This study was carried out on perception and acceptance of caesarean section among pregnant women in Igbinedion University Teaching Hospital (IUTH), Okada, Edo State. Maternal mortality is unacceptably high in low resource countries. This is disturbing, considering that some of these deaths are preventable through caesarean section. To determine the perception and factors associated with the acceptance of caesarean section among high-risk pregnant women, a structured interviewer-administered questionnaire was used to assess pregnant women's knowledge and acceptance of CS. The study proposal was approved by the Ethics and Research committee of the institution and informed consent was obtained from the participants prior to recruitment into the study. The data obtained was analysed using SPSS version 17.0 statistical software. Qualitative variables were summarized using frequencies and percentages, while mean and standard deviation were used to summarize quantitative variables. Although this study revealed that 93.8% of the respondents were aware of CS, 40.9% had adequate knowledge of it while 2.7% knew that the woman undergoing CS was required to give consent for the surgery. The study recommended that doctors should actively get involved in the education of pregnant women.

CHAPTER ONE

INTRODUCTION

1.1 Background of Study

Maternal mortality remains a leading cause of death among pregnant women globally, with the burden disproportionately concentrated in low- and middle-income countries, particularly in sub-Saharan Africa. According to the 2025 joint report by WHO, UNICEF, UNFPA, the World Bank Group, and UNDESA, an estimated 260,000 maternal deaths occurred worldwide in 2023, with sub-Saharan Africa accounting for approximately 70% of this global burden (WHO et al., 2025). Nigeria bears a particularly heavy toll: the country recorded an estimated 75,000 maternal deaths in 2023, representing nearly 29% of global maternal deaths the highest of any single nation (WHO et al., 2025). A woman in Nigeria faces a 1 in 25 lifetime risk of dying from a maternal cause, one of the starkest such risks in the world (UNICEF, 2025).

Caesarean section (CS) is widely recognised as a life-saving intervention when vaginal delivery poses a risk to the mother or baby. A 2023 systematic review and meta-analysis covering Nigerian health facilities found that over 80,000 pregnant women died from pregnancy-related complications in Nigeria in 2020 alone, and that appropriately conducted CS reduces the odds of maternal death (Osayande et al., 2023). Despite this evidence, CS utilisation in Nigeria remains alarmingly low. Maitanmi et al. (2023) documented that the CS rate in Nigeria has remained as low as 2.7%, far below the 10–15% threshold recommended by the World Health Organization.

The joy of every woman is to deliver her baby normally (vaginally). For many Nigerian women, the prospect of abdominal delivery is associated with deep cultural stigma. Edward et al. (2023) confirmed that Nigerian women are generally unwilling to have a caesarean section because of the widespread belief that abdominal delivery constitutes reproductive failure, regardless of the declining mortality risk from CS or the documented feasibility of vaginal birth after caesarean. Elom et al. (2023) similarly reported that in typical Nigerian culture, caesarean section is perceived as a method of delivery for women who are not strong a perception that generates significant negative attitudes toward the procedure, particularly among male partners. In a study of religious leaders and community members in Ogbomoso, South West Nigeria, Salami et al. (2024) found that being perceived by peers as a reproductive failure was the most commonly cited barrier to CS acceptance, alongside high cost and religious beliefs.

A qualitative study by Michael et al. (2024), which explored the perceptions and experiences of postpartum women in Ibadan, Nigeria, found that societal pressures and cultural expectations played a significant role in shaping women's perceptions of caesarean sections. The study documented diverse emotional responses, ranging from relief and gratitude to disappointment and feelings of loss for not experiencing vaginal birth. Aversion to CS in the South-South geopolitical zone of Nigeria was equally documented by Pereowei et al. (2023), who reported that the principal reasons for rejecting the procedure included postoperative pain, perceived physician incompetence, fear of death, and the stigma of "failure of womanhood." Notably, the vast majority (89.4%) of participants in that study indicated they would only accept CS if their life or that of their unborn child was in great danger.

The influence of social norms extends beyond the individual woman. Faysal et al. (2024), in a scoping review of counselling, informed consent, and debriefing practices for CS in sub-Saharan Africa, identified that cultural and gender norms frequently limit women's participation in the informed consent process for CS. Barriers were identified at service, individual, provider, and societal levels, reflecting the complex and multi-layered nature of CS refusal in the region. Importantly, underlying cultural factors and beliefs affect not only access to health facilities but also contribute to avoidable maternal deaths through delays in decision-making and help-seeking (Ugwu and de Kok, 2015, as referenced in current systematic reviews).

At the global level, caesarean section rates have risen dramatically. Global CS rates increased from approximately 7% in 1999 to over 21% in 2023, with approximately 21.1% of births worldwide now occurring via CS a figure projected to rise to nearly 29% by 2030 (Sam and Kasu, 2025; Etcheverry et al., 2024). Significant regional disparities persist: while Latin America and the Caribbean report CS rates exceeding 40%, sub-Saharan Africa maintains an average CS rate of around 5%, largely due to limited access to surgical facilities and healthcare infrastructure (Etcheverry et al., 2024). This paradox of CS overuse in some regions and dangerous underuse in others has prompted ongoing debate about what constitutes an optimal rate.

Since 1985, the international healthcare community has considered an optimal caesarean section rate to fall between 10% and 15%. The World Health Organization's 2015 statement reaffirmed that when CS rates rise toward 10% across a population, the number of maternal and newborn deaths decreases, but that above 10%, there is no evidence that mortality rates improve (WHO, 2015). More recently, the European Association of Perinatal Medicine recommended that caesarean delivery rates at the country level should be in the 15–20% range, based on evidence of decreased maternal and neonatal mortality at rates approaching 15% (EAPM & EMA, 2024). Globally, obstetric practice continues to be informed by efforts to balance access to necessary CS while avoiding medically unjustified procedures.

A 2024 multicountry survey by Etcheverry et al. involving women in low- and middle-income countries found that the vast majority preferred vaginal birth, and that the preference for caesarean section was primarily linked to women's fear of pain during labour and the influence of doctors' recommendations. Similarly, a 2022 study by Dumont et al. published in PLOS Global Public Health highlighted that women's fear and uncertainty about vaginal delivery, combined with limited empowerment in decision-making, generate decision conflict and are among the main determinants of high CS rates in low- and middle-income countries. These findings underscore the importance of evidence-based antenatal education and shared decision-making in obstetric care.

A study of perception of CS among pregnant women in a rural community in Enugu, Southeast Nigeria (Global Health Network, 2022) found that overall perception of CS was negative among 75.4% of respondents, and that less than half (47%) would accept it even for medical reasons. These findings reinforce the urgent need for community- and facility-based educational interventions to improve knowledge, correct misconceptions, and enhance acceptance of CS in settings where it is clinically indicated.

1.2 Statement of Problem

Traditionally, Nigerian women are unwilling to have CS because of the general belief that abdominal delivery is reproductive failure on their part, regardless of the feasibility of vaginal birth after CS and the decreasing mortality from caesarean sections (Edward et al., 2023). This is compounded by the very low national CS uptake rate of 3.11% documented among women of reproductive age in Nigeria (Ajayi et al., 2023), which reflects the wide gap between clinical need and actual utilisation. Multilevel factors including ethnicity, religion, parity, level of education, rural residence, and lack of partner support have been shown to independently predict non-acceptance of indicated caesarean section in Nigeria (Maitanmi et al., 2023; Ajayi et al., 2023). Available reports on knowledge of CS amongst women are mainly from tertiary health facilities situated in cities and in the southern parts of the country, while little is known about the perception and acceptance of pregnant women towards caesarean section in Igbinedion University Teaching Hospital in Edo State.

1.3 Research Objectives

1. To explore the perception and acceptance of pregnant women in Igbinedion University Teaching Hospital, Edo State toward caesarean section.

2. To ascertain what is known about caesarean section and the reasons for dislike by our women.

3. To explore the factors influencing the perception and acceptance of pregnant women in Igbinedion University Teaching Hospital, Edo State towards caesarean section.

1.4 Research Questions

1. What is the perception and acceptance of pregnant women in Igbinedion University Teaching Hospital, Edo State toward caesarean section?

2. What is known about caesarean section and the reasons for dislike by our women?

3. What factors influence the perception and acceptance of pregnant women in Igbinedion University Teaching Hospital, Edo State towards caesarean section?

1.5 Significance of Study

The findings from this study would be used in planning strategies towards improving the knowledge, perception and acceptance towards CS in the community in order to possibly reduce the delay in presentation to the health facility when CS is needed, improve utilisation of this mode of delivery and limit the avoidable maternal and foetal complications. This is particularly important given that evidence consistently shows CS reduces the odds of maternal death when performed under appropriate clinical indications (Osayande et al., 2023), and that educational interventions have been shown to significantly improve women's knowledge and attitudes toward caesarean delivery (Edward et al., 2023).

1.6 Scope of Study

This study focused on the perception and acceptance of pregnant women towards caesarean section. It was carried out in Igbinedion University Teaching Hospital (IUTH), Okada in Edo State.

1.7 Definition of Terms

Perception: The process of recognizing and interpreting sensory stimuli, including information about medical procedures such as caesarean section. It encompasses individual judgements, beliefs, and attitudes shaped by personal experience, cultural background, and social context.

Acceptance: In human psychology, a person's assent to the reality of a situation recognising a process or condition (often a negative or uncomfortable situation) without attempting to change or protest it. In the context of this study, it refers to a pregnant woman's willingness to consent to a caesarean section when medically indicated.

Caesarean Section (CS): Also known as C-section or caesarean delivery a surgical procedure in which one or more babies are delivered through incisions made in the mother's abdomen and uterus. A caesarean section is often necessary when vaginal delivery would put the baby or mother at risk due to complications such as fetal distress, malpresentation, prolonged obstructed labour, or other obstetric emergencies (Maitanmi et al., 2023).

REFERENCES

Ajayi, K. V., Olowolaju, S., Wada, Y. H., Panjwani, S., Ahinkorah, B., Seidu, A. A., Adu, C., Tunji-Adepoju, O., & Bolarinwa, O. A. (2023). A multi-level analysis of prevalence and factors associated with caesarean section in Nigeria. PLOS Global Public Health, 3(6), e0000688. https://doi.org/10.1371/journal.pgph.0000688

Dumont, A., de Loenzien, M., Nhu, H. M. Q., Dugas, M., Kabore, C., Lumbiganon, P., Torloni, M. R., Gialdini, C., Carroli, G., Hanson, C., & Betran, A. P. (2022). Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries. PLOS Global Public Health, 2(11), e0001264. https://doi.org/10.1371/journal.pgph.0001264

Edward, M. I., Bolarinwa, O. S., Ajibade, O. S., & Aregbesola, T. M. (2023). Effect of guided education on perception and attitude of childbearing women towards caesarean section in Nigeria. NSC Nursing, 2(5), 85–106. https://doi.org/10.32549/opi-nsc-90

Elom, N. A., Nwimo, I. O., Ilo, C. I., Ngwakwe, P. C., Ezugwu, U. A., Alegu, D. N., Ojide, R. N., & Okpata, O. O. (2023). Belief towards caesarean section: A community based study of male partners in Ebonyi State, Nigeria. SAGE Open Medicine, 11. https://doi.org/10.1177/20503121221147810

Etcheverry, C., Betran, A. P., de Loenzien, M., Kaboré, C., Lumbiganon, P., Carroli, G., Mac, Q. N. H., Gialdini, C., & Dumont, A. (2024). Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries. Midwifery, 132, 103979. https://doi.org/10.1016/j.midw.2024.103979

European Association of Perinatal Medicine (EAPM) & European Midwives Association (EMA). (2024). Joint position statement: Caesarean delivery rates at a country level should be in the 15–20% range. European Journal of Obstetrics and Gynecology and Reproductive Biology. https://doi.org/10.1016/j.ejogrb.2024.01.005

Faysal, M., Brhane, K., & Bohren, M. A. (2024). Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review. International Journal of Gynecology & Obstetrics. https://doi.org/10.1002/ijgo.15079

Global Health Network. (2022). Perception and acceptance of caesarean section among pregnant women in a rural community in Enugu, Southeast, Nigeria. The Global Health Network Conference Proceedings 2022. https://tghncollections.pubpub.org/pub/4igd5c4y

Maitanmi, B. T., Oluyomi, O. V., Aderemi, I. O., Maitanmi, J. O., Aminu, A., Ojewale, M. O., Okondu, O. E., & Akingbade, O. (2023). Knowledge, attitude and perception of cesarean section among pregnant women attending antenatal clinic at Babcock University Teaching Hospital, Ilishan-Remo, Ogun State. Journal of Maternal-Fetal & Neonatal Medicine, 36(2), 2278019. https://doi.org/10.1080/14767058.2023.2278019

Michael, T. O., Agbana, R. D., & Naidoo, K. (2024). Exploring perceptions of cesarean sections among postpartum women in Nigeria: A qualitative study. Women, 4(1), 73–85. https://doi.org/10.3390/women4010006

Osayande, I., Ogunyemi, O., Gwacham-Anisiobi, U., Olaniran, A., Yaya, S., & Banke-Thomas, A. (2023). Prevalence, indications, and complications of caesarean section in health facilities across Nigeria: A systematic review and meta-analysis. Reproductive Health, 20(1), 81. https://doi.org/10.1186/s12978-023-01598-9

Pereowei, S. P., Kalio, D. G. J., & Amakiri, C. N. U. (2023). The perceptions and attitude of pregnant women towards caesarean section in South South Nigeria. Tropical Journal of Obstetrics and Gynaecology. https://doi.org/10.4103/tjog.tjog_329

Sam, J., & Kasu, C. (2025). Determinants of caesarean section use in Ghana: A trend analysis of 2003–2022 DHS data. PLOS Global Public Health. https://doi.org/10.1371/journal.pgph.0005473

Salami, B., Awoleke, J. O., & colleagues. (2024). Influence of beliefs of religious leaders on the acceptance of caesarean section as a delivery option among women in Ogbomoso, South West Nigeria. Saudi Journal of Obstetrics and Gynaecology, 7(2). https://doi.org/10.36348/sijog.2024.v07i02.004

UNICEF. (2025). Trends in maternal mortality estimates 2000 to 2023. United Nations Children's Fund. https://www.unicefusa.org/media-hub/reports/trends-maternal-mortality

World Health Organization. (2015). WHO statement on caesarean section rates (WHO/RHR/15.02). World Health Organization.

World Health Organization, UNICEF, UNFPA, World Bank Group, & UNDESA/Population Division (MMEIG). (2025). Trends in maternal mortality: 2000 to 2023. WHO Press. https://www.unfpa.org/publications/trends-maternal-mortality-2000-2023