**1. Introduction**

Happiness is a mental or emotional state of well-being and happy individuals tend to interpret and process feelings in a positive way [1]. Pregnancy and childbirth cause a wide range of physical, mental, and social alterations in women. Pregnant women's perceptions and attitudes toward pregnancy are important due to their impact on the individual's mental and emotional well-being [2]. Psychologically healthy women consider the pregnancy as a manifestation of self-actualization [3], feminine identity [4] contemplate gestation as a unique experience, and in most cases feel happy during pregnancy [5].

The birth event itself is a pivotal experience in a woman's life and the transition to motherhood is a multi-level endeavor that influences many aspects of psychophysiological wellness and happiness [2]. In particular, a long-term sense of self-efficacy, what may be termed 'empowerment,' has the potential to be either critically enhanced or critically eroded during this time, via the birthing experience itself, but also through the woman's overall quality of life during the perinatal period [6]. The time leading up to the birth event, the period of recovery and bonding with the neonate which follows, are times of extraordinary physical and psychological fluctuation and change, as well as cognitive development or adjustment [7].

It is not undue to liken a woman's birthing journey to a type of second adolescence–a key developmental milestone, marked by intense bodily changes, fluctuating feelings of expectation, growth and uncertainty, and an emerging identity which determines long-term happiness for the woman herself and influences the trajectory of the family ecosystem [6]. Clearly, it is a period that ought to be skillfully navigated, ideally with adequate support structures already in place, and with ease of access to expert individualized care, perhaps particularly so in the case of a prim gravida.

As with other transitional life events, the perinatal period offers potential for joy and well-being, but it is also a period of heightened vulnerability to various stressors [7]. Birthing itself is viewed by many women as a liminal experience, regardless of low-risk designation. In this context, a feeling of uncertainty over outcomes and re-activation of past traumas can become especially salient for many women [8]. Feelings of anxiety may negatively impact labor progression and the general physical and psychological health of the pregnant mother, the fetus, the neonate, and the family unit [9]. Effectively addressing these normal feelings, preventing them from escalating into phobias, learning and practicing new health-promoting habits and coping skills, and re-kindling a sense of embodiment and internal locus of control, gain paramount importance [7]. Coming to a carefully considered, conscious, informed choice about mode of birth is vital, as is access to evidence-based information at each decision-point [10].

### **1.1 What is an informed choice about mode of birth, how does it relate to happiness and why advocate for it?**

Informed choice is predicated on relevant and balanced information [11]. Women during the perinatal period negotiate a complex array of decision points regarding mode of birth [10]. In this chapter, we shall discuss three basic modes of birth: normal birth, cesarean section (CS), and elective cesarean section (ELCS).

The term 'normal birth' has become a controversial one in the current increasingly medicalized birthing climate [12]. While cultural and socio-economic factors play a role in determining birth choice, there is still a majority of women around the world who express the desire to "birth normally" [13, 14]. Normal birth should not be confounded with vaginal delivery. The term "normal birth" encompasses vaginal delivery but is not limited to this descriptor. In its comprehensive definition, "normal birth" refers to a physiological birthing experience with minimal intervention, including avoidance of excessive monitoring, induction with synthetic hormones, routine episiotomy and IV placement, artificial rupture of membranes, favoring nonpharmacological techniques for labor pain management, mobility, choice of birthing position, spontaneous eating and drinking, and non-extractive delivery [15].

Numerous studies have shown that normal birth is associated with better physiological and psychological outcomes for mother and infant [15–20]. Normal birth is an

### *Healthy Mothers, Healthy Children: A Keystone for Happiness in Society DOI: http://dx.doi.org/10.5772/intechopen.107412*

inevitable physiological process which has many positive effects, such as timely first contact of mother and newborn, which is crucial for mother-child attachment and the child's optimal psychological development [16]. Recent studies have shown that initial mother-child interactions, such as skin-to-skin, seeing, holding, and feeding the newborn are critical to the psychobiological process of bonding [17–19]. Positive effects have been documented on the newborn's thermoregulation, stress reactivity and autonomic functioning [17–20]. Normal birth has been correlated with prolonged breastfeeding duration and reduced risk of postpartum hemorrhage [21]. The birth experience also has numerous implications for the psychological health of the mother [22].

Cesarean section (CS) is an emergency procedure for saving the lives of women and newborns [23]. Planned CS is also medically indicated for saving the lives of women and newborns from pregnancy and childbirth-related complications, such as umbilical cord prolapse, abnormal lie and presentation, uterine rupture, fetal asphyxia, eclampsia and HELLP syndrome, failure to progress in labor and pathological cardiotocography [23, 24]. Elective cesarean sections (ELCS) are cases where women determine their own acceptable risk level and opt for CS births in the absence of any medical indication [25]. Women who make this choice perceive CS to offer the advantage of enhanced safety and minimized risk, due to the fact that surgery is a controlled, fully planned procedure managed by a medical expert [26].

Most of the women who deliver by CS report substantially lower satisfaction with the birth experience [24] and less positive memories of the birth [25]. Negative birth experiences are associated with postpartum depression, post-traumatic stress disorder, and a preference for CS in future pregnancies [22]. CS is also associated with increased risk of uterine rupture in subsequent pregnancies, longer recovery time, longer hospital stays, effects on breastfeeding, pain at incision location, mother and child complication with anesthesia and other heightened maternal risks compared to natural delivery [24]. Babies born by CS have different hormonal, physical, bacterial, and medical exposures that alter neonatal physiology. Short-term risks of CS include altered immune development, increased likelihood of allergy, atopy, and asthma, and reduced diversity in the intestinal gut microbiome [23]. Enhanced preparation and communication and an evidence-based risk-benefits analysis, can reduce women's distress and improve satisfaction with a CS birth [27].

Whether birth mode is normal, emergency, or medically indicated CS or ELCS, self-reports consistently demonstrate that women want a satisfying birth experience. Positive birth experiences have far-reaching implications in a woman's life through safeguarding physical health but also through the psychological pathways of increased self-efficacy [28], sense of mastery and competence [29], achieving a peak experience [30], and increased confidence as a new mother [31].

### **1.2 Growing tide of medicalized birth**

In the current birthing climate, it can be argued that vaginal, un-medicalized birth, is not in fact the worldwide norm any longer. According to the World Health Organization (WHO) [32], 21% of births worldwide happen by CS, up from around 7% in 1990. In many countries, interventions and managed labor techniques are automatic protocols, adhered to regardless of individualized risk assessment of a woman's potential to birth without complications. In many places, even women at extremely low risk are not diligently informed of their right to consent in these precautionary interventions, either in the educational period leading up to the birth or at the birthing facility following the onset of labor [33].

In addition to the shrinking definition of "normal" birth and the dramatic rise in CS deliveries, some countries have seen a steep rise in the phenomenon of nonemergency ELCS. Cyprus is one such country and can therefore be used as lenses for understanding systemic elements that drive and normalize such a hyper-medicalized birthing culture [33]. While the World Health Organization (WHO) has long stated that the emergency CS rate should be between 10% and 15%, in stark contrast, Cyprus has a rate of 56% (2014–2018). This –the highest rate of birth by CS in Europe [32, 33]– comprises a large proportion of cases of non-medically indicated ELCS. Correlated with this Cyprus has a very low breastfeeding rate. The "BrEaST start in life" project was a nationwide study jointly carried out by the Cyprus Breastfeeding Association and Nursing department of Cyprus University of Technology showed that fewer than 20% of women in Cyprus breastfeed exclusively even 48 hours after birth and fewer than 5% for 6 months, which is the WHO's recommendation [34]. The project also showed fragmented and suboptimal practices across Cypriot maternity clinics in the context of promoting and protecting breastfeeding [35].

The causes for this exceptionally medicalized birthing culture, in which nonemergency managed labor has become a statistical norm, are complex and certainly not adequately explained by the wishes and autonomous choices of women [33]. Contextual factors beyond the scope of the individual woman are at play, including commercialization of medical service provision and a health system skewed toward maximal risk aversion. In this context, many midwives feel it is their ethical duty to advocate for women at low risk of birthing complications who desire a psychologically safe, non-medicalized birthing experience [36].

As part of this venture, two first-time studies on perinatal care were undertaken recently in Cyprus. One is an ethnographic study that has yielded a preliminary description of the culture of parenting preparation classes in Cypriot public and private birthing facilities. The second is a participation in the EU-wide Babies Born Better (BBB) survey which has yielded self-reports of women in Cyprus on their positive or negative birth experiences.
