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Background: Cesarean section rates throughout the developed world continue to rise. Although satisfaction with cesarean section has been widely studied, relatively little is known about the causes of “distress” that may contribute to dissatisfaction. The aim of this study was to explore the factors that women identified as “distressing” so as to understand their responses to standard questions on satisfaction. Methods: A questionnaire study of 1,661 women who had delivered their first babies by cesarean section in Aberdeen, Scotland, between 1980 and 1995 elicited a 75 percent response rate and showed that 81 percent of women were satisfied with the experience. Nevertheless, 36 percent rated an aspect as distressing, and 42 percent provided written descriptions of one or more experiences that had distressed them. These responses were coded using content analysis into 5 major categories: before, during, and after the birth, psychological/general, and overall. Results: The most distressing factors were of a psychological or general nature, with 66 percent of distressed women mentioning poor communications, fears, missing out on the birth or the immediate postpartum period, or other emotions. Events happening before, during, and after the birth caused 23, 45, and 44 percent of women to be distressed, respectively. Surgical complications and infections were distressing, but anesthesia was the single factor that caused most distress, leaving 102 women (20%) with unsatisfactory memories of the birth. Conclusions: The impact of cesarean birth on women’s psychological well-being is highlighted by this study. Enhanced communication during labor and delivery, and preparation or education on issues surrounding cesarean section, can reduce distress and improve women’s satisfaction with birth. (BIRTH 34:2 June 2007) [ABSTRACT FROM AUTHOR]