patients scheduled for surgery experience varying levels of anxiety , due to factors like , cultural diversity , type of surgery , previous anesthesia experience , and preoperative information . previous studies have reported anxiety of being awake during surgery as one of the most common reasons for choosing general anesthesia ( ga ) , but whether higher level of preoperative anxiety influences patient 's decision to refuse regional anesthesia ( ra ) needs to be determined . literature has reported a higher level of preoperative anxiety in obstetric patients compared to general surgical population . cesarean section ( cs ) is one of the most common surgical procedures performed on obstetric patients , and ra is the preferred technique of anesthesia in terms of risk and benefits for both mother and fetus . in modern obstetric anesthesia practice , unfortunately , in our setup there is still a high rate ( 46% ) of ga in patients undergoing cs and patient 's preference is found to be the commonest reason for choosing ga . therefore , the hypothesis of this study is based on the presumption that a high preoperative anxiety level among parturient scheduled for cs can affect their decisions to prefer ga as the choice of anesthesia technique . it is essential to determine if anxiety influences the choice of anesthesia among women , in order to take measures to reduce the level of anxiety . the primary objective of the study was to determine the frequency of anxiety in patients selecting ga or ra for cs . the secondary objective was to determine the factors associated with anxiety in patients selecting either ga or ra . after approval from the hospital ethics committee , this cross - sectional study was conducted in obstetric wards from april 01 , 2011 to may 31 , 2011 . those included in the study were american society of anesthesiologists i and ii female patients ( age between 18 and 45 years ) undergoing elective cs who were able to make their own decision for selecting ga or ra . the exclusion criteria included patients not willing to participate in the study , with known psychiatric illness , a history of taking any antianxiety or antidepressant medications , language barrier , having absolute or relative contraindication for either ga or ra , bad obstetric history , complicated pregnancy or having congenital fetal anomaly . primary investigator visited the patients one night before the surgery between 18:00 h and 22:00 h. the study participants were detailed about the purpose of the study and were familiarized with visual analog scale for anxiety ( vas scale ) . data collection proforma was comprised of two sections , the first section contained the demographic details of the participants and the other section was based on vas for measuring anxiety by showing a 100 mm straight line , with a zero on the left side indicating no anxiety , and 100 on the right side indicating maximum anxiety . participants were asked to mark the line below with a vertical stroke to show how anxious they felt at the moment . patients then were asked about their source of information regarding anesthesia techniques and their choice of anesthesia for scheduled cs . it was based on the previous study in which anxiety among the obstetric population was reported in the range of 73.3 - 86% . a total of 154 pregnant women were needed to estimate the anticipated rate of anxiety of 73.3% within 7% level of precision with 95% confidence interval . all statistical analysis was performed using statistical packages for social science version 19 ( spss inc . , chicago , il , usa ) . mean and standard deviation were computed for age of the patients . frequency and percentage were computed for age categories , educational level , occupation , source of information , parity , previous experience of anesthesia , type of anesthesia and anxiety score and analyzed by the chi - square test . logistic regression was also applied to compute odd ratio with 95% confidence interval for the association of factors leading to anxiety and choice of anesthesia of the patients and association between various factors and prevalence of anxiety . during the study period , a total of 157 elective cs were scheduled in our obstetric unit . out of them 154 patients were enrolled , who consented to be a part of the study and fulfilled the inclusion criteria . the characteristics of the patients population in terms of age , education level , occupation , parity , previous anesthesia experience , source of information and choice of anesthesia are presented in table 1 . the majority of the study patients were housewives , with graduate level of education , having previous anesthesia experience and received information from an anesthetist . rate of anxiety was significantly high in patients of ga group as compared to ra group ( 97.2% [ 69/71 ] vs. 51.8% [ 43/83 ] ; p < 0.01 ) as shown in figure 1 . patient characteristics in terms of age , education , occupation , parity , previous exposure , source of information and choice of anesthesia comparison of incidence of anxiety between patients with general and regional anesthesia ( 97.18 vs. 51.81% ; p = 0.0005 ; odds ratio = 32.09 95% confidence interval : 7.37 - 139.62 ) a statistically significant association with preoperative anxiety ( vas  50 ) was observed with factors like age < 25 years , working women , nulli and primiparous , no previous anesthesia experience , having previous anesthesia experience under ga and those having their source of information from nonanesthestists as presented in table 2 . association between various factors and prevalence of anxiety ( n=154 ) on further analysis , it was found that anxious patients had a statistically significant association ( p < 0.05 ) with factors like nulli and primiparous , having previous anesthesia under ga and getting information from nonanesthetists [ table 3 ] . the study showed an overall high level of anxiety in patients scheduled for elective cs , as 72.2% of the patients had a vas 50 , which is consistent with previous studies reporting high level of anxiety in obstetric patients . high levels of anxiety in cs patients can possibly be due to the fear of surgery , added to the anxiety of pregnancy . holmes and rahe in their social readjustment rating scale have ranked pregnancy 12 out of 43  life 's most stressful experiences ,  while surgery ( personal injury or illness ) is ranked 6 place in this scale . therefore , patients undergoing cs , belong to the susceptible group of patients having high level of preoperative anxiety . this study has shown an association between preoperative anxiety and selection of ga , as high level of anxiety was found in patients selecting ga as compared to those opting for ra ( p < 0.05 ) . previous studies have shown that patients who are unable to cope with the additional challenges of being awake during surgery request ga . in addition , fear of regional block not working and needle phobia are additional causes of anxiety preventing patients to choose ra . consequently , preoperative anxiety due to multiple reasons can affect the patient 's choice of anesthesia . despite ra being the recommended technique for cs , it is contraindicated in cases when there is a patient refusal . in our institution , patient 's refusal for ra is one of the major reasons for the failure to achieve the internationally recommended rate of ra for cs . other investigators have also cited maternal request as the chief reason for ga especially in elective cs . the average age of patients presenting for cs in our hospital during this study was 29.18  4.46 years , and a correlation was observed between age < 25 years with anxiety that is consistent with previous studies . however , the study conducted by domar et al . , has failed to show age as a determinant of preoperative anxiety . another factor related to high anxiety in obstetric patients could be female sex as previous studies have reported a high level of anxiety in the female gender . yet as per the findings , educated patients were more anxious as compared to less educated but the difference was not statistically significant . the literature also shows conformity of high levels of anxiety among educated patients due to their awareness of complications . however , other studies contradict the association between anxiety and education . the study findings and literature state that nulliparous patients tend to have a high level of anxiety . while , thorp et al . a significant association of anxiety was found in patients having previous surgery under ga , who preferred to have ga again . kindler et al . , found higher scores of anxiety in patients with previous negative experience . in this study , patients receiving information from other than anesthetist were more anxious , and majority of them opted for ga . studies have shown that the source of information from family / friends and misconceptions related to anesthesia are the top most reasons for patients refusing ra . in contrast patients , receiving information from anesthetist were less anxious , and majority of them selected ra . previously reported literature has shown that a preoperative visit by an anesthetist alone was almost as effective in reducing anxiety as compared to the combination of the preoperative anesthetic visit and premedication . ngan kee et al . , concluded that anesthetist do influence the decision of patients and can encourage them for ra . the study has few limitations for instance the indication for cs was not observed , which could influence the level of anxiety among parturient . however , factors like bad obstetric history , complicated pregnancy and patients having congenital fetal anomaly , were among the exclusion criteria of the study . in addition , the satisfaction score among parturients choosing either ga or ra was not measured , but could have reflected patient 's satisfaction in relation to the choice of anesthesia technique . this study has clearly indicated that anxiety was one of the reason for refusing ra in our patient population , therefore specific measures to reduce anxiety in these patients could help us in achieving the international target for ra in cs patients . it is suggested that every patient coming for elective cs should be assessed for the presence of anxiety in their routine preoperative anesthesia assessment and patients found to have a high level of anxiety should be scheduled for an additional counseling session from an anesthetist . this measure helps to reduce the anxiety level and assists in making a rational decision regarding their choice for anesthesia technique .
background and aims : we aimed to measure the frequency of preoperative anxiety in patients undergoing elective cesarean section ( cs ) and its impact on patients decision regarding the choice of anesthesia.material and methods : this cross - sectional study included 154 consecutive patients , who were scheduled for elective cs . 
 visual analog scale ( vas ) for anxiety was the study tool , and vas 50 was considered as significant anxiety . 
 enrolled patients were interviewed by the primary investigator the day before the surgery and their vas score and choice of anesthesia technique either general anesthesia ( ga ) or regional anesthesia ( ra ) were recorded . 
 additional data included demographics , parity , educational status , previous anesthesia experience and source of information.results:preoperative anxiety ( vas  50 ) was seen in 72.7% of patients , which was significantly higher ( p < 0.005 ) in patients selecting ga ( 97.18% , 
 n = 71/154 ) as compared to those selecting ra ( 51.81% , n = 83/154 ) for elective cs . 
 statistically significant association of anxiety ( p < 
 0.005 ) was seen with age < 25 years , nulli and primiparous , higher education status , previous anesthesia experience and source of information from nonanesthetist.conclusion:patients scheduled for elective cs were found to have high frequency of anxiety ( 72.7% ) , and ga was observed to be the choice of anesthesia technique in anxious patients .