Factors associated with awareness and attitudes toward childbirth methods among pregnant women: a structural equation modeling study

Awareness and attitudes influence the childbirth method chosen by pregnant women, but the pathways linking sociodemographic and obstetric characteristics, awareness, and attitudes are rarely modeled together. This study used structural equation modeling (SEM) to examine these relationships among pregnant women in Birjand, Iran. In this analytical cross-sectional study, 370 pregnant women from eight comprehensive health centers in Birjand were recruited by quota and convenience sampling between October 2023 and March 2024. Awareness (7 items, scored 0–14) and attitude (10 items; higher scores indicating a more favorable attitude toward cesarean delivery) were measured with researcher-developed questionnaires. A measurement model for the two latent constructs was combined with a structural model in which sociodemographic variables predicted awareness, and awareness, obstetric, and sociodemographic variables predicted attitude. Estimation used polychoric correlations, unweighted least squares, and bootstrap standard errors; fit was assessed with the SRMR. Bivariate comparisons were supplementary. All items loaded significantly on their latent constructs (standardized loadings 0.30–0.61 for awareness and 0.58–0.71 for attitude). The awareness scale had low internal consistency (ordinal alpha = 0.62), whereas the single-factor attitude model fitted well (CFI = 0.999). The full model reproduced the observed correlations acceptably (SRMR = 0.056). Awareness was not significantly associated with attitude (β = −0.08, 95% CI − 0.28 to 0.18, p = 0.454). Maternal age, maternal education, household income, and spouse education were not significantly associated with awareness (β = 0.05–0.13, all p > 0.18), nor were previous delivery experience, occupation, and insurance status with attitude (all p > 0.13). The model explained 4.7% of the variance in awareness and 1.7% in attitude. In unadjusted analyses, attitude scores were higher among women with a previous cesarean delivery and among those who preferred cesarean delivery. Neither awareness nor the modeled sociodemographic and obstetric characteristics was significantly associated with attitudes toward childbirth methods, whereas attitudes differed markedly by previous delivery type and delivery preference in unadjusted analyses. Given the low reliability of the awareness scale, this null finding should be interpreted cautiously; better-validated instruments and longitudinal studies are needed. Not applicable.