Abstract
Background:
Despite the global rise in caesarean section (CS), Nigeria has a CS rate of 2.8%, which is far below the World Health Organisation recommendation of 10%–15%. Primigravida and/or first-time mothers constitute a cohort of women who are prone to obstetric emergencies such as cephalo–pelvic disproportion and obstructed labour.
Objectives:
To evaluate the first-time mothers’ knowledge, perceptions, and attitudes towards CS.
Materials and Methods:
This was a mixed-methods study conducted among first-time mothers (primigravids >28weeks and first-time CS-delivered) at Adeoyo Maternity Teaching Hospital, Ibadan, using questionnaires that assessed knowledge and attitude for the quantitative aspect and in-depth interviews for the qualitative aspect using a structured topic guide. Responses from the quantitative aspect were analysed using STATA 15, and each participant’s level of knowledge was scored and categorised as: Good knowledge >70%, fair knowledge 50%–70% and poor knowledge <50%. Content analysis was done for the qualitative aspect, and emerging themes on perception and interpretation in CS were summarised and presented as results for interpretation.
Results:
About 275 mothers (178 pregnant and 97 CS-delivered) were sampled. Only a few (13.45%) of the participants had good knowledge with an equivocal attitude towards CS. The majority (84%) believed that CS helped in saving lives. Also, there was a statistically significant difference between their knowledge and their educational level, occupation, religion, ethnicity, and family income (P < 0.05). The multinomial regression showed that gainfully employed Christian women significantly had more fair and good knowledge than Muslims (RR = 2.01, 95% CI = 1.13–3.57, P = 0.017) (RR = 2.71, 95% CI = 1.23–5.95, P = 0.013).
Conclusion:
Only a small number of the participants had good knowledge, and their perceptions about CS varied. The attitudes of participants towards CS appeared mixed, as nearly equal proportions of participants had positive and negative attitudes. Hence, there is a need to increase advocacy, antenatal education, and counselling during antenatal clinic visits. Also, first-time mothers need to be put on insurance to reduce the burden of costs.
Keywords: Attitude, caesarean section, first-time mothers, knowledge, perception
Introduction
Caesarean section (CS) is the commonest surgical procedure performed on women worldwide[1] to expedite delivery when the mother’s and/or baby’s lives is/are at risk. The World Health Organisation (WHO) recommended a CS rate of 10%–15% in most settings as a standard to reduce maternal and/or neonatal mortality and morbidity, and rates above or below this threshold have not been found to reduce fatality.[2] CS rates are rising globally (accounting for about 21% of all live births), especially in high-income countries in Eastern Asia, Western Asia, and Northern Africa (44.9%, 34.7%, and 31.5%, respectively).[3] Factors contributing to these rising CS rates include maternal request, a higher rate of elective inductions before 39 weeks gestation, with nearly 40% of CS deliveries resulting from dystocia, the use of continuous electronic foetal heart rate monitoring, and fear of litigation. Other factors like preterm birth, breech, advanced maternal age, infertility, and concerns about the mother’s pelvic floor are also common indications.[4] Low-middle-income countries have also witnessed rising CS rates, while a country like Nigeria still has low rates (at 1.8% in 2008 and 2.7% in 2018) despite being one of the countries with the highest maternal morbidity and mortality rates in the world.
Based on the prevalence of obstructed labour and fistulas in Nigeria, the WHO estimated that 16% of pregnancies would benefit from CS to avoid these complications.[5] This further emphasised the problems associated with underutilisation of CS in Nigeria. Most studies have shown that women preferred vaginal births over CS,[6,7] with a reason being that it connotes womanhood in some cultures.[6] Many people in low-income nations still hold strong cultural ideas regarding caesarean delivery, even in the face of the availability of evidence-based safe techniques and advancements. Some of the reasons for aversion include a sense of reproductive failure, financial implications, fear of death, anxieties of negative experiences, and prolonged hospital stay, among others.[8,9] In Nigeria, most pregnant women are aware of the CS, but they do not willingly accept it even when it is indicated because of various beliefs, perceptions/misconceptions. Most pregnant women perceive CS to be dangerous and have a negative effect on the health of the mother, the baby, or both.[10]
One of the studies conducted in Nigeria revealed that roughly 34% of participants attributed their negative opinion of CS to the cultural influence of their communities.[11] However, the perceptions of CS by pregnant women have been an important consideration for healthcare providers. Promoting positive perceptions in CS-related issues is necessary because this can help women to effectively adapt to the role of a mother. Negative perceptions can cause women to feel that they have failed, lost control, or doubt their ability to bear children.[12]
The attitudes of women concerning the mode of birth have been found to be influenced by maternal knowledge and occupation.[13] Certain research findings indicated that women who possess greater education were more inclined to consent to CS if it became necessary.[14,15] When a patient has had a bad experience with surgery in the past, the likelihood of her refusing a CS increases.[16] Primigravida are regarded as a critical group that requires regular assistance in terms of antenatal, natal, and postnatal care, which are beneficial to them during pregnancy, labour, and puerperium. Primigravida is significant in terms of subsequent obstetrical performance.[17] A study done by Kuntal et al.[18] observed that CS was frequently used in primigravida due to an increased risk of prolonged labour, severe pre-eclampsia, cephalo-pelvic disproportion, antepartum haemorrhage, and foetal distress.
These first-time mothers are prone to different myths and misconceptions about pregnancy and delivery because of socio-cultural influence. They are also prone to poor obstetric performance if not well managed. A study done by Daniel et al.[19] observed increased CS rates in primiparous women than in multiparous women and another study by Mulugeta et al.[20] found that primigravida have poor knowledge about birth-preparedness and complication readiness, which can influence their perception and attitude towards CS.
Most of the previous studies on perception and attitude towards CS were conducted on a heterogeneous group of pregnant women, regardless of parity and past obstetric experiences, and not specifically first-time mothers. So, there is a paucity of data on the study of first-time mothers/primigravida’s (a homogenous group of participants) perception and attitude towards CS in Nigeria. Hence, considering the suboptimal CS rate in Nigeria, the high maternal mortality and morbidity, and the key role of first-time mothers in life-long delivery decisions, a study on them was considered. This study mainly investigated the perception, knowledge, and attitude of first-time mothers towards CS.
Materials and Methods
This was a mixed-methods study conducted in Adeoyo Maternity Hospital, a secondary health care facility in Ibadan. The quantitative aspect of the study involved 275 participants. The 275 participants consisted of two groups of women defined as first-time mothers (Group 1: Primigravida with gestational age ≥28 weeks; Group 2: First-time mothers delivered via CS and within 6 weeks postpartum). Selection of participants was done using a simple random sampling technique. Data were collected face-to-face by trained research assistants in a private room within the maternity ward and antenatal clinic to ensure patient confidentiality. The tool for the quantitative aspect was a 38-item structured questionnaire consisting of open- and close-ended questions, and it obtained information on the participants’ biodata and obstetric history, knowledge, perception, and attitude towards CS. The dependent (outcome) variables included first-time mothers’ knowledge, perception/interpretation, and attitude towards CS, while the independent (explanatory) variables comprised of first-time mothers’ sociodemographic factors (age, educational level, occupation, marital status, religion, ethnicity, personal income, and family income).
The questionnaire for the quantitative data had four sections: Demographic variables, knowledge of CS, perception of CS, and attitude towards CS. Data were manually entered into an Excel spreadsheet and analysed with STATA 15. The knowledge section contained 10 questions, with 8 questions having “Yes/No/Don’t know” responses and two open-ended questions. A correct answer was scored 1 point, while an incorrect answer, and don’t know were scored 0. The highest obtainable score was 8, while the least obtainable score was 0. A scoring system was developed for the level of knowledge of the participants; correct answers attracted 1 mark and incorrect answers received 0 mark. The total score was categorised as good knowledge >70%, fair knowledge 50%–70% and poor knowledge <50%. The section on participants’ perceptions contained 14 questions on a five-point Likert scale ranging from 1 to 5 per question. Total obtainable scores were 70 as the highest and 14 as the lowest.
The section on participants’ attitudes contained 13 questions on a five-point Likert scale, with scores ranging from 1 to 5, and 1 open-ended question. Total obtainable scores were 65 as the highest and 13 as the lowest. An attitude score below the mean score was considered negative, while an attitude score above/equal to the mean score was considered positive. Frequency distributions were generated for all categorical variables and means, and the standard deviation, median, and interquartile range, were determined for continuous variables. Chi-square was used to test for the significance of categorical variables. Means and standard deviations, or median with interquartile range, was determined for continuous variables. Multiple logistic regressions were used to identify factors associated with knowledge, attitude, and perception about CS.
The qualitative aspect of the study was used to gather data on the perceptions of participants about CS through in-depth interviews (IDIs). Eight participants were recruited purposefully for the IDIs. The inclusion criteria were first-time mothers delivered via CS: Two via elective CS (without complications), two via emergency CS (without complications), two via emergency CS (with complications), and two via elective (with complications). A structured topic guide was developed from literature to determine their perceptions and concerns about CS. Trained interviewers and the primary researcher conducted the interviews. The interviews were conducted in a private room within the postnatal ward and lasted for about 30 min. The interviews were audio recorded and transcribed verbatim, and manual coding was done with a reflexive diary. Content analysis was done, and there were emerging themes on perception, interpretation, and concerns about CS, which were summarised and presented as results for interpretation.
Ethical consideration
Ethical approval was obtained from the appropriate ethics board before the commencement of the study. Additional approvals were obtained from both the head of the hospital and the matrons in charge of the antenatal and breastfeeding clinics. Informed consent was obtained from all the participants by clearly explaining the purpose and benefits of the study to them.
Results
Most (58.76%) of the participants are within the age bracket (25–34), with more than half practicing Islam as their religion, and most of them (95.64%) are of Yoruba ethnicity. The total number of participants who were currently pregnant was 178 (64.73%), while 97 (35.27%) were first-time mothers who had CS as their mode of delivery, out of which 78 (80.41%) had emergency CS and 19 (19.59%) had elective CS [Table 1].
Table 1.
Sociodemographic information of the participants
| Variables | Frequency | Percent |
|---|---|---|
| Age group | ||
| 15–24years | 96 | 34.67 |
| 25–34 years | 161 | 58.76 |
| ≥35 years | 18 | 6.57 |
| Educational level | ||
| ≤Primary | 19 | 6.91 |
| Secondary | 160 | 58.18 |
| Tertiary | 96 | 34.91 |
| Occupation | ||
| Employed | 43 | 15.64 |
| Self-employed | 197 | 71.64 |
| Unemployed | 35 | 12.73 |
| Marital status | ||
| Single | 30 | 10.91 |
| Married | 245 | 89.09 |
| Religion | ||
| Christianity | 100 | 36.36 |
| Islam | 175 | 63.64 |
| Ethnicity | ||
| Yoruba | 263 | 95.64 |
| Non-Yoruba | 12 | 4.36 |
| Personal income | ||
| Low-income earner | 232 | 84.36 |
| Middle-income earner | 39 | 14.18 |
| High-income earner | 4 | 1.45 |
| Family income | ||
| Low-income earner | 118 | 42.91 |
| Middle-income earner | 112 | 40.73 |
| High-income earner | 45 | 16.36 |
| Obstetric status | ||
| Still pregnant | 178 | 64.73 |
| CS-delivered | 97 | 35.27 |
| CS-delivered | ||
| Elective CS | 19 | 19.59 |
| Emergency CS | 78 | 80.41 |
Knowledge about CS
As shown in Figure 1 and Table 2.
Figure 1.
Knowledge of participants on CS
Table 2.
Knowledge of first-time mothers about CS
| Statements | Correct | Incorrect |
|---|---|---|
| n (%) | n (%) | |
| Reasons for CS | ||
| Vagina bleeding in pregnancy before delivery | 87 (31.64) | 188 (68.36) |
| Convulsions in pregnancy | 91 (33.09) | 184 (66.91) |
| Big baby | 202 (73.45) | 73 (26.55) |
| Prolonged labour | 202 (73.45) | 73 (26.55) |
| Small pelvis | 174 (63.27) | 101 (36.73) |
| Abnormal positioning of the baby | 177 (64.36) | 98 (35.64) |
| The woman can be given blood during and/or after CS | 133 (48.36) | 142 (51.64) |
| How long should a patient stay in the hospital after CS? | 23 (85.09) | 41 (14.91) |
| A woman who has had CS has normal vaginal delivery | 183 (66.55) | 92 (33.45) |
| Benefits of CS | ||
| Less painful than vaginal delivery | 104 (37.82) | 171 (62.18_ |
| Protects the woman’s private part from tears | 161 (58.55) | 114 (41.45) |
| Saves the lives of the mother and/or baby in emergencies | 226 (82.18) | 49 (17.82) |
| No benefit | 247 (89.82) | 28 (10.18) |
| Complications of CS | ||
| Bleeding | 118 (42.91) | 157 (57.09) |
| Loss of life | 72 (26.18) | 203 (73.82) |
| Inability to conceive again | 28 (10.18) | 247 (89.82) |
| Infection | 81 (29.45) | 194 (70.55) |
| No complications | 56 | 219 (79.64) |
| With more than how many CS can one be prone to more complications? | ≤4 138 (50.18) | >4 137 (49.82) |
| n (%) | ||
| Who should give consent for CS | ||
| Doctors | 68 (24.73) | |
| Spouse | 103 (37.45) | |
| Parent/family of a pregnant woman | 73 (26.55) | |
| Pregnant woman | 23 (8.36) | |
| Pastor/Imam | 3 (1.09) | |
| Anyone present | 5 (1.82) | |
| Sources of information about CS | ||
| Hospital | 113 (41.09) | |
| Community/church | 26 (9.45) | |
| Family | 54 (19.64) | |
| Internet/social media/radio/TV | 18 (6.55) | |
| Personal experience | 5 (1.82) | |
| None | 16 (5.82) | |
Perception about CS
Table 3 shows their responses to the questions asked on perception with most of the participants disagreeing that women who had CS are cursed or that they die more from CS. A larger percentage (84%) of the participants believed that CS helps in saving lives, though most (about 66%) of them disagreed with the fact that it is also a normal way of giving birth.
Table 3.
Perception of first-time mothers about CS
| Statements | Agree | Neither | Disagree |
|---|---|---|---|
| n (%) | n (%) | n (%) | |
| Do you believe that women die more in CS? | 61 (22.18) | 24 (8.73) | 190 (69.09) |
| Do you believe women who have CS are cursed? | 34 (12.36) | 16 (5.82) | 225 (81.82) |
| Do you believe CS is culturally accepted? | 132 (48.00) | 39 (14.18) | 104 (37.82) |
| Do you believe more CS is being done to make more money for the hospital? | 55 (20.00) | 39 (14.18) | 181 (65.82) |
| Do you believe women who have CS don’t really need it but are being used by doctors for training? | 40 (14.55) | 25 (9.09) | 210 (76.36) |
| Do you believe CS is a way of maintaining the tightness of the vagina? | 81 (29.45) | 46 (16.73) | 148 (53.82) |
| Do you believe CS is a normal way of giving birth? | 70 (25.45) | 24 (8.73) | 181 (65.82) |
| Does CS take away the joy of childbirth? | 40 (14.55) | 28 (10.18) | 207 (75.27) |
| Do you believe CS helps in saving lives? | 231 (84.00) | 11 (4.00) | 33 (12.00) |
| Does the surgery always come with complications? | 73 (26.55) | 93 (33.82) | 109 (39.64) |
| CS is very dangerous | 120 (43.64) | 31 (11.27) | 124 (45.09) |
| Women who had CS recover faster than those who had vaginal delivery | 29 (10.55) | 29 (10.55) | 217 (78.91) |
| CS prevents future sexual problems (e.g., vaginal laxity) compared with vaginal delivery | 72 (26.18) | 70 (25.45) | 133 (48.36) |
| CS prevents future bladder problems (e.g., urgency, frequency, involuntary passage of urine) compared with vaginal delivery | 86 (31.27) | 76 (27.64) | 113 (41.09) |
The cost implication was seen as a reason why some women do not perceive CS as a good thing; this was seen in their responses:
“‘CS is a bad thing o’” in fact I don’t wish it for my enemies because my own experience with it is not good at all because it drains one’s pocket.” (Female/33yrs/AMTH/Respondent2/2023)
“CS is not a good thing at all, it’s just like planting devourer into one’s life….,” (Female/19yrs/AMTH/Respondent3/2023).
Some of the religious views affecting their perception are:
“I don’t mind having it again if it means to save my life and that of my baby’s because even labor pain is not funny at all. My religion (Christianity) or culture is not against it ….” (31 years/respondent5/AMTH/2023)
“I didn’t believe I was supposed to have it because it was not God’s plan for me, but I thank God.” (Female/20yrs/AMTH/Respondent4/2023)
“I don’t mind going through CS over and over again if that’s the way my baby and I will be secured, though my husband’s family were against it, even my imam said why can’t I wait for Gods miracle, but I know am the one who is carrying the pregnancy and I want to carry an healthy baby too…….,” (39 years/respondent6/AMTH/2023)
“……My religion (Christianity) still believes natural delivery is the best according to God’s plan for mankind…….”
(30 years/respondent7/AMTH/2023)
“I had been to my church before coming here praying for safe delivery but I was rushed here when I was getting tired, I don’t believe this is God’s will for me…”
(Female/19yrs/AMTH/Respondent3/2023)
Theme on support was also noted:
“The support I got from my husband and family members made me not to regret my decision of having a CS done when the doctors told me, it was what I needed for my baby’s survival. They rally round me and I am recovering well.”
(31 years/respondent5/AMTH/2023)
One of the regrets of another participant was the lack of support that she didn’t get after the delivery process. A participant has this to say:
“I didn’t get any family support, ….this affected my healing process, now I have to come for wound dressing alternate day and the doctors have told me they will be resuturing my wound later.”
(20 years/respondent4/AMTH/2023)
Some of the participants’ experiences after the surgery and how it affected their decision for a repeat CS:
“I do not pray to have a repeat CS because of my experience of blood transfusion after…….”
(female/19yrs/AMTH/Respondent3/2023)
“I will not want a repeat CS because of the fact that I had to carry catheter for 10 days also my wound broke down, it is not a palatable experience for me.”
(20 years/respondent4/AMTH/2023)
“My experience with the surgery was ok, I don’t mind having the surgery again if that is the only way for my baby and I to survive….”
(Female/31yrs/AMTH/Respondent5/2023).
Attitude towards CS
The attitude of the participants appears equivocal with 50.18% having a negative attitude and 49.82% having a positive attitude. More than half (62.55%) of the participants were willing to accept CS as a mode of delivery if medically indicated and majority (82.18%) agreeing to having CS done when vagina delivery is not safe. Some of the reasons for not accepting CS include fear of complications, religious beliefs [Table 4].
Table 4.
Attitude of participants towards CS
| Statements | Agreed | Neither | Disagree |
|---|---|---|---|
| n (%) | n (%) | n (%) | |
| Caesarean delivery reduces mother-to-child bonding | 40 (14.55) | 35 (12.72) | 200 (72.73) |
| I will accept CS as a mode of delivery if medically indicated | 172 (62.55) | 38 (13.81) | 65 (23.64) |
| In the absence of financial constraints, a CS is preferable. | 75 (27.27) | 48 (17.45) | 152 (55.27) |
| CS is preferred to avoid the unpalatable pain of vaginal delivery | 110 (40.00) | 40 (14.55) | 125 (45.45) |
| CS is as safe as vaginal delivery | 114 (41.45) | 47 (17.09) | 114 (41.45) |
| I will be willing to have a repeat CS | 48 (17.45) | 48 (17.45) | 179 (65.09) |
| Babies born through CS are healthier | 68 (24.73) | 60 (21.82) | 147 (53.45) |
| Pain in CS is unbearable | 79 (28.73) | 95 (34.55) | 101 (36.73) |
| If there is an intention for permanent family planning (tubal ligation), CS is better | 81 (29.45) | 123 (44.73) | 71 (25.82) |
| CS should be done when vaginal delivery is not safe | 226 (82.18) | 32 (11.64) | 17 (6.18) |
| CS should be done if a mother chooses it | 214 (77.82) | 29 (10.55) | 32 (11.64) |
| I will prefer CS even in the face of its probable complications | 63 (22.91) | 69 (25.09) | 143 (52.00) |
| Vaginal delivery has more pleasant outcomes than CS | 183 (66.55) | 38 (13.82) | 54 (19.64) |
| Reasons why women won’t accept CS as a mode of delivery | |||
| Responses | Frequency% | ||
| Religious belief | 48 (17.45) | ||
| If no medical reason | 34 (12.36) | ||
| None | 60 (21.82) | ||
| Funds | 46 (16.73) | ||
| Fear of complications | 50 (18.18) | ||
| Husband/family not supporting | 10 (3.64) | ||
Table 5 showed that participants who were Christian significantly had fair and good knowledge of CS compared to Muslim women (RRR = 2.01, 95% CI = 1.13–3.57) (RRR = 2.71, 95% CI = 1.23–5.95). Women who were gainfully employed significantly had fair knowledge of CS compared to respondents who were unemployed (RRR = 3.89, 95% CI = 1.72–8.79).
Table 5.
Multinomial logistics regression of factors associated with knowledge of CS
| Knowledge | Variables | Relative risk ratio (RRR) | 95% CI lower limit | 95% CI upper limit | P value |
|---|---|---|---|---|---|
| Poor | (base outcome) | ||||
| Fair | Religion | ||||
| Christianity | 2.010769 | 1.133077 | 3.568331 | 0.017* | |
| Family income | |||||
| Middle-income earner | 1.548164 | 0.8622152 | 2.779829 | 0.143 | |
| High-income earner | 0.8030793 | 0.3505382 | 1.839846 | 0.604 | |
| Occupation | |||||
| Employed | 3.886528 | 1.720581 | 8.779071 | 0.001* | |
| Unemployed | 1.863623 | 0.8059624 | 4.309245 | 0.146 | |
| Good | Religion | ||||
| Christian | 2.708738 | 1.234173 | 5.945084 | 0.013* | |
| Family income | |||||
| Middle-income earner | 1.674695 | 0.6921964 | 4.051745 | 0.253 | |
| High-income earner | 2.36146 | 0.8332587 | 6.692394 | 0.106 | |
| Occupation | |||||
| Employed | 0.8862114 | 0.2182621 | 3.598291 | 0.866 | |
| Unemployed | 2.54822 | 0.9019215 | 7.199547 | 0.078 | |
p<0.05
Discussion
This study evaluated first-time mothers’ perceptions, knowledge, and attitudes regarding CS as a mode of delivery, as well as determined some associated factors in a secondary health facility. This study is unique compared to previous studies that used a mix of women with and without previous experience with CS. The study revealed that most of the participants had fair to poor knowledge as a little above 1 in 10 had a good knowledge of CS. The attitude of participants towards CS appeared mixed as nearly equal proportions of participants had positive and negative attitudes using a composite tool of 14 questions on a Likert scale. The participants’ knowledge was significantly correlated with their family income, occupation, educational attainment, and religion with the multinomial regression showing that Christians had fair and good knowledge compared to Muslims and women who were gainfully employed were more knowledgeable on CS than unemployed women.
In this study, most participants had fair to poor knowledge, which was similar to a study in Ghana[7] where most of their respondents had poor knowledge on CS. A similar study in Southwestern Nigeria also showed that 17% of participants reported to have good knowledge.[13] The reason for poor knowledge among our participants might be due to their lack of previous experience with childbirth, including CS. It is also plausible that the lower level of education of a significant proportion of our participants may contribute to the lower level of knowledge of CS. A study by Ogunlaja et al. in Ogbomoso showed that participants with tertiary education had a higher proportion of those with good knowledge than women with lower levels of education.
The perceptions of participants were influenced by marital support, lack of experience of complications, cost of the surgery, religion, and tertiary education. Married first-time mothers had a positive perception relative to those who were not married. This may be due to better support from the spouse among those who were married.
Social support during pregnancy is associated with less stress, anxiety, and mental disorders.[21] Extending support into the postpartum period helps in the transition to motherhood, and reduces symptoms of anxiety and depression, which ultimately contribute to a good perception.[22,23,24] Women with tertiary education had a positive perception towards CS. Some have associated higher education with increased female empowerment, better independent decision making, reduced delay in seeking care, and increased knowledge about CS. Female education, according to the WHO has helped in improving access to emergency obstetric care, including access to CS. This was also confirmed in a study done in Ghana[7] which showed that educational status, maternal age, and religion remain significantly associated with poor perceptions of CS.
Majority (84%) of the participants believed that CS helps in saving lives, and a significant number (66%) disagreed with the fact that it is a normal way of giving birth. This is in line with a study in KBTH, Ghana[25] which showed that the majority believed CS deliveries were natural and it also corroborated a study in Ogun state[26] where most (78.5%) believed CS helps in saving lives of mother and baby. Most of the participants didn’t perceive CS as a good intervention. A study in Benin City showed that women expressed concerns such as the high cost of funds on CS.[15] Other concerns that participants had about CS included fear of death, postoperative pain, and the risk of complications. Women with some religious beliefs about CS tend to refuse counselling about CS.[27]
Findings on the attitude of first-time mothers showed that nearly an equal number of them had both a negative and positive attitude. Briefly, more than half were willing to accept CS if it was medically indicated. This has been previously reported in another Nigerian study[28] that most participants will accept CS, especially if it is meant to save the lives of the mother and baby. Another study in Jos and Ogbomoso also showed that most women will accept CS if it is medically indicated.[10] Some of the reasons associated with refusing CS include religion, funds, and fear of complications. Religion could sometimes be a major barrier to healthcare. In this study, some participants believed that delivery with CS is not an act that is acceptable to God. A study has reported a similar observation.[28] Most women with such beliefs would consult with spiritual leaders before refusing or consenting to CS. Paying out of pocket and the cost of CS drain the meagre resources in a family, and this has created a negative attitude towards CS.
This study has some potential limitations. The cross-sectional design makes it difficult to ascertain the causal relationship between explanatory variables and outcome measures. In addition, this study was conducted among women attending secondary health facilities. It is possible that some of the participants might have learned about CS from relatives or friends who might have experienced it or work in a health facility where CS is performed. Despite these limitations, our study focused on a homogenous group of pregnant and delivered mothers (first-time mothers) who are at increased risk of CS. We also explored different factors that may influence their attitudes and perceptions of CS. In addition, we conducted an in-depth interview to have a deeper understanding of the perception, knowledge, and attitudes of these women learning from their personal experiences.
Conclusion
This study showed that most first-time mothers had fair to poor knowledge; a little above 1 in 10 had a good knowledge about CS. They had mixed attitudes because nearly equal proportions of participants had positive and negative dispositions towards CS. We recommend advocacy, antenatal education, birth-preparedness, counselling need to be increased during the antenatal clinic visits, and more first-time mothers might need to be put on insurance to reduce the burden of cost and make it affordable for women that have the medical need for it.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.Konar H. D.C. Dutta. Textbook of obstetrics including perinatology and contraception. 7th ed. London: New Central Book Agency Publishing Ltd; 2011. [Google Scholar]
- 2.World Health Organisation. Caesarean sections should only be performed when medically necessary says WHO. 2015. [Last accessed on 20 Aug 2023]. Available from: https://www.who.int/news/item/09-04-2015-caesarean-ections-should-only-be-performed-when-medically-necessary-says-who .
- 3.Betran AP, Ye J, Moller A, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Global Health. 2021;6:e005671. doi: 10.1136/bmjgh-2021-005671. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Guzman E, Ludmir J, DeFrancesco M. High cesarean section rates in Latin America, a reflection of a different approach to labor? Open J Obstet Gynecol. 2015;05:433–5. [Google Scholar]
- 5.Gunn JK, Ehiri JE, Jacobs ET, Ernst KC, Pettygrove S, Center KE, et al. Prevalence of caesarean sections in Enugu, southeast Nigeria: Analysis of data from the Healthy Beginning Initiative. PLoS One. 2017;12:e0174369. doi: 10.1371/journal.pone.0174369. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ezechi OC, Nwokoro CA, Kalu BKE, Njokanma FO, Okeke GCE. Caesarean morbidity and mortality in a private hospital in Lagos, Nigeria. Trop J Obstet Gynaecol. 2002;19:97–100. [Google Scholar]
- 7.Naa Gandau BB, Nuertey BD, Seneadza NAH, Akaateba D, Azusong E, Yirifere JY, et al. Maternal perceptions about caesarean section deliveries and their role in reducing perinatal and neonatal mortality in the Upper West Region of Ghana; a cross-sectional study. BMC Preg Childbirth. 2019;19 doi: 10.1186/s12884-019-2536-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ezechi CO, Fasubaa OB, Kalu BEK, Nwokoro CA. Caesarean delivery: Why the aversion? Trop J Obstet Gynaecol. 2004;21:164–67. [Google Scholar]
- 9.Chigbu CO, Iloabachie GC. The burden of caesarean section refusal in a developing country setting. BJOG. 2007;114:1261–5. doi: 10.1111/j.1471-0528.2007.01440.x. [DOI] [PubMed] [Google Scholar]
- 10.Egbodo OC, Akunaeziri UA, Edugbe AE, Shambe IH, Kahansim ML, Ocheke AN. Awareness, attitudes and perception of antenatal patients to caesarean section: The Jos, Nigeria experience. Int J Adv Res Gynaecol Obstet. 2023;1:7–14. [Google Scholar]
- 11.Sunday-Adeoye I, Kalu CA. Pregnant Nigerian women’s view of cesarean section. Niger J Clin Pract. 2011;14:276–9. doi: 10.4103/1119-3077.86766. [DOI] [PubMed] [Google Scholar]
- 12.Mboho M, Furber C, Waterman H. Social-cultural practices and beliefs influencing maternal mortality. Afr J Midwif Womens Health. 2013;7:26–31. [Google Scholar]
- 13.Faremi AF, Ibitoye O, Olatubi M, Koledoye PN, Ogbeye G. Attitude of pregnant women in south western Nigeria towards caesarean section as a method of birth. Int J Reprod Contracept Obstet Gynecol. 2014:709–14. [Google Scholar]
- 14.Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015;314:2263–70. doi: 10.1001/jama.2015.15553. [DOI] [PubMed] [Google Scholar]
- 15.Aziken M, Omo-Aghoja L, Okonofua F. Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta Obstet Gynecol Scand. 2007;86:42–7. doi: 10.1080/00016340600994950. [DOI] [PubMed] [Google Scholar]
- 16.Olofinbiyi BA, Olofinbiyi RO, Aduloju OP, Atiba BP, Olaogun OD, Ogundare OR. Maternal views and experiences regarding repeat caesarean section. Niger J Clin Pract. 2015;18:489–92. doi: 10.4103/1119-3077.156883. [DOI] [PubMed] [Google Scholar]
- 17.Danish N, Fawad A, Abbasi N. Assessment of pregnancy outcome in primigravida: Comparison between booked and un-booked patients. J Ayub Med Coll Abbottabad. 2010;22:23–5. [PubMed] [Google Scholar]
- 18.Kuntal N, Gupta S, Gupta VK, Nimawat A. To study indications for primary caesarean section in primigravida and multigravida. Int J Clin Obstet Gynaecol. 2019;3:155–8. [Google Scholar]
- 19.Daniel CN, Singh S. Caesarean delivery: An experience from a tertiary institution in north western Nigeria. Nigerian J Clin Pract. 2016;19:18–24. doi: 10.4103/1119-3077.164350. [DOI] [PubMed] [Google Scholar]
- 20.Mulugeta AK, Giru BW, Berhanu B, Demelew TM. Knowledge about birth preparedness and complication readiness and associated factors among primigravida women in addis ababa governmental health facilities, Addis Ababa, Ethiopia, 2015. Reprod Health. 2020;17:15. doi: 10.1186/s12978-020-0861-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Asselmann E, Kunas SL, Wittchen HU, Martini J. Maternal personality, social support, and changes in depressive, anxiety, and stress symptoms during pregnancy and after delivery: A prospective-longitudinal study. PLoS One. 2020;15:e0237609. doi: 10.1371/journal.pone.0237609. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Maharlouei N. The importance of social support during pregnancy. Womens Health Bull. 2016;3:1. [Google Scholar]
- 23.Battulga B, Benjamin MR, Chen H, Bat-Enkh E. The impact of social support and pregnancy on subjective well-being: A systematic review. Front Psychol. 2021;12:710858. doi: 10.3389/fpsyg.2021.710858. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Stapleton LRT, Schetter CD, Westling E, Rini C, Glynn LM, Hobel CJ, et al. Perceived partner support in pregnancy predicts lower maternal and infant distress. J Fam Psychol. 2012;26:453–63. doi: 10.1037/a0028332. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Dorkenoo JE, Abor PA. Pregnant women’s knowledge, perception and attitudes towards caesarian section among obstetrics unit attendants in a teaching hospital. Res J Health Sci. 2021;9:207–20. [Google Scholar]
- 26.Maitanmi BT, Oluyomi OV, Aderemi IO, Maitanmi JO, Aminu A, Ojewale MO, et al. Knowledge, attitude and perception of cesarean section among pregnant women attending antenatal clinic at Babcock University Teaching Hospital, Ilishan-Remo, Ogun State. J Matern Fetal Neonatal Med. 2023;36:2278019. doi: 10.1080/14767058.2023.2278019. [DOI] [PubMed] [Google Scholar]
- 27.Ugwa EA, Ashimi A, Abubakar MF. Caesarean section and perinatal outcomes in a sub-urban tertiary hospital in North-West Nigeria. Niger Med J. 2015;56:180–4. doi: 10.4103/0300-1652.160360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Bello FA, Olayemi O, Ogunbode OO, Adekunle AO. Attitude to caesarean section amongst antenatal clients in Ibadan, Nigeria. Trop J Health Sci. 2011;18 [Google Scholar]