Hassanzadeh and et al., conducted a research on the comparison of factors related to the choice of cesarean and birth methods in primiparous mothers and reached the following conclusion: out of 140 cesarean births, 66 births (46.5%) It has no medical advice and one of its most important reasons is the fear of vaginal pain, the safety and health of the fetus. With a 1% increase in awareness about the benefits of birth and the disadvantages of cesarean delivery, the chance of birth increases by 15% and 12%, respectively (P < 0.001). Also, with a 1% improvement in socioeconomic status, the chance of choosing a cesarean section increases by 2.45 times. According to the results of this study, increasing awareness about the advantages of birth and the disadvantages of cesarean delivery have a high impact on choosing the natural delivery method. Therefore, considering this case, educational interventions are recommended in the mentioned cases for mothers who intend to become pregnant [15].

Badri and et al., conducted a study on the women’s quality of life after birth and caesarean section and reached the following conclusion: There was no significant relationship between the quality of life of mothers based on the type of delivery, but in the field of physical health. The mothers’ quality of life after birth was significantly higher than the mothers’ quality of life after cesarean delivery. Considering the higher quality of life in the field of physical health in the period after natural delivery, training on emphasizing the effects of this issue on the health of the mother and baby is recommended for specialists and mothers in childbirth preparation classes [16].

In 2017, Mohammad and et al., conducted a research on the effect of specializing educational messages on the choice of the type of delivery in pregnant women and reached the following conclusion: special messages based on awareness, self-efficacy, attitude and perceived social support increase the selection of the method. Birth occurs in pregnant women. Educational programs based on these psychological factors are suggested to guide courtship educational interventions [17].

Ahmadi and et al., conducted a research on the quality of breastfeeding of new mothers in natural delivery and caesarean section in selected military hospitals in Tehran and reached the following conclusion: the quality of breastfeeding in women who gave birth naturally was 114/89 ± 5. 35, which was significantly higher than the quality of breastfeeding in women who gave birth by cesarean section (66.110 ± 36.12) (P = 0.045). Since the quality of breastfeeding is higher in birth, therefore, it is recommended to educate and encourage mothers to perform birth [18].

Interventions and complications of childbirth, including emergency cesarean and postpartum hemorrhage, were significantly related to dissatisfaction with childbirth. Such events are common and awareness of these associations may lead to more individualized care of women during childbirth and after [19].

A combination of medical and non-medical factors increases the rate of cesarean deliveries. Nevertheless, our analysis shows that a significant number of cesarean deliveries have taken place in the absence of medical justification. It seems that the factors providing health and treatment services are effective factors in influencing the rate of cesarean delivery in the studied hospitals [20].

Most of the women in this study had a positive attitude towards caesarean section if necessary. Lack of formal education, age less than 19 years, and unemployment are associated with the weakness of mothers from cesarean section. Education is necessary to improve the perception of cesarean section as a promoter of child survival, and to cool down the perception that causes the negative result of perinatal birth is especially in the population at risk [21].

The present study was conducted in order to investigate the effect of education during pregnancy on the knowledge and attitude of primiparous women and according to the results, the level of knowledge and attitude of the people under the research improves after the education compared to before, which is similar to the results of other studies [1, 22, 23]. On the other hand, in some studies, education during pregnancy did not have a great effect on raising women’s awareness and, as a result, encouraging them to have a natural birth [24, 25]. The majority of people under the present study, before and after the training, had chosen birth as their desired childbirth method, and similar results were obtained in a research [1]. In another study conducted in this direction, women under training who still had a negative attitude towards birth and had not changed, chose cesarean section (3 to 6 times more than others) as their elective delivery [26].

Fear of childbirth is one of the main reasons why women prefer cesarean section. Fear of natural birth, feeling of security, peace and more control in cesarean section are the reasons of Australian primiparous pregnant women to perform elective cesarean section [27]. Wiklund et al. also believe that primiparous pregnant women suffer from the fear of birth pain and therefore prefer elective cesarean section [28]. In Hong’s study, it was found that Taiwanese primiparous pregnant women consider birth as a They understood the threat to the mother and baby and considered cesarean as a way to eliminate this threat [29]. In the studies conducted in Iran, it has also been stated that women, especially primiparous women, prefer cesarean delivery due to the fear of birth pain, fear of harming the baby and mother, fear of reproductive system disorders, and fear of inappropriate handling in the delivery room. They give [9, 29,30,31]. Metinnia et al. showed that the severe fear of primiparous pregnant women can be due to insufficient and inappropriate training and their lack of information [32].

Therefore, it can be concluded that the fear of birth is one of the main reasons for preferring cesarean section, especially among young and primiparous Iranian women. Rudsari et al.‘s study showed that proper communication by midwives and doctors with pregnant women and providing childbirth advice to them reduces women’s fear and anxiety to perform birth and encourages them to perform birth [33,34,35].

In Zamani et al.‘s study, it was found that the most important predictor of choosing the type of delivery is mental norms and modifying women’s attitudes about the benefits and complications of both types of delivery can help increase natural delivery among women [36].

In the design of educational interventions to reduce caesarean section, attitude structures towards choosing the type of delivery and mental norms of primiparous pregnant women should be taken into consideration. Despite the fact that midwives and doctors are influential people in choosing the type of delivery, but various obstacles make the training and counseling done by them ineffective.

Determining the main reasons for choosing a cesarean section and designing a brief intervention and implementing it through people who influence pregnant women (midwives and doctors) can increase the quality and effectiveness of training in health service centers. The content and quality of services provided to pregnant women is a very important and decisive variable in shaping the attitude of pregnant women and the intention to choose the type of delivery. Educational programs, interventions in centers and classes should provide the opportunity for pregnant women to talk about their feelings, concerns and fears. Fear of childbirth is one of the main reasons for preferring cesarean section, especially among young and primiparous women. Therefore, promoting painless childbirth methods and making birth pleasant can be a way to reduce this fear and change the choice of cesarean surgery. Another reason for choosing cesarean is the low awareness of pregnant women about the benefits and side effects of both delivery methods. Training programs that are tailored to the needs and desires of pregnant women can be a way to increase the awareness of pregnant women, and these training programs should be held at a time when the majority of pregnant women can participate [37].

In this research, as a side finding, the delivery performance of the people under study was followed and it was found that although 72.86% had chosen the type of natural delivery after the training, only 62.86% of them had actually experienced a natural delivery. This finding was somewhat unexpected. According to the results of the present research, which shows the effect of education on the preparation for birth, and considering the education provided, the high rate of cesarean in the country can be related to factors other than the mother’s choice, such as unnecessary interventions in the childbirth process.

However, in a study, childbirth preparation method was effective on anxiety during pregnancy and during childbirth and significantly reduced it, and after stopping these trainings, its effect gradually decreased and anxiety increased again [38]. Unlike the present study, which showed a significant relationship between training and changing the attitude of the people under research, in a study, the training provided did not have a significant effect on the attitude of the people [23]. This is probably due to the difference in the educational contents of the emotional domain in the two studies.