Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran


Introduction: Although cesarean section has saved many mothers’ and infants’ lives,
the problem is in its increasing prevalence. According to recent statistics, the current rate
of cesarean in Iran is in fact 3–4 times as more than the standard rate defined by WHO.
Therefore, the present study is aimed to estimate the effect of an instructional program based
on health belief model on reducing cesarean rate among primiparous pregnant women.
Materials and Methods: In this semi‑experimental research, 60 primiparous women who
had visited Bandar Abbas Healthcare Centers were selected as the subjects. They were in
their 26–30th week of pregnancy. They were selected in a multi‑stage cluster sampling method
(a combination of clustering and simple randomization), and were divided into two groups,
subjects and control group. The data were gathered using a valid and reliable questionnaire.
The instructional intervention was done after the completion of the pretest questionnaire based
on the sub‑constructs of the health belief model in six instructional sessions. 1 month after the
intervention, posttest questionnaires were completed by the subjects in both groups. The data
were analyzed using descriptive statistics, standard deviation, independent t‑test, and paired
t‑test. The significance level was set at <0.05. Results: Two groups had a significant difference
between awareness score, perceived sensitivity, intensity, benefits, barriers, self‑efficacy, and
the performance (P < 0.001). In the experimental group, nine subjects (30%) had a natural
delivery. Conclusion: According to the findings of the current research, an instructional program
illuminated (designed) by the health belief model can significantly influence pregnant women’s
awareness, intention, and choice of delivery type.


1. Liu NH, Mazzoni A, Zamberlin N, Colomar M, Chang OH, Arnaud L,
et al. Preferences for mode of delivery in nulliparous Argentinean
women: A qualitative study. Reprod Health 2013;10:2.
2. Zamanialavijeh F, Shahry P, Kalhory M, Haghighizadeh M,
Sharifirad G. Identification of factors related to elective cesarean
labor: A theory‑based studty. Daneshvar Med 2011;19:1.
3. Asadi ZS, Solhi M, Taghdisi MH, Hoseini VM, Javan R, Hashemian M.
The effect of educational intervention based on Theory of
Reasoned Action (TRA) on selected delivery method, for selective
cesarean section in pregnant women. Iran J Obstet Gynecol Infertil
4. Rahmanian K, Rahmanian V, Ghasvar M. The knowldege of pregnant
women about short comings of cesarean and its associated factors
in 2009. J Res Dev Nurs Midwifery 2013;10:84‑91.
5. Cunningham FG, Leveno KJ, Bloom SL. Williams Obstetrics and
Gynecology. 23th ed. USA: McGraw‑Hill; 2010.
6. Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary
tenfold among US hospitals; reducing variation may address quality
and cost issues. Health Aff (Millwood) 2013;32:527‑35.
7. UNDP, UNFPA, WHO. Caesarean section without medical indication
increases risk of short‑term dverse outcomes for mothers. Policy
brief WHO/RHR/HRP/1020; 2010. p. 2.
8. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health
Education: Theory, Research, and Practice.London: John Wiley &
Sons; 2008.p592.
9. Amidi M, Akbarzadeh K. The effects of health education on pregnant
woman’s knowledge and attitude ob cesarean section. J Ilam Univ
Med Sci 2005;14:17‑26.
10. Niaki MT, Behmanesh F, Mashmuli F, Azimi H. The effect of prenatal
group education on knowledge, attitude and selection of delivery
type in primiparous women. Iran J Med Educ 2010;11:124‑30.
11. Sharifirad GR, Moghadam MH, Fathyian F, Rezaeian M. The effect of
health education using behavior intention model on of cesarean in
Khomainy‑shahr, Iran. Iran J Nurs Midwifery Res 2009;14 (3):105‑10.
12. Toghyani R, Ramezani M, Izadi M, Shahidi S, Aghdak P, Motie Z.
The effect of prenatal care group education on pregnant mothers’
knowledge, attitude and practice. Iran J Med Educ 2008;7:317‑24.
13. Sanavi FS, Ansari‑Moghaddam A, Rakhshan F, Navabi Rigi S. Two
teaching methods to encourage pregnant women for performing
normal vaginal delivery. Iran J Med Educ 2012;12:184‑92.
14. Azh N, Ghadam SS, Younesian M. The effect of health education on
the rate of cesarean section. J Qazvin Univ Med Sci 2011;.14 (4):71‑6.
15. Khorsandi M, Ghofranipour F, Hidarnia A, Faghihzadeh S,
Ghobadzadeh M. The effect of PRECEDE PROCEED model combined
with the health belief model and the theory of self‑efficacy to
increase normal delivery among nulliparous women. Procedia Soc
Behav Sci 2012;46:187‑94.
16. Besharati F, Hazavehei SM, Moeini B, Moghimbeigi A. Womens
attitudes toward elective delivery mode based on the theory of
planned behavior. J Guilan Univ Med Sci 2011:20 (79):68‑76.
17. Sanavi FS, Ansari‑Moghaddam A, Shovey MF, Rakhshani F. Effective
education to decrease elective caesarean section. J Pak Med Assoc
18. Statistices. Statistices Cesarean. Bandar Abbas: Hormozgan
University Medical Sciences; 2013.
19. Ghaffari M, Sharifirad G, Akbari Z, Khorsandi M, Hassanzadeh A.
Health the belief model‑based education and reducation of cesarean
among preganant women: An interventional study. Health Syst Res
20. Jeihooni AK, Shahidi F, Kashfi SM. Effectiveness of educational
program based on the theory of reasoned action to decrease the
rate of cesarean delivery among pregnant women in Fasa, Southern
Iran. J Educ Community Health 2014;1:62‑71.
21. Moeini B, Besharati F, Hazavehei S, Moghimbeigi A. Women’s
attitudes toward elective delivery mode based on the theory of
planned behavior. J Guilan Univ Med Sci 201120 (79):68‑76.
22. Fathian Z, Sharifirad GR, Fathian Z, Pezeshkihebi F. Frequency of
cesarean section and its related factors in Khomeinyshahr‑Isfahan
province 2005. Health Syst Res 2011:6 (4):786‑93.
23. Lagrew DC Jr, Morgan MA. Decreasing the cesarean section rate
in a private hospital: Success without mandated clinical changes.
Am J Obstet Gynecol 1996;174:184‑91.
24. Kjærgaard H, Wijma K, Dykes AK, Alehagen S. Fear of childbirth in
obstetrically low-risk nulliparous women in Sweden and Denmark.
J Reprod Infant Psychol 2008;26:340‑50.
25. Ryding EL. Investigation of 33 women who demanded a cesarean
section for personal reasons. Acta Obstet Gynecol Scand
26. Rahimikian F, Mirmohamadaliei M, Mehran A, Ghforoodi KA,
Barough NS. Effect of education designed based on health belief
model on choosing delivery mode. Hayat 2009;14:25‑32.
27. Freimuth V, Linnan HW, Potter P. Communicating the threat of
emerging infections to the public. Emerg Infect Dis 2000;6:337‑47.
28. Hatefnia E, Niknami S, Mahmoudi M, Ghofranipour F, Lamyian M.
The effects of health belief model education on knowledge, attitude
and behavior of Tehran pharmaceutical industry employees
regarding breast cancer and mammography. J Kermanshah Univ
Med Sci 2010;14.(1):42‑53.
29. Lowe NK. Maternal confidence for labor: Development of the
Childbirth Self‑Efficacy Inventory. Res Nurs Health 1993;16:141‑9.
30. Svensson J, Barclay L, Cooke M. Randomised‑controlled trial of
two antenatal education programmes. Midwifery 2009;25:114‑25.
31. Ip WY, Tang CS, Goggins WB. An educational intervention to
improve women’s ability to cope with childbirth. J Clin Nurs
32. Saisto T, Toivanen R, Salmela‑Aro K, Halmesmäki E. Therapeutic
group psychoeducation and relaxation in treating fear of childbirth.
Acta Obstet Gynecol Scand 2006;85:1315‑9.
33. Park S, Chang S, Chung C. Effects of a cognition‑emotion focused
program to increase public participation in Papanicolaou smear
screening. Public Health Nurs 2005;22:289‑98.
34. Sharifirad G, Rezaeian M, Soltani R, Javaheri S, Mazaheri MA.
A survey on the effects of husbands’ education of pregnant women
on knowledge, attitude, and reducing elective cesarean section.
J Educ Health Promot 2013;2:50.