| ObjectiveThis study was guided by the Theory of Planned Behavior,and established a theoretical behavior model for elective cesarean section(ECS)among pregnant women.Based on accurate measurement of the core variables in the theoretical model,a longitudinal follow-up study was used to analyze the trends in the intention of delivery modes and driving factors.At the same time,the determinants of ECS were identified,and the actual behavior model of ECS was constructed.These will provide accurate intervention targets and management entry points for controlling the excessive choice of cesarean section(CS)in pregnant women.MethodsIn this study,literature research and expert group discussions were used to construct a theoretical behavior model for ECS among pregnant women.In order to accurately measure the core variables of the theoretical behavior model,this study was based on a cross-sectional survey from May to July 2018 with 1,053 primiparas in four cities in China as the research object.In addition,in accordance with the principles and methods of scale development,pregnant women's delivery attitude scale and pregnant women's subjective norms scale were developed,as well as the pregnant women's self-efficacy scale was introduced.On this basis,data were collected from primiparas in Wuhan and Qianjiang of Hubei province by longitudinal design.This longitudinal follow-up survey was conducted at four time points: 1st trimester,2nd trimester,3rd trimester,and four weeks postpartum.From September 2018 to October 2019,a total of794 pregnant women completed all four surveys,with a follow-up rate of 75.40%.Latent variable growth curve modeling(LGCM)and Growth mixture modeling(GMM)were used to examine the average trend and subgroup heterogeneity of the trajectory of the delivery mode intention for pregnant women,as well as the influence of related factors(delivery attitude,subjective norms,self-efficacy,etc.)on their intention development trajectory.At the same time,the structural equation Model(SEM)was used to analyze the relationship between variables in the theoretical model,identify the determinants and construct a practical behavior model for ECS.Results1 Cronbach's Alpha coefficients of the delivery attitude scale and subjective norms scale developed in this research were 0.86 and 0.89,respectively.The reliability of the two scales was good.Confirmatory factor analysis showed that the factor structures of the two scales fit well with the actual data,and both scales had good structural validity.2 In this study,the sample size included was estimated to be 656 cases.Considering the loss of investigation subjects and the final exclusion of subjects with medical indications for cesarean section,the sample size recruited in the first baseline survey was estimated to be 1010 cases.In the actual longitudinal follow-up survey,1053 pregnant women were recruited at the first baseline survey.A total of 794 pregnant women completed all four surveys and 259 were lost to follow-up,with a follow-up rate of 75.40%.However,233 investigation subjects with medical indications for cesarean section were excluded,that is,a total of 561 samples were finally included in the analysis of this study.Univariate analysis showed that there was no statistically significant difference in the basic demographic characteristics between those who were lost to follow-up and those who were not lost in the baseline survey(P>0.05).In addition,there was no statistically significant difference between the two groups in the distribution of the delivery mode intention,delivery attitude,subjective norms and self-efficacy scores(P>0.05).3 Among the 794 pregnant women who completed all four surveys,the total number of CS was 354,and the CS rate was 44.58%(354/794),of which,233 pregnant women reported medical indications for cesarean section,and the total number of ECS was 121.The overall ECS rate in this study was 15.24%(121/794)and the proportion of ECS in CS was 34.18%(121/354).Among the 561 samples included in the analysis,the proportion of pregnant women presenting CS intention in the 1st,2nd and 3rd trimester were10.0%,9.6% and 10.9%,respectively.4 The development trend of the delivery mode intention was mainly explained from two aspects: the average trend and subgroup heterogeneity of the developmental trajectory of the intention.(1)The average trend: the results of LGCM showed that the average growth rate of the intention of delivery modes during follow-up has significant statistical significance(mean value of eta1(latent slope development factor)is-0.140,P<0.01).Individuals have significant individual differences in the initial level and growth rate of the intention of delivery modes(variances of eta0(latent intercept development factor)and eta1 are estimated to be 0.676 and 0.121,respectively,P <0.01).In addition,self-efficacy,delivery attitude,subjective norms,whether or not the only child and whether or not there is a history of abortion have significant effects on the delivery mode intention development trajectory(P<0.05).(2)Subgroup heterogeneity: the results of GMM showed that there are three different development trajectories in the intention of delivery modes of pregnant women,namely,CS intention-stable trajectory,vaginal delivery(VD)intention-slow enhancement trajectory and the intention from VD to CS-fast enhancement trajectory;The number of people in each development trajectory group was 7.8%,87.2%,and 5.0%,respectively.Compared with those with VD intention-slow enhancement trajectory,those who have a CS intention-stable trajectory are about 9.58 times more likely to take the behavior of ECS;about 6.53 times more likely to take the behavior of ECS among people with the intention from VD to CS-fast enhancement trajectory.5 The results of the SEM showed that the intention of delivery modes has a positive predictive effect on the actual delivery modes of pregnant women(standardized path coefficient is 0.23).The delivery attitude and subjective norms of pregnant women have a direct effect on their intention of delivery modes(standardized path coefficients are-0.10 and 0.34,respectively).Self-efficacy not only has a direct effect on the actual delivery modes(the standardized path coefficient is-0.10),but also has an indirect effect on the actual delivery modes through the intention of delivery modes(the indirect effect value is-0.34*0.23=-0.08).In addition,whether or not there is a history of abortion and whether or not the only child has a direct effect on the actual delivery modes(the standardized path coefficient is 0.10,-0.11,respectively).Conclusions1 The pregnant women's delivery attitude scale and subjective norms scale developed in this research have high reliability and validity,which can accurately measure the individual differences of pregnant women's attitudes and subjective norms to delivery.2 The ECS rate of pregnant women is at a high level,and more effective interventions and management measures are urgently needed to reduce the use of CS.3 The Theory of Planned Behavior is effective in revealing the mechanism of ECS for pregnant women;the delivery attitude,self-efficacy,and subjective norms of pregnant women have significant effects on the trajectory of the delivery mode intention and the actual delivery modes.Therefore,reducing the CS rate requires multiple interventions,such as improving the self-efficacy of pregnant women,changing their negative attitude towards VD,and enhancing subjective norms in favor of VD.4 The risk of ECS was significantly increased in sub-populations with CS intention-stable trajectory and the intention from VD to CS-fast enhancement trajectory.In view of this,the sub-populations of these two types of trajectory groups need to attract the attention of health workers,and it is necessary to provide them with personalized and targeted health education during pregnancy. |
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