CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Caesarean section (C-section) is one of the most commonly performed surgical procedures

worldwide, often employed to ensure the safety of both the mother and child in cases where

vaginal delivery poses risks (WHO, 2020). While Caesarean section have been instrumental

in reducing maternal and neonatal morbidity and mortality, the procedure is frequently met

with a variety of perceptions and attitudes, which can influence its acceptance (Aziken et al.,

2017). These perceptions are shaped by a combination of factors, including cultural beliefs,

fear of surgery, and concerns about recovery (Ashimi et al., 2018). For many pregnant

women, the decision to opt for a Caesarean section or vaginal delivery is not solely based on

medical advice, but also on social and psychological factors (Ashimi et al., 2018).

The history of cesarean section extends well over four centuries (Awoyinka, et al, 2016). Up

until the end of the nineteenth century, the operation was avoided because of its high

mortality rate. In 1926, the Munro Kerr low transverse uterine incision was introduced and

became the standard method for the next fifty years (Danso, et at., 2019). Since the 1970's,

newer surgical techniques gradually became the most commonly used method today because

of Intra-operative and postpartum benefits. Concurrently, despite attempts to encourage

vaginal birth after previous cesareans, the cesarean delivery rate increased steadily from five

to thirty-two percent over the last ten years (Danso, et at., 2019).

Globally, the caesarean section rate has been increasing over the past few decades, with an

estimated twenty-one percent of births worldwide being delivered via Caesarean section,

according to the World Health Organization (2020). This rise has been particularly marked in

high-income countries where access to advanced medical technologies and skilled surgeons

has improved (Ecker, 2017). However, there are concerns about the overuse of the procedure,
with some countries exhibiting C-section rates far higher than the medically recommended

threshold of fifty percent (Finger, 2018). In low- and middle-income countries, C-sections are

often underutilized, despite being a life-saving intervention in obstetric emergencies (Dumont

et al., 2019). The global variation in C-section rates highlights the importance of

understanding not just the medical indications but also the cultural and societal attitudes that

influence women's decisions about childbirth (Behaque, 2014). Studies have shown that in

some regions, women may resist or delay opting for a Caesarean section, despite indications

for the procedure, due to fears, misinformation, or cultural norms that favor vaginal delivery

(Chigbu & Iloabachie, 2017).

In Nigeria, the acceptance of caesarean section is a complex issue influenced by factors

ranging from healthcare access to cultural beliefs and socio-economic status (Olusanya &

Solanke, 2019). In urban centers like Abuja, the rates of Caesarean section have been

increasing as healthcare infrastructure improves and medical professionals become more

proficient in performing the procedure (Aziken et al., 2017). However, in rural areas, where

access to healthcare facilities is limited, the procedure remains less common, contributing to

higher maternal and neonatal mortality rates. Studies conducted in Nigeria show that many

women have mixed perceptions about Caesarean section, with some viewing it as a last resort

when vaginal delivery is no longer possible (Awoyinka et al., 2016). Fear of surgical

complications, along with cultural beliefs about childbirth, often influences these perceptions

(Aziken et al., 2017). For example, many Nigerian women believe that vaginal birth is a

natural and preferable mode of delivery, and there is often a social stigma attached to having

a Caesarean section (Becher & Stokke, 2019). Despite the growing acceptance of C-sections

in urban hospitals, the challenge remains to address the misconceptions and social resistance

that prevent some women from consenting to the procedure, even when medically necessary

(Olusanya & Solanke, 2019).

Maternal mortality represents the leading cause of death among the pregnant women in most

developing countries including Nigeria (Awoyinka, et al, 2016). Furthermore, it is estimated

that one third of all maternal deaths globally occur in just two countries, namely India and

Nigeria (Danso, et at., 2019). According to United Nations Population Fund (UNPF) (2012),

in 2010, India was accountable for about twenty percent of global maternal deaths (fifty-six

thousand) and Nigeria, forty percent (forty thousand). In recent time women in Nigeria have

expressed worries about choices of childbirth especially the issues surrounding vaginal birth

which includes maternal complications like, uterine rupture, postpartum hemorrhage, perianal

tears, prolonged labor and neonatal complications like sepsis, meningitis, shoulder dystocia,

brachial plexus injuries and perinatal asphyxia (Danso, et at., 2019).

The issue of perception and acceptance of caesarean sections is not unique to Nigeria but is a

significant concern in many parts of the world, particularly in low-resource settings where

maternal health is closely tied to socio-cultural dynamics (Olusanya & Solanke, 2019). The

refusal or delay in accepting Caesarean section has serious implications for maternal and

neonatal health, particularly in the face of complications that can arise during childbirth

(Dumont et al., 2019). Women’s perceptions of Caesarean section, shaped by personal

experiences, cultural beliefs, and social pressures, can directly affect their health outcomes

(Danso et al., 2019). In Nigeria, where maternal mortality remains high, particularly among

women in rural areas, it is essential to understand and address the factors contributing to

resistance to C-sections (Olusanya & Solanke, 2019).

1.2 Statement of Problem

The decision to undergo a caesarean section is influenced by a variety of factors, including

medical necessity, personal perceptions, cultural beliefs, and societal norms. In many cases,

the refusal or hesitation to accept a Caesarean section can lead to increased risks for both the

mother and child, especially in obstetric emergencies. Despite the potential life-saving nature
of the procedure, some pregnant women in Nigeria exhibit resistance or limited acceptance of

Caesarean section due to fear, misinformation, or cultural beliefs that favor vaginal delivery

(Awoyinka et al., 2016). Annually, an estimated five hundred and twenty-nine thousand

women die from complications of pregnancy and childbirth globally. Ninety-nine percent of

these deaths occur in developing countries and one percent in the developed countries. This

means that every year, close to nine million people suffer some type of injury from pregnancy

and childbirth that can have profound effect on their lives and families, (WHO, 2020).

Understanding the underlying factors that shape perceptions of Caesarean section is essential

to improving maternal health outcomes (Chigbu & Iloabachie, 2017). In a country like

Nigeria, where maternal mortality rates remain high, particularly in rural and semi-urban

areas, addressing these perceptions is crucial (Danso et al., 2019). According to Aziken et al.

(2017), the lack of adequate information or the influence of traditional practices can hinder

timely medical intervention, exacerbating the risks associated with childbirth. Hence, this

study aims to explore the perceptions and acceptance of Caesarean section among pregnant

women in Gwagwalada, Abuja, to identify the barriers and develop strategies that promote

better decision-making for maternal health.

1.3 Objectives of the Study

1. To determine the perception of Caesarean Section among pregnant women attending

antenatal clinic in university of Abuja teaching hospital, Gwagwalada.

2. To assess the attitude of pregnant women towards Caesarean Section among pregnant

women attending antenatal clinic in University of Abuja Teaching Hospital,

Gwagwalada.

3. To determine the level of acceptance of Caesarean Section among pregnant women

attending antenatal clinic in University of Abuja Teaching Hospital, Gwagwalada.

 4. To identify the factors influencing the decision to accept or reject caesarean section

among pregnant women attending antenatal clinic in University of Abuja Teaching

Hospital, Gwagwalada.

1.4 Research Questions

1. What is the perception of caesarean section among pregnant women attending

antenatal clinic in University of Abuja Teaching Hospital, Gwagwalada?

2. What is the attitude of pregnant women attending antenatal clinic in University of

Abuja Teaching Hospital, Gwagwalada towards Caesarean Section?

3. What are the factors affecting acceptance of caesarean section among pregnant

women attending antenatal clinic in University of Abuja Teaching Hospital,

Gwagwalada?

4. What are the factors influencing the decision to accept or reject caesarean section

among pregnant women attending antenatal clinic in University of Abuja Teaching

Hospital, Gwagwalada?

1.5 Significance of the Study

The findings from this study will help the hospital management draw out a policy where

pregnant women can meet with women who have had caesarean section done for words of

encouragement. This will improve utilization of this mode of delivery assist in improving

quality of patient’s life.

It will help the nursing profession to determine perception about caesarean section with focus

on misconception to be corrected through specific antenatal education and counseling.

It will help to curb negative attitude of some pregnant women attending antenatal clinic

towards caesarean section, which will help to reduce the delay in presentation to the health

facility and prevent the high mortality rate of maternal and fetal complication and death.
The findings will help the Nursing professional body to organize seminars and workshop on

effective communication and counseling to pregnant women attending antenatal clinic,

thereby increasing their confidence and level of acceptability.

The findings will also contribute to the body and knowledge of research and stimulates for

further reading.

1.6 Scope and Limitations of the Study

This study is focused on the perception, attitude and acceptance of Caesarean section among

pregnant women attending antenatal clinic in UATH. It will be carried out in University of

Abuja Teaching Hospital, Gwagwalada (UATH).

1.7 Operational Definition of Terms

Acceptance: The willingness of pregnant women to consent to or choose caesarean section

as a mode of delivery.

Antenatal: Referring to the care and activities that occur before birth, during pregnancy,

including monitoring maternal and fetal health.

Caesarean Section: A surgical procedure used to deliver one or more babies through an

incision in the abdomen and uterus, often when vaginal delivery presents risks to the mother

or baby.

Childbirth: The process of bringing forth a child from the womb or uterus.

Maternal mortality: The death of a woman during pregnancy or within forty-two days of

childbirth due to pregnancy-related causes.

Perception: The general mindset or understanding of pregnant women towards caesarean

section and its role in childbirth.

Pregnancy: The period in which a fetus develops inside a woman's womb or uterus, leading

to childbirth.
 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

The following reviews shall be studies under this chapter of the study:

• Conceptual Review

• Theoretical Framework

• Empirical Review

2.1 Conceptual Review

2.1.1 Overview of Cesarean Section

A caesarean section is a surgical procedure involving the delivery of a baby through incisions

made in the abdominal wall and the uterus, often performed when vaginal delivery poses

risks to the mother or fetus (World Health Organization, 2022). It is considered a major

abdominal surgery and is typically carried out under regional anaesthesia such as spinal or

epidural, although general anaesthesia may be used in emergencies (Kweekel et al., 2020).

The procedure has undergone significant transformation over the past century, progressing

from a high-risk, last-resort operation to a routine surgical intervention due to advances in

medical technology, surgical techniques, and antiseptic protocols (Gibbons et al., 2018). In

contemporary obstetric care, the Caesarean section is not only a life-saving intervention but

also a procedure surrounded by social, emotional, and cultural interpretations, particularly in

low- and middle-income countries where vaginal delivery is still perceived as the norm

(Ezeonu et al., 2023). Understanding the definition and evolution of the Caesarean section is

fundamental to appreciating the broader discourses surrounding maternal health choices,

particularly as they relate to safety, autonomy, and the institutionalization of childbirth.

Medical indications for caesarean delivery are diverse and generally aimed at preserving

maternal and fetal well-being in complex obstetric scenarios (National Institute for Health

and Care Excellence [NICE], 2021). These include conditions such as cephalopelvic

disproportion, placenta previa, obstructed labour, eclampsia, fetal malpresentation, multiple

gestations, and failed induction of labour (World Health Organization, 2020). In some

contexts, Caesarean section are also performed upon maternal request, even in the absence of

clinical indications, due to fear of labour pain or concerns about vaginal trauma (Mazzoni et

al., 2019). Globally, the rate of caesarean deliveries has risen significantly, increasing from

twelve percent in 2000 to over twenty-one percent in 2021, with projections suggesting it

could reach twenty-nine by 2030 if current trends continue (Betrán et al., 2021). In Nigeria,

the national average Caesarean section rate hovers around thirteen percent, with higher rates

reported in tertiary health facilities due to better access to surgical care and specialist services

(Ikeako et al., 2021). This upward trend has prompted debates around the medicalization of

childbirth and the balance between clinically necessary and elective Caesarean section

(Boatin et al., 2022). Understanding the prevalence and medical rationale for Caesarean

section is critical for contextualizing how pregnant women in Nigeria view and ultimately

accept or reject the procedure.

Despite its potential to prevent maternal and neonatal morbidity and mortality, caesarean

section carries several clinical, psychological, and socio-economic risks that influence its

overall acceptability (Chigbu et al., 2018). On the one hand, it offers benefits such as reduced

perinatal trauma, timely intervention in fetal distress, and lower incidence of pelvic floor

damage in high-risk cases (Barber et al., 2020). On the other hand, the procedure is

associated with complications including haemorrhage, infections, delayed wound healing,

anaesthesia-related issues, and increased likelihood of complications in subsequent

pregnancies like placenta accreta or uterine rupture (Silver, 2019; World Health
Organization, 2018). In low-resource settings, these risks are magnified due to infrastructural

constraints, lack of post-operative follow-up, and financial burdens placed on families

(Kabakian-Khasholian & Campbell, 2021). Moreover, the social consequences of Caesarean

section such as perceived failure in natural childbirth or stigma attached to surgical delivery

can discourage women from accepting the procedure even when medically indicated (Ezechi

et al., 2024). Therefore, the interplay between the medical facts and the social realities of

Caesarean section must be considered when exploring the broader patterns of perception and

acceptance among pregnant women in Nigeria.

2.1.2 Perception of Cesarean Section among Pregnant Women

Perceptions of caesarean section (C-section) among pregnant women are often shaped by a

range of beliefs, including misconceptions about the procedure’s necessity, safety, and

implications for maternal identity. Many women particularly in low- and middle-income

countries regard vaginal delivery as the “natural” or ideal mode of childbirth, while

Caesarean section is viewed as a deviation from normalcy (Ezechi et al., 2004). This

perception is frequently underpinned by the belief that surgical delivery reflects weakness or

failure on the part of the mother, thus leading to stigma and diminished self-esteem (Chigbu

et al., 2010). Studies conducted in sub-Saharan Africa, including Nigeria, have found that

women commonly associate Caesarean section with loss of womanhood, surgical

complications, and even increased mortality (Ikeako et al., 2014). These entrenched attitudes

not only affect individual decision-making but also contribute to the widespread reluctance to

consent to surgical birth, even when clinically necessary. Consequently, healthcare providers

often encounter resistance or delayed acceptance of emergency Caesarean section, which can

endanger both maternal and neonatal outcomes (Boatin et al., 2018). Understanding these

beliefs is therefore essential to designing culturally sensitive health education interventions

that promote informed and timely maternal choices.

Beyond personal beliefs, broader cultural, social, and religious frameworks also play a

significant role in shaping how Caesarean section are perceived and accepted. In many

African societies, childbirth is not merely a biological event but a socially constructed rite of

passage, deeply embedded in expectations of feminine strength, resilience, and natural

motherhood (Okonkwo et al., 2012). Within this context, vaginal birth is often idealized,

while surgical intervention may be interpreted as a disruption of divine or traditional

processes. Religious beliefs, particularly among Muslim and Christian communities, can

influence perceptions of C-section either positively or negatively depending on prevailing

teachings and interpretations (Ezeonu et al., 2017). Some women believe that resorting to

surgery suggests a lack of faith or spiritual weakness, while others see medical intervention

as a manifestation of divine provision. Moreover, social narratives perpetuated by family

elders, peers, and even traditional birth attendants can reinforce distrust of hospitals and

modern obstetric care, contributing to fear and avoidance of Caesarean section (Kabakian-

Khasholian & Campbell, 2005). These socio-cultural dynamics are especially pronounced in

rural and low-literacy populations, where misinformation and myths are more prevalent.

Addressing these external influences requires multi-sectoral engagement, including

collaboration between healthcare providers, religious leaders, and community gatekeepers.

Psychological and emotional responses to the idea of caesarean section further complicate

women’s acceptance of the procedure. Many pregnant women experience anxiety, fear, or

even grief when told that a Caesarean section is necessary, particularly if they had anticipated

a natural birth (Mazzoni et al., 2011). This emotional distress is often heightened by fears of

surgical complications, post-operative pain, and extended recovery time (Barber et al., 2011).

Some women report feelings of disappointment, failure, or disconnection from their

childbirth experience, which may have long-term consequences for maternal mental health,

including increased risk of postpartum depression (Silver, 2012). In contexts where

information about the surgical process is limited or poorly communicated, these concerns can

escalate into outright refusal or delay of the procedure. Additionally, concerns about the

potential impact on future fertility or the risk of repeat Caesarean section in subsequent

pregnancies contribute to hesitancy (WHO, 2018). To improve psychological preparedness

and reduce emotional resistance, healthcare providers must prioritize effective antenatal

counselling, empathetic communication, and shared decision-making. When pregnant women

feel informed, supported, and respected in their choices, they are more likely to accept

medically indicated Caesarean section without fear or regret.

2.1.3 Acceptance of Cesarean Section among Pregnant Women

The concept of “acceptance” in maternal health refers not only to a woman’s consent to

undergo a particular medical intervention but also to her psychological readiness and positive

acknowledgment of its necessity and safety (Boatin et al., 2018). In the context of caesarean

section, acceptance involves recognizing the clinical rationale for surgical delivery and

viewing the procedure as a valid, sometimes life-saving, alternative to vaginal birth. It also

includes a degree of emotional reconciliation with the shift from expected natural labour to

surgical intervention (Addis & Evans, 2025). Studies show that women who accept

Caesarean section tend to report a sense of empowerment and maternal agency when they

perceive the decision as medically justified and adequately communicated (Singh et al.,

2019). Conversely, lack of acceptance is often rooted in miscommunication, lack of

understanding, or cultural framing of the procedure as undesirable (Chigbu et al., 2018).

Therefore, acceptance is not merely a binary ‘yes or no’ decision but a multidimensional

process shaped by medical, emotional, and socio-cultural factors that require sensitive

handling in clinical settings.

Pregnant women’s willingness or reluctance to undergo a caesarean section varies widely

depending on their individual perceptions, previous experiences, and the influence of external

opinions. Willingness is often found among women who have received adequate health

education, experienced prior obstetric complications, or are advised by trusted clinicians

(Kweekel et al., 2020). However, a large proportion of women especially in low-resource

settings display significant reluctance, stemming from fear of pain, postoperative recovery,

financial cost, and perceived loss of control (Ikeako et al., 2019). Cultural norms that value

natural childbirth over surgical interventions further deepen this reluctance, often reinforcing

the idea that a Caesarean section signifies failure or inadequacy (Ezeonu et al., 2018). This

emotional and cultural burden can result in the rejection of medically necessary interventions,

with serious implications for maternal and fetal outcomes (Betrán et al., 2021). A key factor

influencing willingness is trust in healthcare providers; when women feel confident in their

care team, they are more likely to comply with medical advice and undergo a Caesarean

section when recommended (Scerri et al., 2019). Therefore, fostering relational trust and

addressing misconceptions can be crucial to bridging the gap between reluctance and

acceptance.

The role of information dissemination and antenatal counselling in enhancing acceptance of

Caesarean section cannot be overstated. Evidence consistently shows that when women are

informed early and clearly about the possibility of surgical delivery, including its indications,

risks, and benefits, they are more psychologically prepared to accept the procedure if

necessary (Barber et al., 2018). Structured antenatal education and counselling sessions serve

as platforms to correct myths, build trust, and reduce anxiety around caesarean delivery

(Chigbu et al., 2018). Moreover, such interventions can empower women by involving them

in birth planning, giving them a sense of control even when Caesarean section becomes

inevitable (Mazzoni et al., 2019). A study by Addis & Evans (2025) found that women who
received individualized counselling were significantly more likely to describe their Caesarean

section experience as positive and empowering, compared to those who underwent

emergency procedures without prior explanation. Inadequate or rushed counselling,

particularly during emergencies, often leads to trauma, dissatisfaction, or long-term negative

perceptions (Silver, 2020). Therefore, integrating comprehensive antenatal counselling into

maternal healthcare services is a strategic approach to improving acceptance rates and

ensuring safer childbirth outcomes.

2.1.4 Factors Influencing Acceptance of Cesarean Section among Pregnant Women

The acceptance of caesarean section among pregnant women is significantly shaped by their

educational background, which influences health literacy and decision-making autonomy.

Educated women are more likely to engage actively with health information, seek

clarification from medical professionals, and base their decisions on evidence rather than on

cultural myths or hearsay (Chigbu et al., 2018; Boatin et al., 2018). In contrast, women with

lower levels of formal education may rely more on community narratives or traditional

beliefs, often associating Caesarean section with weakness or failure in womanhood (Ezeonu

et al., 2020). This educational gap is further complicated by access to antenatal counselling,

where poorly resourced facilities may lack the time or personnel to provide adequate health

education. As a result, informed consent becomes a challenge, especially in communities

where literacy rates are low and social norms strongly favour vaginal birth as the default

method (Scerri et al., 2019).

In addition to education, prior birth experiences and the role of healthcare providers

profoundly influence acceptance levels. Women who have previously experienced obstetric

complications or emergency caesarean sections often approach subsequent pregnancies with

heightened awareness and are more open to surgical delivery if reassured by a competent

clinical team (Addis & Evans, 2025). However, women who have experienced poor provider
communication, traumatic deliveries, or post-operative complications may develop fear or

mistrust toward repeat procedures (Silver, 2020). Moreover, the attitude and communication

style of healthcare providers play a crucial mediating role; respectful, empathetic, and

informative counselling increases trust and cooperation, whereas coercive or dismissive

interactions can lead to resistance and anxiety (Singh et al., 2019). Thus, the quality of

provider-patient engagement directly affects how women perceive not only the necessity of a

Caesarean section but also the safety and dignity associated with the process.

Socioeconomic and cultural contexts act as overarching frameworks within which these

individual decisions are made. Financial constraints, especially in low-resource settings, can

make caesarean sections seem unaffordable or even unnecessary, prompting families to

decline them despite medical indications (Ikeako et al., 2019). In communities where health

insurance is limited or non-existent, the high cost of surgery and post-operative care often

deters acceptance (Betrán et al., 2021). Cultural and religious beliefs further shape decisions;

some women view Caesarean section as a sign of divine punishment or personal failure,

while others fear the loss of social status associated with non-vaginal birth (Ezechi et al.,

2020). Family dynamics, especially pressure from husbands or in-laws, may also reinforce

these views, limiting women's autonomy over their birth choices. Therefore, improving

access to equitable healthcare, providing inclusive antenatal counselling, and engaging

families and communities are vital strategies to increase acceptance and ensure that caesarean

sections are viewed through a clinical rather than a cultural or economic lens.

2.2 Theoretical Framework

2.2.1 Health Belief Model (HBM)

The Health Belief Model (HBM) is a widely recognized theory in public health that seeks to

explain and predict health behaviors, particularly in relation to preventive health actions
(Gutierrez & Wolfe, 2022). Developed in the early 1950s by social psychologists Irwin M.

Rosenstock, Godfrey Hochbaum, and Stephen Kegels, the model was originally designed to

understand the widespread failure of people to accept disease prevention strategies, especially

in the context of tuberculosis screening programs (Khoramabadi et al., 2019). The model

proposes that an individual’s likelihood of engaging in health-promoting behaviors is

influenced by their perceptions of susceptibility to a health problem, the severity of that

problem, the benefits of taking a preventive action, and the barriers to taking that action

(Gutierrez & Wolfe, 2022). Furthermore, factors such as cues to action and self-efficacy are

also considered to enhance the understanding of health behavior. This model emphasizes that

individuals are more likely to take preventative actions if they believe they are at risk, if the

outcomes are severe, if taking action will reduce the risk, and if they perceive few barriers to

the action (Khoramabadi et al., 2019).

In the context of caesarean section acceptance, the Health Belief Model provides a relevant

framework to understand how women’s beliefs and attitudes toward surgical delivery

influence their healthcare decisions. Specifically, the model helps to explain how individual

perceptions about risk, seriousness of complications, and the perceived advantages or

disadvantages of undergoing a Caesarean section affect its acceptance among pregnant

women. Women are more likely to accept Caesarean section when they believe they are at

high risk of complications from vaginal delivery (perceived susceptibility), when they

understand the possible severity of such complications (e.g., obstructed labor, fetal distress),

when they perceive that a Caesarean section can offer safety and better health outcomes for

mother and baby (perceived benefits), and when they encounter fewer barriers such as fear,

stigma, misinformation, or cost (Khoramabadi et al., 2019). In addition, external cues such as

advice from health professionals, media campaigns, and previous childbirth experiences,
along with a woman's confidence in her ability to make and act on health-related decisions

(self-efficacy), all contribute to shaping her perception and acceptance of caesarean delivery.

Figure 2.1 Diagrammatic representation of the Health Belief Model

2.2.2 Application of the Health Belief Model to Caesarean Section Perception and

Acceptance

The Health Belief Model (HBM) helps explain how pregnant women’s perceptions influence

their decision to accept or reject caesarean section (C-section) as a mode of delivery. One of

the core components, perceived susceptibility, refers to how women evaluate their likelihood

of developing complications during childbirth. Women who have been informed of clinical

risk factors such as prolonged labor, fetal distress, or a history of previous Caesarean section

may more likely view themselves as vulnerable and therefore accept surgical delivery. In
contrast, those who do not believe they are at risk may decline Caesarean section, even when

medically advised.

Another crucial element is perceived severity, which relates to the seriousness women

attribute to potential childbirth complications. If women believe that refusing a necessary

Caesarean section could lead to severe outcomes such as maternal or neonatal death, uterine

rupture, or long-term disability they may be more inclined to undergo the procedure.

However, in contexts where cultural or religious beliefs downplay the seriousness of delivery

complications or promote natural birth at all costs, women may undervalue the benefits of

surgical intervention and resist medical advice. This underscores the need for education that

highlights the real consequences of delaying or refusing Caesarean section when clinically

necessary.

The constructs of perceived benefits and perceived barriers further shape Caesarean section

acceptance. Pregnant women are more likely to accept the procedure if they believe it will

lead to a safe delivery, prevent complications, or protect their baby’s life. However, barriers

such as fear of pain, cost, societal stigma, misinformation, or limited decision-making power

can discourage acceptance. Enhancing cues to action such as counselling by healthcare

professionals and promoting self-efficacy, by empowering women to ask questions and make

informed decisions, can significantly improve Caesarean section acceptance. Thus, the HBM

provides a useful guide for developing maternal health interventions that encourage informed

and timely decisions about surgical delivery.

2.3 Empirical Review

This is a review of the work of other researchers on the perception and acceptance of

caesarean section among pregnant women.

2.3.1 Perception of caesarean section

Sunday-Adeoye and Kalu (2018) carried out a study to determine the perceptions of antenatal

clients in the southeastern Nigeria on cesarean section. It was a cross-sectional study of three

hundred consenting pregnant clients attending the antenatal clinic using a structured

questionnaire. The data were analyzed and presented in a simple frequency table and the

following findings were made, of the three hundred consenting pregnant clients attending the

antenatal clinic, the average Caesarean section rate in the hospital was sixteen point six

percent. Only four representing (one point four percent) viewed Caesarean section as

very good and elected to undergo Caesarean section. Thirty-four representing (twelve point

two percent) considered Caesarean section as bad and would reluctantly undergo the

procedure. Two hundred and twenty-five representing (eighty point two percent) would

accept Caesarean section if their life or that of their fetus is in great danger. They concluded

that this study affirms previous suspicion that a significant proportion of antenatal clients are

averse to Caesarean section and the negative cultural perception of the people to

C/S reinforced this aversion.

A similar study was carried out by Saoji et al. (2019) to determine the women’s knowledge,

perceptions, and potential demand towards caesarean section in university of Rajshahi,

Bangladesh. A cross-sectional study was undertaken with an objective to determine the level

of knowledge, attitudes, and perceptions about cesarean section among pregnant women. Five

hundred and sixty-six pregnant women attending antenatal clinic were interviewed with a

structured questionnaire. Data analysis was done by using Epi info software. The study

revealed among other findings that two hundred and twenty-six women (nine-one point five

percent) preferred vaginal delivery against caesarean section, when asked for their preferred

mode of delivery. The reasons given for preferring vaginal delivery to caesarean section were

natural way to deliver, safer way to deliver, less expensive and early discharge from hospital.

The researchers concluded that there is need to provide better information for pregnant
women during the antenatal period about modes of delivery, their indications, advantages and

adverse consequences which will enable them to make an informed decision.

Enabudoso et al. (2016) carried out a study to explore the perception and attitude of women

with previous caesarean section towards repeat caesarean section university of Benin

teaching hospital, Benin city, Nigeria. It was an observational study of women with prior

caesarean delivery using an anonymous semi-structured questionnaire. Information elicited

include the socio-demographic characteristic, outcome of the last caesarean delivery,

experience of complications or domestic violence, acceptance of repeat caesarean section if

advised by the doctor and the reason for any refusal. The statistical analysis was done with

Epi-info version 3.5.1 software. A p- value of ≤ 0.05 was taken as significant at nine five

percent confidence limits. Their results revealed that of the one hundred and thirty-nine

parturient who participated in the study, seventy-seven percent had one previous caesarean

delivery while fifty-four point forty six percent will decline a repeat caesarean section. Major

reasons for refusal were postoperative pain, cultural aversion, fear of death, and cost of

caesarean delivery. The rate of acceptance was significantly higher amongst those with more

than one prior caesarean section while the rate of refusal was significantly higher amongst

those who experienced domestic violence in the last caesarean delivery. Twelve percent

experienced domestic violence (almost entirely psychological) mainly from the spouse or his

relatives. They recommended that there is need for behavioral change communication

involving the community, improved postoperative pain management, and better counselling

especially on safety of the procedure.

2.3.2 Acceptance of caesarean section

A study was carried out by Jeremiah, Enyidah and Fiebai (2018) to assess the acceptance of

antenatal patients at a tertiary hospital in Southern Nigeria towards cesarean section. It was a

cross sectional study conducted among four hundred clients seen at the University of Port
Harcourt Teaching hospital between 1st and 31st September 2009. Data management was

carried out using SPSS 15.0 statistical software. Chi-square tests were used to compare the

groups as appropriate. The study revealed among other findings that out of the four hundred

women studied, sixty-eight point five percent favoured caesarean section while one third was

averse to it. They concluded that the acceptance is directly linked with the educational status

of the women while cultural and religious beliefs were the main reason for aversion of the

procedure. They recommended that female education and community health education about

the benefits of cesarean delivery when indicated at primary care level is needed to reduce the

number of women declining cesarean delivery and the morbidities and mortalities associated

with such an action and improve the pregnancy outcome.

Buyukbayrak and Lufti (2019) on cesarean delivery or vaginal birth: Preference of Turkish

pregnant women and influencing factors at Obstetrics Clinic, Education and Research

Hospital, Istanbul Turkey. The aim of the study was to assess the preference of pregnant

women for mode of delivery in an uncomplicated pregnancy and reasons of their choice, also

to determine if maternal characteristics were predictors of maternal preference. It was a cross-

sectional study carried among pregnant women applying to the antenatal clinic for a routine

control visit. After verbal consents, a questionnaire was administered to one thousand five

hundred and eighty-eight pregnant women. The data were analyzed using Epi Info 6. Of the

women questioned, eighty-five point one percent opted for vaginal delivery, whereas only

fifty point nine opted for an elective cesarean delivery. The main reasons for vaginal delivery

preference were; earlier healing and earlier discharge, being a more physiological way of

delivery and previous vaginal delivery history. The most common reasons for choosing

cesarean delivery were fear of vaginal delivery, tubal ligation demand, and previous cesarean

section and to avoid labor pain. Educational status, occupation and gestational age were not
found to be influencing factors but age, parity and monthly income were found to be

influencing factors for maternal preference.

2.3.3 Knowledge gaps misconception related to caesarean section

Orji, et al. (2019) posited that there is a general aversion to Caesarean section in developing

countries such as Nigeria, giving rise to difficulties in persuading patients to undergo surgery

even in the context of obstetric emergencies. Porreco, Thorp (1996) affirmed that Nigerian

women are averse to Caesarean section for reasons that include the feeling of a sense of

reproductive failure, social misfit, “not woman enough” and for its financial implications.

Aziken, Omo-Aghoja, and Okonofua (2017) stated that qualitative studies have in fact

established that some women will not even accept Caesarean section under any

circumstances for reasons such as the fear of pain or death, financial cost, embarrassment by

friends, religious beliefs and husband's disapproval.

Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed

because they are profitable for the hospital, because a quick Caesarean is more convenient

for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a

scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not

predetermined (Savage 1997). Another reason for doctors to recommend Caesarean

section is money. In China, doctors are compensated based on the monetary value of medical

treatments offered. As a result, doctors have an incentive to persuade mothers to choosing

the more expensive Caesarean section.

Agumuo (2020) noted that some women bluntly decline the operation, insisting that God has

not promised them anything short of safe delivery. Despite the pressure being mounted on

them by the medical personnel in the hospitals where they are registered, to allow an easy

procedure, they refuse.

Olusanya & Solanke, (2019), stated that non-vaginal delivery is generally viewed as a sign of

maternal laziness, reproductive failure or a curse from perceived enemies or deity in this

population. It was therefore not uncommon even where Caesarean section was indicated by

past pregnancy history for women to attempt vaginal delivery until there was a glaring failure

with obvious threat to the life of the mother or unborn child.

CHAPTER THREE

METHODOLOGY

This chapter is concerned with the research design, area of the study, population for the

study, the sample and sampling technique, the instrument for data collection, validity and

reliability of the instrument, method of data collection and data analysis.

3.1 Research Design

The cross-sectional descriptive design was used for the study. The design is considered

appropriate for the study because the information was collected directly from the pregnant

women.

3.2 Research Setting

The location of this study is the University of Abuja Teaching Hospital Gwagwalada. The

hospital is located along Passo road, 3km away from the University of Abuja annex and 5km

away from the kaduna/Lokoja expressway. It has a landmark of 135km. The hospital is

headed by the Chief Medical Director and the nursing department is headed by Deputy

Director of Nursing. University of Abuja teaching hospital is a tertiary institution; it was

commissioned by the then Head of State, General Ibrahim Babagida in May 1992. It was
upgraded to a teaching hospital by the then President of the federal republic of Nigeria,

General Olusegun Obasanjo in August 2005. The hospital has a capacity of about 350 beds.

3.3 Target population

The target population for the study consisted of all the pregnant women who attend and are

registered for antenatal clinics at the hospital in one week which is 250.

3.4 Sample and Sampling Techniques

The sample size for the study is 152 pregnant women using Krejcie and Morgan sample size

determination.
3.5 Instrument for Data Collection

The instrument for data collection is a questionnaire. It was developed by the researcher to

elicit information on the perception, attitude and acceptance of caesarean section among

pregnant women attending antenatal clinic in university of Abuja teaching hospital,

Gwagwalada.

The questionnaire consists of section A-D. Section A contains information regarding the

demographic characteristics of the respondents. Section B-D contains 15 items arranged in a

four point Likert scale aimed at finding out the perception attitude and acceptance of

caesarean section among pregnant women attending antenatal clinic in University of Abuja

Teaching Hospital, Gwagwalada. The pregnant women indicated their degree of agreement

and degree of disagreement using the likert rating scale: strongly agree (SA), agree (A),

disagree (D) and strongly disagree (SD).

3.7 Validity of the instrument.

A well-structured questionnaire was constructed based on the research questions by the

researcher and was presented to the supervisor for face and content validity.

3.8 Reliability of the instrument.

A pilot study was carried out at Joway Clinics and Maternity, Old Kuntunku, Gwagwalada. 8

pregnant women attending antenatal clinics were selected randomly to test and retest the

instrument on two different occasions. The reliability of the questionnaire was established

using the test-retest method. The test-retest scores were analyzed and a coefficient figure of

0.92 was obtained. The reliability leads to the conclusion that the instrument is reliable.

3.9 Method of Data Collection

A letter of introduction signed by the Ethical Committee of University of Abuja Teaching

Hospital (UATH) seeking permission to carry out the research on perception attitude and

acceptance of caesarean section among pregnant women attending antenatal clinics at the
University of Abuja Teaching Hospital, Gwagwalada, was presented to the head of antenatal

clinic. Copies of the questionnaire were administered to the pregnant women by the

researcher and research assistants who were briefed on the modalities of administration. A

total number of 118 questionnaires were distributed within one week and same number was

recovered.

3.10 Method of Data Analysis

The data collected using the questionnaire were analyzed using percentage statistical method,

mean and Linkert scale.

3.11 Ethical Consideration

This research proposal was sent to the Ethics Committee of university of Abuja Teaching

Hospital, Gwagwalada for ethical clearance and approval. This implies the code of conduct

that guides and directs the researcher. Care was taken not to intrude on the mental and social

health of the target population, thereby maintaining the right and integrity of this work by

obtaining informed consent and voluntary participation. Consent and confidentiality of the

information obtained was maintained and data collected was used solely for the purpose of

this research.
 CHAPTER FOUR

RESULTS

4.0 Introduction

This chapter focuses on presentation, analysis and interpretation of data collected from the

respondents through questionnaire. The presentation of results will be in relation to set

objectives.

Table 4.1 showing Socio-demographic Characteristics of Respondents

Variables Options Frequency Percentage (%)

Age 15-25 30 19.7
26-35 72 47.4
36-45 38 25.0
46 and above 12 7.9
Total 152 100
Ethnicity Hausa 45 29.6
Igbo 58 38.2
Yoruba 28 18.4
Others 21 13.8
Total 152 100
Highest educational attainment No Formal Education 6 3.9
Primary 32 21.1
Secondary 54 35.5
Tertiary 60 39.5
Total 152 100%
Religion Christianity 92 60.5
Islam 58 38.2
Others 2 1.3
Total 152 100%
How did you deliver your previous baby or No previous delivery 39 25.7
babies
Natural/vaginal 55 36.2
delivery
Cesarean delivery 32 21.1
Both vaginal & CS 26 17.0
Total 152 100.0

Table 1 shows that the majority 72 (47.4%) of the respondents were between the ages of 26–

35 years, followed by 38 (25.0%) who were between 36–45 years. Majority 58 (38.2%) of the

respondents were Igbo, followed by Hausa 45 (29.6%), Yoruba 28 (18.4%), and Others 21

(13.8%). Regarding educational attainment, most 60 (39.5%) of the respondents had tertiary

education, followed by secondary education 54 (35.5%). With respect to religion, the

majority were Christians 92 (60.5%), while Muslims accounted for 58 (38.2%), and only 2

(1.3%) practiced other religions. Most 55 (36.2%) of the respondents reported having had

vaginal delivery, 32 (21.1%) had caesarean delivery, and 26 (17.0%) had experienced both

vaginal and caesarean delivery. About 39 (25.7%) of the respondents had no previous

delivery.
Table 4.2: Showing Perception of the Women to Cesarean Section

Statement 5 4 3 2 1 Mean Decision

SA A U D SD
Caesarean section is a safe 58 45 12 25 12 3.74 Agree
mode of delivery (38.2%) (29.6%) (7.9%) (16.4%) (7.9%)
Caesarean section is only done 40 54 15 30 13 3.50 Agree
when complications arise (26.3%) (35.5%) (9.9%) (19.7%) (8.6%)
CS is a sign of weakness on the 18 27 11 57 39 2.53 Disagree
part of a woman (11.8%) (17.8%) (7.1%) (37.1%) (25.7%)
Caesarean section can endanger 32 46 20 34 20 3.23 Moderately
the life of the mother (21.1%) (30.3%) (13.2%) (22.4%) (13.2%) Agree
Caesarean section saves the life 60 52 10 20 10 3.82 Strongly
of mother and baby (39.5%) (34.2%) (6.6%) (13.2%) (6.6%) Agree
A caesarean section is more 40 44 14 28 26 3.29 Agree
painful than vaginal delivery. (26.3%) (28.9%) (9.2%) (18.4%) (17.1%)
Total 3.35 Moderately
Agree

Table 4.2 shows that majority of the respondents agreed that caesarean section is a safe mode

of delivery as represented by a mean value of 3.74. Most of the respondents also agreed that

caesarean section is only done when complications arise as shown by a mean value of 3.50.

Majority of the respondents disagreed that caesarean section is a sign of weakness on the part

of a woman as evidenced by a mean value of 2.53. Most of the respondents moderately

agreed that caesarean section can endanger the life of the mother as represented by a mean

value of 3.23. Furthermore, majority of the respondents strongly agreed that caesarean

section saves the life of both mother and baby as shown by a mean value of 3.82. Majority of

the respondents also agreed that caesarean section is more painful than vaginal delivery as

represented by a mean value of 3.29. In overall, majority of the respondents showed

moderately positive perception towards caesarean section as represented by a total mean

value of 3.35.
Table 4.3: Showing Attitude Towards Caesarean Section

Statement 5 4 3 2 1 Mean Decision

SA A U D SD
I am willing to undergo CS 64 38 10 26 14 3.74 Agree
if I or my baby’s life is at (42.1%) (25.0%) (6.6%) (17.1%) (9.2%)
risk.
I prefer vaginal delivery to 35 47 20 30 20 3.25 Agree
CS regardless of the risk (23.0%) (30.9%) (13.2%) (19.7%) (13.2%)
involved.
I would accept CS if my 48 44 12 28 19 3.52 Agree
doctor recommends it. (31.6%) (28.9%) (7.9%) (18.4%) (25.1%)
I would feel disappointed if I 30 36 18 40 28 2.99 Moderately
delivered through CS. (19.7%) (23.7%) (11.8%) (26.3%) (18.4%) Agree

I would encourage other 56 52 12 18 14 3.78 Agree

women to accept CS when (36.8%) (34.2%) (7.9%) (11.8%) (9.2%)
medically indicated.
I believe CS should only be 44 42 15 28 23 3.37 Agree
used as a last resort. (28.9%) (27.6%) (9.9%) (18.4%) (15.1%)
Total 3.44 Moderately
Agree

Table 4.3 shows that majority of the respondents agreed that they are willing to undergo

caesarean section if their life or that of their baby is at risk as represented by a mean value of

3.74. Majority of the respondents also agreed that they prefer vaginal delivery to caesarean

section regardless of the risk involved as shown by a mean value of 3.25. Most of the

respondents agreed that they would accept caesarean section if it is recommended by their

doctor as evidenced by a mean value of 3.52. Majority of the respondents moderately agreed

that they would feel disappointed if they delivered through caesarean section as represented

by a mean value of 2.99. Furthermore, majority of the respondents agreed that they would

encourage other women to accept caesarean section when medically indicated as shown by a

mean value of 3.78. Most of the respondents also agreed that caesarean section should only
be used as a last resort as represented by a mean value of 3.37. In overall, majority of the

respondents showed a moderately positive attitude towards caesarean section as represented

by a total mean value of 3.44.

Table 4.4: Showing Acceptance of Women Towards Caesarean Section

Statement 5 4 3 2 1 Mean Decision

SA A U D SD
I will accept to undergo 72 31 11 22 16 3.80 Agree
caesarean section if it is the (47.4%) (20.4%) (7.2%) (14.5%) (10.5%)
only safe option for delivery.
I will accept caesarean section 41 29 17 37 28 3.12 Moderately
even if my relatives or partner (27.0%) (19.1%) (11.9%) (24.3%) (18.4%) Agree
do not approve.
CS is acceptable to me because 24 33 19 46 30 2.80 Disagree
it makes me not to experience (15.8%) (21.7%) (12.5% (30.3%) (19.7%)
the pains of natural child birth. )
CS is unacceptable to me 38 44 16 34 20 3.20 Moderately
because it is expensive (25.0%) (28.9%) (10.5%) (22.4%) (13.2%) Agree

I will encourage other women 67 39 12 18 16 3.81 Strongly

to accept caesarean section (44.1%) (25.7%) (7.9%) (11.8%) (10.5%) Agree
when necessary.
Total 3.35 Moderately
Agree

Table 4.4 shows that majority of the respondents agreed that they will accept to undergo

caesarean section if it is the only safe option for delivery as represented by a mean value of

3.80. Most of the respondents moderately agreed that they will accept caesarean section even

if their relatives or partner do not approve as shown by a mean value of 3.12. Majority of the

respondents disagreed that caesarean section is acceptable to them mainly because it helps

them avoid the pains of natural childbirth as evidenced by a mean value of 2.83. Furthermore,

most of the respondents moderately agreed that caesarean section is unacceptable to them

because it is expensive as represented by a mean value of 3.30. Majority of the respondents

strongly agreed that they will encourage other women to accept caesarean section, when

necessary, as shown by a mean value of 3.81. In overall, majority of the respondents showed
moderately positive acceptance towards caesarean section as represented by a total mean

value of 3.37.

Table 4.5: Showing Factors Affecting the Acceptance and Rejection of Caesarean

Section

Statement 5 4 3 2 1 Mean Decision

SA A U D SD
One’s level of education 69 33 14 20 16 3.79 Agree
influences their decision to (45.4%) (21.7%) (9.2%) (13.2%) (10.5%)

accept or reject a CS.

Religious beliefs play a major 36 41 15 39 27 3.08 Moderately
role in willingness to undergo a (23.7%) (27.0%) (9.9%) (25.7%) (17.8%) Agree
caesarean section.
Financial cost influences 62 31 18 24 17 3.63 Agree
acceptance of a caesarean (40.8%) (20.4%) (11.8%) (15.8%) (11.2%)
section.
Fear of pain or complications 42 39 18 32 21 3.25 Moderately
discourages one from (25.6%) (25.7%) (11.8%) (21.1%) (13.8%) Agree
considering caesarean section.
Trust in the healthcare 71 35 13 19 14 3.85 Strongly
provider’s judgment affects (46.7%) (23.0%) (8.6%) (12.5%) (9.2%) Agree
people’s decision on delivery
method.
Total 3.52 Moderately
Agree

Table 4.5 shows that majority of the respondents agreed that one’s level of education

influences their decision to accept or reject a caesarean section as represented by a mean

value of 3.79. Most of the respondents moderately agreed that religious beliefs play a major

role in willingness to undergo a caesarean section as shown by a mean value of 3.08.

Majority of the respondents agreed that financial cost influences acceptance of a caesarean

section as evidenced by a mean value of 3.63. Furthermore, most of the respondents

moderately agreed that fear of pain or complications discourages one from considering
caesarean section as represented by a mean value of 3.25. Majority of the respondents

strongly agreed that trust in the healthcare provider’s judgment affects people’s decision on

delivery method as shown by a mean value of 3.85. In overall, majority of the respondents

showed moderately positive attitude towards the factors affecting the acceptance and

rejection of caesarean section as represented by a total mean value of 3.52.

 CHAPTER FIVE

DISCUSSION OF FINDINGS

5.0 Introduction

This chapter focuses on discussion of major findings, implication of the study, limitation of

the study, summary of the study, conclusion, recommendation and suggestion for further

studies.

5.1 Identification of Key Findings

Perception of the Women to Cesarean Section

Findings from this study showed that majority of the respondents agreed that caesarean

section is a safe mode of delivery. Most of the respondents also agreed that caesarean section

is only done when complications arise. Majority of the respondents disagreed that caesarean

section is a sign of weakness on the part of a woman. Most of the respondents moderately

agreed that caesarean section can endanger the life of the mother. Furthermore, majority of

the respondents strongly agreed that caesarean section saves the life of both mother and baby.

Majority of the respondents also agreed that caesarean section is more painful than vaginal

delivery. In overall, majority of the respondents showed moderately positive perception

towards caesarean section. The study is in line with one conducted previously by Akbar et al.

(2017), where it was discovered that pregnant women acknowledged the life-saving benefits

of caesarean section but at the same time expressed concerns about pain and possible

complications associated with the procedure. Their results align with the statistics obtained in

this study, further confirming that women’s perception of caesarean section is influenced by

both positive recognition of its necessity and lingering fears about its risks. However, this

finding contrasts with the study of Chigbu et al. (2018), who reported that a majority of

women in their study population held largely negative perceptions of caesarean section, often

associating it with failure of womanhood and poor outcomes. In their context, cultural and
religious beliefs strongly influenced women’s views, leading to reluctance and resistance

toward the procedure, even when medically necessary.

Attitude Towards Caesarean Section

Findings from this study has shown that majority of the respondents agreed that caesarean

section is a safe mode of delivery. Most of the respondents also agreed that caesarean section

is only done when complications arise. Majority of the respondents disagreed that caesarean

section is a sign of weakness on the part of a woman. Most of the respondents moderately

agreed that caesarean section can endanger the life of the mother. Furthermore, majority of

the respondents strongly agreed that caesarean section saves the life of both mother and baby.

Majority of the respondents also agreed that caesarean section is more painful than vaginal

delivery. In overall, majority of the respondents showed moderately positive perception

towards caesarean section. This result is in line with the study of Barber et al. (2018), who

found that although most women accepted the medical necessity of caesarean section,

negative attitudes persisted due to fear of surgery, cultural stigma, and preference for vaginal

delivery. Similarly, the study of Aziken et al. (2017) supported this finding by showing that

women’s attitudes toward caesarean section were shaped not only by clinical factors but also

by social influences, with many women perceiving caesarean section as a procedure to be

considered only when unavoidable.

Acceptance of Women Towards Caesarean Section

Findings from this study revealed that majority of the respondents agreed that they will

accept to undergo caesarean section if it is the only safe option for delivery. Most of the

respondents moderately agreed that they will accept caesarean section even if their relatives

or partner do not approve. Majority of the respondents disagreed that caesarean section is

acceptable to them mainly because it helps them avoid the pains of natural childbirth.
Furthermore, most of the respondents moderately agreed that caesarean section is

unacceptable to them because it is expensive. Majority of the respondents strongly agreed

that they will encourage other women to accept caesarean section, when necessary. In overall,

majority of the respondents showed moderately positive acceptance towards caesarean

section. This finding is in line with the study of Awoyinka et al. (2016), who reported that

while many Nigerian women were initially hesitant, most eventually accepted caesarean

section when it was deemed the only safe option to protect maternal and child health.

Similarly, Högberg et al. (2018) highlighted that acceptance levels improve when women

receive adequate counselling and reassurance from healthcare professionals about the

necessity and safety of the procedure. However, this finding contrasts with that of Ikeako et

al. (2019), who observed widespread rejection of caesarean section in rural communities,

where it was often associated with cultural stigma, marital disharmony, and perceptions of

diminished womanhood. This shows that acceptance of caesarean section is largely

influenced by social, cultural, and economic contexts

Factors Affecting the Perception, Attitude and Acceptance of Caesarean Section

Findings from this study showed that majority of the respondents agreed that one’s level of

education influences their decision to accept or reject a caesarean section. Most of the

respondents moderately agreed that religious beliefs play a major role in willingness to

undergo a caesarean section. Majority of the respondents agreed that financial cost influences

acceptance of a caesarean section. Furthermore, most of the respondents moderately agreed

that fear of pain or complications discourages one from considering caesarean section.

Majority of the respondents strongly agreed that trust in the healthcare provider’s judgment

affects people’s decision on delivery method. In overall, majority of the respondents showed

moderately positive attitude towards the factors affecting the acceptance and rejection of

caesarean section. This finding is in line with the study of Chigbu (2018), who reported that
women with higher educational attainment were more likely to understand and accept

caesarean section when medically indicated. Similarly, Kweekel et al. (2020) noted that

financial constraints, fear of complications, and cultural beliefs were significant barriers

influencing women’s acceptance of caesarean section in Nigeria. On the contrary, a study by

Olusanya & Solanke (2019) highlighted that in some rural communities, even when

education levels were higher, strong cultural and religious influences still overrode women’s

willingness to undergo caesarean section. This contrast emphasizes that acceptance is not

shaped by a single factor but rather by an interplay of education, financial resources, cultural

perceptions, and trust in healthcare providers.

5.2 Implications of Finding to Nursing

The findings of this study on women’s perception of caesarean section revealed that most

respondents recognized caesarean section as a safe and life-saving mode of delivery, though

many still viewed it as painful and potentially risky. This implies that nurses have a critical

role in providing accurate health education to dispel myths and misconceptions surrounding

caesarean section (Scerri et al., 2019). Clear communication about the procedure, possible

outcomes, and effective pain management strategies is essential in building women’s

confidence and trust in the procedure (WHO, 2020). According to Nwosu et al. (2018),

patient-centered education by nurses significantly improves maternal understanding and

reduces fear, which can promote more positive perceptions of caesarean section.

In terms of attitude towards caesarean section, the study showed that while respondents

generally displayed a moderately positive attitude, fears about complications and the

perception of weakness still exist. For nursing practice, this finding highlights the importance

of psychological support and antenatal counseling (Ezeonu et al., 2020). Nurses must engage

in culturally sensitive discussions that not only address clinical benefits but also tackle the

stigma associated with caesarean delivery. As emphasized by Odetola (2017), nurses who
incorporate empathy, counseling, and family involvement in maternal care help in reshaping

attitudes, thereby encouraging more supportive environments for women who undergo

caesarean section.

With regard to acceptance, the study found that women were more likely to accept caesarean

section when it was the only safe option but hesitated due to factors such as cost, partner

disapproval, and fear of pain. This finding implies that nurses, as advocates for women’s

health, must strengthen their role in shared decision-making processes, ensuring that women

understand the necessity of caesarean section when indicated (Högberg et al., 2018).

Furthermore, nurses can advocate for policies that reduce financial and social barriers to

accessing caesarean section. As noted by Okafor et al. (2019), nurses’ advocacy is essential

in improving access and acceptance of safe delivery practices, especially in low-resource

settings.

Finally, the findings on factors influencing acceptance of caesarean section highlighted the

role of education, financial cost, religious beliefs, fear of complications, and trust in

healthcare providers. For nursing practice, this means that interventions must go beyond

clinical explanations and address broader socio-cultural and economic issues. Nurses must

collaborate with community leaders, religious institutions, and policymakers to promote

accurate information and reduce misconceptions (WHO, 2020). Trust in healthcare providers,

particularly nurses, emerged as a strong predictor of acceptance, meaning that professional

competence, good communication, and respectful maternity care are crucial. This aligns with

the work of Bohren et al. (2017), who emphasized that respectful and trust-based nurse–

patient relationships directly improve maternal outcomes and healthcare-seeking behaviors.

5.3 Limitations of the Study

The following were the limitations encountered during the study.

 1. Limited time

2. Financial resources.

3. Self-reported responses.

4. Cultural and religious sensitivity.

5.4Summary

This study was carried out to assess the perception, attitude and acceptance of caesarean

section among pregnant women attending antenatal clinic in the University of Abuja

Teaching Hospital, Gwagwalada. The main objectives of the study were to determine the

perception of caesarean section among pregnant women, to assess their attitude towards

caesarean section, to determine their level of acceptance, and to identify the factors

influencing the decision to accept or reject caesarean section. Research questions were

developed in line with the objectives of the study. Literature was reviewed from relevant

texts, journals, and other scholarly articles under the following sub-headings: conceptual

review, theoretical framework (with the use of the Health Belief Model), and empirical

review. The study adopted a cross-sectional descriptive design which was considered

appropriate because information was obtained directly from the pregnant women. The sample

size for the study was 152 pregnant women, determined using Krejcie and Morgan’s sample

size determination formula. Data were collected with the use of a structured questionnaire

and analyzed using percentages, mean, and Likert scale. Findings from the study revealed

that majority 72 (47.4%) of the respondents were between the ages of 26–35 years. Majority

58 (38.2%) of the respondents were Igbo, while most 60 (39.5%) of the respondents had

tertiary education. The obstetric history of respondents showed that most 55 (36.2%) had

delivered vaginally, 32 (21.1%) had delivered through caesarean section, while 26 (17.0%)

had experienced both vaginal and caesarean deliveries. Overall, the findings indicated that

majority of the respondents showed moderately positive perception towards caesarean

section, a fairly positive attitude towards the procedure, and a moderately positive acceptance

of caesarean section as a mode of delivery.

5.5 Conclusion

Caesarean section has been discovered to play a vital role in reducing maternal and neonatal

mortality when complications arise during delivery. The study revealed that although the

respondents generally have a moderately positive perception, attitude, and acceptance

towards caesarean section, their views are still shaped by factors such as cultural and

religious beliefs, financial cost, fear of pain, and misconceptions about the procedure. While

many acknowledged that caesarean section is life-saving and necessary in certain conditions,

some still perceived it as undesirable compared to vaginal delivery. These findings highlight

that acceptance is not solely based on medical necessity but is also influenced by personal,

social, and economic factors. Over time, addressing these barriers through continuous health

education, counseling, and support will be critical to improving women’s acceptance of

caesarean section and ultimately ensuring safer maternal and child health outcomes.

5.6 Recommendations

The following recommendations were made at the end of the study:

1. Health education programs and antenatal seminars should be organized regularly to

sensitize pregnant women on the safety, benefits, and necessity of caesarean section

when medically indicated, in order to correct misconceptions and reduce fears.

2. Cultural and religious leaders should be engaged in awareness campaigns to help

address myths, beliefs, and stigma surrounding caesarean section, thereby promoting

acceptance within communities.

 3. The government and healthcare policymakers should develop and implement policies

to subsidize the cost of caesarean section, making it more affordable and reducing

financial barriers that influence rejection of the procedure.

4. Healthcare providers should offer consistent counseling and reassurance during

antenatal visits, emphasizing trust and confidence in medical judgment, as this will

help improve women’s attitudes and willingness to accept caesarean section when

necessary.

5.7 Suggestions for Further Studies

1. Based on the findings of this study, it is suggested that further research be conducted

in other communities and healthcare facilities to compare variations in perception,

attitude, and acceptance of caesarean section across different populations.

2. Future studies should explore the role of healthcare providers’ communication

strategies and counseling methods in shaping women’s decisions towards accepting or

rejecting caesarean section.

3. Research can also be carried out to examine the long-term influence of cultural and

religious beliefs on maternal decision-making regarding caesarean section.

 REFERENCES

Addis, A., & Evans, M. (2025). Understanding women's birth experiences: A comparative

study of surgical and vaginal delivery in West Africa. Maternal Health Journal, 29(1),

15–28.

Adeleye, J. A. (2017). Primary elective Caesarean section in Ibadan, Nigeria. Acta Tropica,

28(45-48). [Link]

Agumuo, Z. (2016). Perception of Caesarean section: Comments and views from Nigeria; A

systematic review. Birth, 37(3), 219-226. [Link]

Ashimi, A., Amole, T., & Aliyu, D. (2018). Knowledge and attitude of pregnant women

toward Caesarean section in a semi-urban community, North West Nigeria.

Awoyinka, B. S., Ayinde, O. A., & Omigbodun, A. O. (2016). Acceptability of Caesarean

delivery to antenatal patients in a tertiary health facility in South-West Nigeria.

Obstetrics and Gynecology, 26, 208-210. [Link]

Aziken, M., Omo-Aghoja, L., & Okonofua, F. (2017). Perceptions and attitudes of pregnant

women toward Caesarean section in urban Nigeria. Acta Obstetricia et Gynecologica

Scandinavica, 86, 42-47. [Link]

Barber, E. L., Grobman, W. A., & Warren, J. M. (2018). Counseling for cesarean delivery:

What should we tell patients? American Journal of Obstetrics & Gynecology, 219(4),

365–372.

Basavanthappa, B. T. (2018). Community health nursing. New Delhi: Japec Brothers Medical

Publishers LTD.

Becher, L., & Stokke, S. (2019). Indications for Caesarean section in St. Joseph Medical

Hospital, Moshi, Tanzania (Master’s thesis, Faculty of Medicine, University of Oslo).

American Journal of Obstetrics and Gynecology.

[Link]
Behaque, D. P. (2014). Beyond the simple economics of Caesarean section birthing:

Women's resistance to social inequality. Culture, Medicine, and Psychiatry, 26, 473-

507. [Link]

Betrán, A. P., Ye, J., Moller, A. B., Zhang, J., Gülmezoglu, A. M., & Torloni, M. R. (2021).

Trends and projections of caesarean section rates: Global and regional estimates. BMJ

Global Health, 6(6), e005671.

Boatin, A. A., Gawande, A., & Oyetunji, A. (2022). Caesarean delivery in sub-Saharan

Africa: A review of trends and outcomes. International Journal of Obstetrics &

Gynaecology, 129(3), 315–322.

Chigbu, C. O., Onyebuchi, A. K., & Nwajiaku, L. A. (2018). Factors influencing the decision

of pregnant women to accept caesarean delivery in southeastern Nigeria. Patient

Preference and Adherence, 12, 1909–1914.

Danso, K., Schwandt, M., Turpin, C., Seffah, J., & Samba, J. H. (2019). Preference of

Ghanaian women for vaginal or Caesarean delivery postpartum. Ghana Medical

Journal, 43(1), 29-33. [Link]

Dumont, A., De-Bernis, L., Bouvier-Colle, M. H., Bréart, G., & Moma, L. (2019). Caesarean

section rate for maternal indication in sub-Saharan Africa: A systematic review.

Lancet, 16(12), 1328-1333. [Link]

Ecker, J. (2017). Elective Caesarean section on maternal request. The Journal of the

American Medical Association, 318(11), 1074-1075.

[Link]

Ezechi, O. C., Onwujekwe, D. I., & Ekwempu, C. C. (2024). Maternal perceptions of surgical

birth: A multi-site Nigerian study. African Journal of Reproductive Health, 28(1), 50–

62.
Ezeonu, P. O., Onoh, R. C., & Umeora, O. U. (2020). The impact of formal education on

attitudes towards caesarean section. Nigerian Journal of Medicine, 29(3), 287–292.

Finger, C. (2018). Caesarean section rates skyrocket in Brazil. Lancet, 362(84), 628-634.

[Link]

Gibbons, L., Belizán, J. M., Lauer, J. A., Betrán, A. P., Merialdi, M., & Althabe, F. (2018).

The global numbers and costs of additionally needed and unnecessary caesarean

sections performed per year. World Health Report Background Paper, No. 30.

Högberg, U., Lynöe, N., & Wulff, M. (2018). Cesarean section by choice? Empirical study of

public attitudes. Acta Obstetricia et Gynecologica Scandinavica, 87, 1301-1308.

[Link]

Ikeako, L. C., Nwajiaku, L. A., & Eze, J. N. (2019). Caesarean delivery: Determinants of

acceptance among women in southeast Nigeria. Nigerian Medical Journal, 60(3),

115–120.

Kabakian-Khasholian, T., & Campbell, O. M. R. (2005). A simple way to increase women’s

satisfaction with hospital-based childbirth in low-resource settings. Birth, 32(3), 223–

229.

Kolwek, I., & Franzisk, H. (2014). Is there a relation between maternal age and preferred

mode of delivery? Journal of Clinical Gynaecology and Obstetrics, 1(1), 4-9.

Kweekel, L., Maas, A., Scherjon, S., & Van Dillen, J. (2020). Women's views on caesarean

section and their role in decision-making: A qualitative study in the Netherlands.

BMC Pregnancy and Childbirth, 20, 340.

Lin, Y., Qian, X., He, W., & Fu, W. (2024). Educational interventions and their effect on

delivery method preference: A systematic review. Journal of Reproductive and Infant

Psychology, 42(1), 22–35.

Mazzoni, A., Althabe, F., & Belizán, J. M. (2019). Attitudes of women and obstetricians

towards caesarean section in Latin America: A systematic review. Birth, 46(3), 289–

298.

National Institute for Health and Care Excellence (NICE). (2021). Caesarean birth: NICE

guideline [NG192]. [Link]

Okonkwo, J. E., Ojengbede, O. A., & Morhason-Bello, I. O. (2012). Disrespect and abuse

during facility-based childbirth in southern Nigeria: A threat to maternal wellbeing.

African Journal of Reproductive Health, 16(4), 55–61.

Olusanya, B. O., & Solanke, O. A. (2019). Adverse neonatal outcomes associated with

previous Cesarean section in an inner-city maternity hospital in Lagos, Nigeria.

International Journal of Gynecology & Obstetrics, 21(12), 65-67.

[Link]

Scerri, M., Lanfranco, R. C., & Grech, K. (2019). Decision-making and delivery preferences:

Role of midwife-led counselling. International Journal of Childbirth, 9(2), 89–97.

Silver, R. M. (2012). Delivery after previous cesarean: Long-term maternal outcomes.

Seminars in Perinatology, 36(5), 308–315.

World Health Organization. (2020). Pregnancy, childbirth, postpartum, and newborn care: A

guide for essential practice. [Link]

 QUESTIONAIRE
Dear Respondents,
I am a final year of the FCT College of Nursing Sciences conducting research on the topic
“Perception, attitude and acceptance of caesarean section among pregnant women
attending antenatal clinic in the University of Abuja Teaching Hospital, Gwagwalada
between January 2024 till date”. This questionnaire is designed to collect socio-
demographic data and also variables the research topic. The purpose of collecting the
information is solely for academic use and would be treated with confidentiality. This study
is part of the requirements for the award of certificate as a Registered Nurse. Please kindly
complete the questionnaire by ticking the spaces provided and note your honest response will
be highly appreciated.
Thanks for your time and cooperation.

Instruction
Directions; tick [√] on the appropriate responses as applied to you.
SECTION A:
1. Age: a. 15-25 years ( ) b. 26-35 years ( ) c. 36 -45 ( ) d. 46 years and above ( )
2. Ethnicity: a. Hausa ( ) b. Igbo ( ) c. Yoruba ( ) d. Others specify ( )
3. What is your highest educational attainment? No formal education ( ) Primary
school [FSLC] ( ) Secondary school [WAEC] ( ) Tertiary institution [OND, NCE,
HND, BSc, MA/[Link]/[Link], Ph.D] ( )
4. Religion: a. Christianity ( ) b. Islam ( ) c. Traditional ( ) d. Others specify ( )
5. How did you deliver your previous baby or babies? No previous delivery ( )
Natural/vaginal delivery ( ) Cesarean delivery (cesarean section) ( ) Natural
delivery in one or more cases and cesarean delivery (cesarean section) in another or
other deliveries ( )

Instructions: (A) Please tick [√] on the appropriate column the option that best
expresses your feeling about each of the statements. (B) Do not tick on more than one
column for each statement.
Meaning of Abbreviations: SA = STRONGLY AGREE, A= AGREE, U= UNDECIDED D
=DISAGREE AND SD= STRONGLY DISAGREE.
Section B: Perception of the Women to Cesarean Section
S/ Statement SA A U D SD
N
6 Caesarean section is a safe mode of delivery
7 Caesarean section is only done when complications arise
8 CS is a sign of weakness on the part of a woman
9 Caesarean section can endanger the life of the mother
10 Caesarean section saves the life of mother and baby
11 A caesarean section is more painful than vaginal delivery.

Section C: Attitude of Women Towards Caesarean Section

S/ Statement S A U D SD
N A
12 I am willing to undergo CS if I or my baby’s life is at risk.
13 I prefer vaginal delivery to CS regardless of the risk involved.
14 I would accept CS if my doctor recommends it.
15 I would feel disappointed if I delivered through CS.
16 I would encourage other women to accept CS when medically
indicated.
17 I believe CS should only be used as a last resort.

Section D: Acceptance of Women Towards Caesarean Section

S/ Statement SA A U D SD
N
18 I will accept to undergo caesarean section if it is the only safe
option for delivery.
19 I will accept caesarean section even if my relatives or partner
do not approve.
20 CS is acceptable to me because it makes me not to experience
the pains of natural child birth.
21 CS is unacceptable to me because it is expensive
22 I will encourage other women to accept caesarean section
when necessary.
Section D: Factors Affecting the Acceptance of Caesarean Section

S/ Statement SA A U D SD
N
23 One’s level of education influences their decision to accept or reject a
CS.
24 Religious beliefs play a major role in willingness to undergo a caesarean
section.

25 Financial cost influences acceptance of a caesarean section.

26 Fear of pain or complications discourages one from considering caesarean

section.

27 Trust in the healthcare provider’s judgment affects people’s decision on

delivery method.