delivery was recognized as pain, but managing the labor pain will be helpful to have a pleasant vaginal delivery. Some participants stated that they did not have information about pain management during vaginal delivery, which made them interested in cesarean section. In this regard, a 27 year old primi- gravida women said: "…I fear from normal labor because I heard vaginal delivery has severe pain like to die, but in cesarean sec- tion, I don't feel anything during labor, I don't receive any information on reduced pain during labor before" (Participant 17). Theme III: Weak healthcare provider's role The third theme that emerged from data analysis was the weak healthcare provid- ers’ role. Two subthemes have resulted from data transcripts: inadequate infor- mation received from the healthcare pro- vider and lack of allocated time for the mothers (Table 1) A: Inadequate information received from the healthcare provider In response to the researcher’s question, most participants had not received any in- formation regarding the mode of delivery during ANC checkups. One response in that regard was: "… my family and people around me tell me the natural delivery is better, and I don't know what the best way is, no one explains to me about the ad- vantage or disadvantage of VD and CS…" (Participant 21). B:Not allocated time for the mothers Most ANC programs in PHC centers and doctor’s clinic does not have an education- al program for labor and delivey modes. They only have to check the women physi- cally and conduct routine blood tests. In addition, the ANC units and some doctor’s clinic are crowded because of many visi- tors. They do not give more time to the client’s question. Regarding this issue, one participant said: "…I didn't receive any in- formation towards a mode of delivery, when I visit the doctor's clinic it was too crowded. The doctor doesn't have time to explain more about a delivery, only writes the prescription and give next appointment time to…" ( Participant 24). Another partic- ipant stated: "…I feel that doctors in pri- vate hospitals push the mothers to do a cesarean section, to finish the labor pro- cess faster and doesn't need to spend more 16 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article delivery are painful and unpleasant. A 34 year old primiparous woman with previous vaginal deliverystated: "… I had a previous vaginal delivery, I liked to have a cesarean section in this pregnancy because I had many stitches in vaginal delivery, I could not sit for weeks after delivery. Vaginal de- livery is better than cesarean delivery, but if I had pain for a month after labor, I pre- fer to do cesarean section" (Participant 7). Also, another participant said: "… both modes of delivery are unpleasant, but in case I prefer cesarean section because I had many sutures in previous vaginal deliv- ery, in last pregnancy I had cesarean and I can get up sooner than vaginal delivery because I didn't have any stitch- es..." (Participant 10). This study explored the women’s percep- tions and attitudes toward modes of deliv- ery. Study findings showed attitude to- wards vaginal delivery was positive in most pregnant women. Most of the participants believed that vaginal delivery is a natural and the safest mode of delivery. Vaginal delivery have more advantages than ce- sarean section, including fast recovery, lim- itation of pain to the labor, ability to breastfeed, care of baby and ability to par- take in physical activities. Women in North of Iran believed that vaginal delivery, as a safe method, is not associated with com- plications occurring due to cesarean sec- tion. Short-term pain, easier breastfeeding, and the ability of the mother to carry out child-related activities ate the advantages of vaginal delivery [15]. Canadian mothers believe that vaginal delivery has ad- vantages such as healthier babies, better breastfeeding, and quick recovery [16]. In our study, some women discussed pain, restricted physical activities, wound heal- ing, and tearing of the abdomen as time caring for the mothers during the labor process….". Theme IV: Fear related to vaginal deliv- ery Fear was recognized as the most appar- ent disadvantage of vaginal delivery. Fear of pain and not tolerating the pain in all pregnant women were identified. The fourth theme that emerged from data analysis was fear related to vaginal deliv- ery. Two subthemes were obtained with- in this: fear from vaginal delivery pain in primigravida women and fear from vagi- nal episiotomy and wound stitches in multipara women. A:Fear from vaginal delivery in primi- gravida women Lack of previous delivery experience in primigravida and not knowing about the labor process leads to the fear of deliv- ery. Some of the participants were afraid of labor pain due to words and experi- ence of others. This is highlighted by one of the participants: "I like to have cesare- an delivery because I am afraid of vaginal delivery, I'm afraid of the pain of labor, I will not be aware the labor process with cesarean, my mother told me vaginal de- livery is better for birthing baby, but I can't tolerate the pain, I heard from peo- ple, and I watched in the net that vaginal delivery have severe pain…" (Participant 11). B: Fear from vaginal episiotomy and wound stitches in multipara women Many multiparous women did not have good experiences of previous vaginal de- livery because of stitches and episioto- mies. Episiotomy has more pain in cases of suturing done without using any local anesthesia. Women who had an episioto- my in vaginal delivery and cesarean sec- tions perceived that both modes of 17 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article section [20]. According to the study find- ings, healthcare providers have an insuffi- cient role in educating pregnant women about labor mode, childbirth, and decision making. Healthcare and health facilities have a weak position in providing infor- mation for pregnant women regarding mode of delivery and childbirth education. This study finding also showed that educa- tional programs regarding childbirth were not found in antenatal care programs in the primary health centers in Erbil. None of the participants received any information about the medical indications for cesarean section, nor its benefits and risks during third-trimester antenatal checkups [2]. An- other study also revealed a need to pro- vide better information for pregnant wom- en during the antenatal period about modes of delivery, indications, advantages, and adverse consequences, which will help them in informed decision-making [43]. This study also highlighted some partici- pants’ perception that the healthcare pro- viders and physicians have not allocated time to educate them towards childbirth because of many visitors and crowded places, even in the private clinics. The find- ings are consistent with some of the stud- ies that staff cannot monitor labor and in- sufficient facility and human power in the hospital [2]. The present study report that some participants believed that the private hospital-physician performed cesarean section without any indication due to inad- equate time to monitor the normal labor process. According to the study findings, most of the participants have a positive attitude to vaginal delivery, but fear is the main disadvantage of vaginal birth. This study showed that some primiparous women had a fear of childbirth. Other studies also showed that most primiparous women had doubts about their preference for delivery due to fear before childbirth and fear from other women's experiences the disadvantages of cesarean section. Other studies also reported that cesare- an sections had more complications than vaginal delivery, including bleeding, wound infections, and breastfeeding problems [17, 18]In this study, findings revealed that women’s lack of knowledge of advantages, disadvantages, indications, pain management, and labor process influenced their decision about the mode of delivery. Some study find- ings showed that increased knowledge and information influence personal abil- ity to obtain critical points and increase their understanding and perception. In- creaing knowledge was more effective the decision to consider vaginal delivery and reducing elective cesarean section [8,19]. According to the finding, the par- ticipants of primiparous women with their first pregnancy experience as well as multipara women have family sources and relative words as their primary source of information. In Erbil city, ante- natal care programs in primary health centers did not include information, difference, benefits, and risks of vaginal and cesarean delivery during antenatal visits. The significant sources of infor- mation for pregnant women are family, friends, and other women who had simi- lar experiences. Few participants pointed to books and media as a source of infor- mation. Other findings of this study shows that primiparous women’s percep- tion of vaginal birth as a painful process, lack of knowledge regarding pain man- agement, and diverse ways to cope with the pain affected their decision to give birth vaginally or cesarean. These find- ings are consistent with a quantitative study that pointed out that women with more information about painless vaginal delivery methods may reduce the num- ber of women with fear of childbirth and the rate of preferred elective cesarean 18 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [1] Mohammadzadeh, Fatemeh and Sheidaei, Sedigheh and jafarnejad, farzaneh and taji- heravi, ala. The Effect of Peer Education on Pregnant Women's Choosing Mode of Deliv- ery. Journal of Midwifery and Reproductive Health. 2019 .vol.7. 1880-1887. Available from doi:10.22038/JMRH.2019.38654.1429. [Accessed 2020 Nov 21] [2] Begum, T., Ellis, C., Sarker, M. et al. A quali- tative study to explore the attitudes of wom- en and obstetricians towards cesarean deliv- ery in rural Bangladesh. BMC Pregnancy Childbirth 2018.vol.18, 368. Available from doi: https://doi.org/10.1186/s12884-018- 1993-9. [Accessed 2020 Nov 20] [3] Dogra, Pooja and Reena Sharma. "Preferences of pregnant women regarding mode of delivery: a questionnaire-based study." International Journal of Scientific 2017.vol. 3: 292-295.Available form doi:10.18203/ISSN.2454- 2156.INTJSCIREP20174870. [Accessed 2020 Des 12] [4] Ajeet S, Jaydeep N, Nandkishore K, Nisha R. Women's Knowledge, Perceptions, and Po- tential Demand towards Caesarean Section. National Journal.2011. vol. 2. 243-248. [Accessed 2020 Nov 20] [5] Varghese S, Singh S, Kour G, Dhar T. Knowledge, attitude and preferences of pregnant women towards the mode of deliv- ery in a tertiary care center. International Journal of Research in Medical Scienc- es,2016.vol 4, No 10. Available from doi: http://dx.doi.org/10.18203/2320- 6012.ijrms20163299. [Accessed 2020 Nov 20] [6] Taheri Z, Mazaheri MA, Khorsandi M, Has- sanzadeh A, Amiri M. Effect of Educational Intervention on Self-efficacy for Choosing Delivery Method among Pregnant Women in 2013. International journal of preventive medicine.2014.vol. 5,10 : 1247-1254. PMCID: PMC4223943. [Accessed 2020 Nov 21] [6, 21]. This study highlighted that fear of episiotomy during vaginal delivery in the multiparous women who had previous episiotomy experience and chose cesare- an section as preference mode for future deliveries. Similar to this study, maternal requests for cesarean delivery after an episiotomy and painful sexual inter- course were mentioned in some research [2, 22]. Strength and limitation of the study Focusing on women’s perception toward a mode of delivery for the first time in the Kurdistan region and involv- ing women of different ages are the strengths of the present study. Most of the participants are housewives which may be considered as one limitation of the study because the different back- grounds of knowledge may affect the re- sult of the study. Another limitation is not examining the relationship between the previous experiences of women with the current attitude regarding mode of delivery. The main themes that emerged from the study were the perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak health care pro- vider’s role, and fear related to vaginal delivery. Vaginal delivery was the pre- ferred mode of most participants. How- ever, preference of mode of delivery de- pended on experiences of families and friends experiences. Developing a health policy for advancing the role of health care providers in supporting women em- powering them in decision making, and providing childbirth education programs for pregnant women regarding mode of delivery is recommended There is no conflict of interest 19 Erbil Journal of Nursing & Midwifery CONCLUSION Conflict of interest REFERENCE https://doi.org/10.15218/ejnm.2022.02 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [14] Moretti F, van Vliet L, Bensing J, Deledda G, Mazzi M, Rimondini M, et al. A standardized approach to qualitative content analysis of focus group discussions from different coun- tries. Patient education and counseling journal,2011. vol. 82,3: 420-8. doi:10.1016/ j.pec.2011.01.005. [Accessed 2021 Aug 11] [15] Zakerihamidi M, Latifnejad Roudsari R, Merghati Khoei E. Vaginal Delivery vs. Cesar- ean Section: A Focused Ethnographic Study of Women's Perceptions in The North of Iran. 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