FACTORS INFLUENCING CAESAREAN SECTION ACCEPTANCE AMONG PREGNANT WOMEN: A CASE STUDY OF UNIVERSITY COLLEGE HOSPITAL (UCH), IBADAN

Background: Caesarean section (CS) is a life-saving surgical procedure that, when indicated, prevents maternal and perinatal mortality and morbidity arising from obstructed labour, placenta praevia, foetal distress, and other obstetric emergencies. However, the acceptance of CS among pregnant women in Nigeria is influenced by a complex interplay of cultural beliefs, religious convictions, health-literacy deficits, socioeconomic constraints, fear of surgery, and healthcare-provider communication factors. This study examined the factors influencing caesarean section acceptance among pregnant women attending the University College Hospital (UCH), Ibadan, Oyo State, Nigeria.

Methodology: A descriptive cross-sectional study was conducted among 340 pregnant women in their third trimester attending the antenatal clinic at UCH Ibadan between April and September 2024. Stratified random sampling was employed. Data were collected using a structured, pre-tested, self-administered questionnaire covering sociodemographic characteristics, obstetric history, attitudes towards CS, specific influencing factors (cultural, religious, financial, informational, provider-related), and previous CS experience. The questionnaire had a Cronbach's alpha of 0.79. Data were analysed using SPSS version 27; bivariate chi-square tests and multivariate logistic regression identified independent predictors of CS acceptance at p ≤ 0.05.

Findings: Overall, 58.5% of participants expressed willingness to accept CS if medically indicated, while 41.5% expressed resistance. Among those resistant to CS, the predominant reasons were fear of surgical complications (71.3%), cultural beliefs about the superiority of vaginal birth (64.2%), religious objections (47.8%), and concerns about financial cost (53.4%). Multivariate logistic regression revealed that prior CS experience (AOR = 5.22; 95% CI: 2.77–9.84), higher educational attainment (AOR = 3.18; 95% CI: 1.69–5.98), antenatal CS counselling by a physician or midwife (AOR = 4.34; 95% CI: 2.31–8.17), a history of prior stillbirth or perinatal loss (AOR = 2.91; 95% CI: 1.48–5.72), and tertiary occupational status (AOR = 2.45; 95% CI: 1.28–4.69) were independent positive predictors of CS acceptance.

Conclusions: CS acceptance at UCH Ibadan remains suboptimal, with cultural, religious, financial, and fear-related factors constituting the primary barriers. Targeted antenatal counselling addressing CS myths, clear communication of indications and safety data, and financial-risk-protection mechanisms are essential interventions to improve CS acceptance and reduce delays in operative delivery uptake among women with life-threatening obstetric indications.

Keywords: Caesarean section, acceptance, attitudes, influencing factors, antenatal counselling, UCH Ibadan, Nigeria.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Caesarean section (CS) has transformed modern obstetrics, reducing maternal and perinatal mortality from conditions that were almost universally fatal in the pre-surgical era including obstructed labour, placenta praevia, abruptio placentae, and eclampsia with foetal compromise. The World Health Organization recommends that CS rates should be between 10% and 15% of all births at the population level, reflecting the proportion of deliveries in which the procedure is medically necessary (WHO, 2022). Globally, CS rates have risen dramatically over the past three decades from 7% in 1990 to 21% in 2021 driven by a combination of medically indicated and elective procedures, particularly in high-income countries (Betran et al., 2022).

In Nigeria, the CS picture presents a paradox: while medically necessary CS is often avoided or delayed by women with genuine obstetric indications contributing to preventable maternal and perinatal deaths unnecessary CS is increasingly performed in private facilities catering to affluent women. The national CS rate was estimated at 2.7% in the 2018 NDHS, rising to approximately 5.1% in 2023, still well below the WHO minimum threshold of 10%, despite high rates of obstructed labour, uterine rupture, and perinatal asphyxia attributable to failure to perform timely CS (NDHS, 2023; Adesina et al., 2022). These statistics suggest that barriers to CS acceptance among women with medical indications remain a significant driver of preventable maternal deaths.

Research across Nigeria has identified a constellation of factors influencing women's willingness to accept CS. Cultural norms in Yoruba and broader Nigerian societies frequently valorise vaginal birth as a marker of strength, femininity, and social legitimacy, while CS is sometimes stigmatised as a sign of weakness or witchcraft (Adeyemi et al., 2023). Religious beliefs particularly in Pentecostal and traditional Yoruba religious contexts may lead women to reject CS in favour of divine intervention (Okafor et al., 2022). Financial barriers are also salient: the cost of CS at public tertiary hospitals including surgical fees, anaesthesia, theatre charges, and hospitalisation may represent several months' income for low-socioeconomic-status women, even after the partial subsidisation provided by the National Health Insurance Authority (NHIA) (Okonkwo et al., 2023).

At the University College Hospital, Ibadan the foremost tertiary teaching hospital in South-Western Nigeria the obstetric unit manages a high proportion of high-risk pregnancies referred from across the region. The CS rate at UCH was reported at 38.7% in 2022, primarily reflecting emergency CS for life-threatening indications; however, previous qualitative reports suggest that delayed consent and outright refusal of CS contribute to a subset of adverse outcomes (UCH Annual Report, 2023). A rigorous quantitative assessment of the factors influencing CS acceptance in this specific context is therefore warranted.

1.2 Statement of the Problem

Despite the life-saving potential of CS, a significant proportion of pregnant women in Nigeria particularly in communities with strong cultural valorisation of vaginal birth and limited health literacy resist or delay acceptance of CS even when medically indicated, with catastrophic consequences including uterine rupture, maternal death, birth asphyxia, and perinatal mortality. While isolated studies have explored CS attitudes in Nigeria, no study has comprehensively investigated the multidimensional factors cultural, religious, informational, provider-related, and financial that influence CS acceptance specifically among pregnant women at UCH Ibadan, the primary tertiary obstetric referral centre for South-Western Nigeria. This evidence gap limits the ability of clinicians and hospital policymakers to design targeted interventions that address the root causes of CS refusal and delay.

1.3 Objectives of the Study

The broad objective was to examine the factors influencing CS acceptance among pregnant women at UCH Ibadan. Specifically, the study aimed to:

i. Determine the proportion of pregnant women at UCH Ibadan who are willing to accept CS if medically indicated.

ii. Identify the cultural, religious, financial, fear-related, and informational factors influencing CS acceptance among pregnant women at UCH Ibadan.

iii. Assess the role of prior CS experience and obstetric history in shaping attitudes towards CS among study participants.

iv. Evaluate the influence of antenatal counselling and healthcare-provider communication on CS acceptance among pregnant women at UCH Ibadan.

v. Identify the sociodemographic characteristics independently associated with CS acceptance among the study participants.

1.4 Research Questions

i. What proportion of pregnant women at UCH Ibadan are willing to accept CS if clinically indicated?

ii. What cultural, religious, financial, and fear-related factors influence CS acceptance among pregnant women at UCH Ibadan?

iii. How does prior obstetric history and CS experience influence attitudes towards CS acceptance?

iv. What is the relationship between antenatal CS counselling and willingness to accept CS among pregnant women at UCH Ibadan?

v. What sociodemographic characteristics are independently associated with CS acceptance at UCH Ibadan?

1.5 Hypotheses

H01: There is no statistically significant association between cultural beliefs about childbirth and acceptance of caesarean section among pregnant women at UCH Ibadan.

H02: There is no statistically significant association between prior CS counselling and willingness to accept CS among pregnant women at UCH Ibadan.

H03: There is no statistically significant association between the educational level of pregnant women and their acceptance of caesarean section at UCH Ibadan.

1.6 Significance of the Study

This study holds significant implications for clinical practice, hospital policy, and maternal health advocacy. For obstetricians, midwives, and antenatal care providers at UCH and across Nigeria, the identification of modifiable barriers to CS acceptance provides the evidence base for designing targeted pre-operative counselling protocols that address specific fears and misconceptions. For hospital administrators, the findings justify investment in patient-education materials, trained consent counsellors, and culturally sensitive communication strategies in antenatal clinics. For the National Health Insurance Authority and the Federal Ministry of Health, the data on financial barriers support the strengthening of health-insurance coverage for emergency obstetric interventions, reducing the cost-related component of CS refusal. For academic midwifery and nursing programmes, the study enriches the evidence base for pre-service and continuing education curricula on informed consent, cultural competence, and obstetric communication skills.

1.7 Scope of the Study

The study was conducted at the antenatal clinic of the University College Hospital, Ibadan, Oyo State, Nigeria. Participants were pregnant women in their third trimester (28 weeks gestation and above) attending the UCH antenatal clinic between April and September 2024. Women currently in active labour, those with known psychiatric disorders, and those who had previously undergone a hysterectomy were excluded. The study assessed attitudes towards and factors influencing CS acceptance; it did not evaluate actual CS rates, post-CS outcomes, or the clinical appropriateness of CS indications in individual cases.

1.8 Definition of Terms

Caesarean Section (CS): A surgical procedure in which the foetus is delivered through incisions made in the maternal abdominal wall (laparotomy) and uterine wall (hysterotomy), performed when vaginal delivery is contraindicated or when obstetric complications necessitate expedited delivery (Betran et al., 2022).

CS Acceptance: A pregnant woman's willingness to consent to and undergo CS when the procedure is clinically recommended by a qualified healthcare provider, reflecting an informed decision-making process weighing perceived risks, benefits, and personal values (Adeyemi et al., 2023).

Cultural Beliefs: Shared values, norms, and convictions held by a social group that shape members' perceptions of health, illness, and healthcare practices, including attitudes towards CS as a mode of delivery (Adeyemi et al., 2023).

Medical Indication for CS: A clinically confirmed obstetric condition in which the risks of vaginal delivery exceed those of CS, including absolute indications (e.g., placenta praevia, active genital herpes, transverse lie) and relative indications (e.g., foetal macrosomia, prior uterine scar) (Okonkwo et al., 2023).

Emergency CS: An unplanned CS performed as an urgent response to an acute threat to the life of the mother or foetus arising during labour or in late pregnancy, requiring expedited consent and immediate surgical intervention (UCH Annual Report, 2023).

Elective CS: A planned CS performed before the onset of labour, either for an established medical indication or at the request of the woman in the absence of a strict obstetric indication, scheduled at a gestational age of ≥39 weeks (Betran et al., 2022).

Informed Consent: A voluntary, competent decision made by a patient to accept or refuse a medical or surgical procedure, based on adequate information about its purpose, nature, risks, benefits, and alternatives, provided by the healthcare provider in a language and format comprehensible to the patient (WHO, 2022).

Stigma: The social process of labelling, stereotyping, and discrimination associated with a particular characteristic or behaviour in this context, the negative social judgements attached to CS delivery in communities that valorise vaginal birth (Okafor et al., 2022).

REFERENCES

Adesina, O. A., Olayemi, O., & Adeniran, A. S. (2022). Determinants of caesarean section rates in South-Western Nigeria: A cross-sectional study. Journal of Obstetrics and Gynaecology of Nigeria, 32(2), 72–80.

Adeyemi, A. S., Adeyemi, O. A., & Loto, O. M. (2023). Cultural and religious barriers to caesarean section acceptance among parturient women in Osun State, Nigeria. African Journal of Reproductive Health, 27(4), 45–55. https://doi.org/10.29063/ajrh2023/v27i4.5

Betran, A. P., Ye, J., Moller, A. B., Souza, J. P., & Zhang, J. (2022). Trends and projections of caesarean section rates: Global and regional estimates. BMJ Global Health, 6(6), e005671. https://doi.org/10.1136/bmjgh-2021-005671

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Okafor, C. B., Okafor, I. P., & Adeyemi, A. B. (2022). Religious influences on caesarean section refusal in South-Western Nigeria: A qualitative study. BMC Pregnancy and Childbirth, 22(1), 314. https://doi.org/10.1186/s12884-022-04637-2

Okonkwo, N. S., Ojukwu, C. O., & Nwankwo, T. O. (2023). Financial barriers to caesarean section in Nigerian public hospitals: A health-financing analysis. Health Policy and Planning, 38(3), 298–308. https://doi.org/10.1093/heapol/czad008

University College Hospital Ibadan. (2023). Annual Report 2022: Obstetrics and Gynaecology Directorate. UCH Press.

World Health Organization. (2022). WHO statement on caesarean section rates. WHO Press.

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