Acta Obstetricia et Gynecologica.

2007; 86: 42
47

ORIGINAL ARTICLE

Perceptions and attitudes of pregnant women towards caesarean

section in urban Nigeria

MICHAEL AZIKEN, LAWRENCE OMO-AGHOJA & FRIDAY OKONOFUA

Department of Obstetrics and Gynecology, College of Medical Sciences, University of Benin, Benin City, Nigeria

Abstract
Objectives . To determine the perceptions and attitudes towards caesarean section [CS] among women attending maternity
care at the University of Benin Teaching Hospital in Nigeria. Methods . Some 413 consecutive women, attending antenatal
care in the hospital, were interviewed with a structured questionnaire that solicited information on their socio-demographic
characteristics, their previous pregnancy and delivery history, and their knowledge and attitudes towards CS. Additional
focus group discussions and in-depth interviews were held with women who recently underwent CS in the hospital, to gain
further insights into attitudes and perception about CS in the women. Results . The women had good knowledge of CS;
however, only 6.1% were willing to accept CS as a method of delivery, while 81% would accept CS if needed to save their
lives and that of their babies. Up to 12.1% of women would not accept CS under any circumstances. Logistic regression
showed that women’s low level of education, and past successful vaginal and instrumental deliveries, were most likely to be
associated with women’s non-acceptance of indicated caesarean section. Further analysis showed that this was mainly due to
inaccurate cultural perceptions of labour and caesarean section in the cohort of women. Conclusion . There is a need for
programs to increase women’s and community understanding and perceptions of CS as a method of delivery in Nigeria.

Key words: Perception, attitudes, caesarean section, pregnancy, Nigerian women

Introduction of delivery in several obstetric complications (2).

Caesarean section [CS] is the most common ob-
stetric operation performed worldwide (1). The
origin of the procedure dates back to 100 BC,
but authoritative evidence about the early use
of the operation by obstetricians did not appear
in the literature until the mid-17th century, when
the classical work of Francois Mauriceau was pub-
lished (1).
At the onset, the operation was associated with
high rates of morbidity and mortality, largely be-
cause of the low level of medical science available at
the time. Consequently, its introduction into ob-
stetric practice was greeted with misgivings and, in
some instances, outright rejection. However, with
advances in medical practice, there has been con-
siderable improvement in maternal safety and neo-
natal outcome associated with caesarean delivery.
Caesarean section is now the recommended method
While acknowledging the general concern about the
rising rates of CS worldwide (3), CS still remains the
most appropriate option for several obstetric situa-
tions (4).
In developed countries, women often accept CS
because of their improved understanding of its role
and safety (5,6). By contrast, in many sub-Saharan
African countries, several reports indicate that wo-
men are often reluctant to accept caesarean delivery
(7,8). Indeed, a recent study (9) reported a gross
underutilisation of CS throughout West Africa,
compared to the large burden of obstetrics morbidity
requiring resolution by CS. The inadequate use of
early CS in African countries has been identified as a
key factor in the continuing high rates of maternal
and perinatal morbidity in the region (10).
To date, there has been no systematic study
exploring women’s knowledge and perceptions of

Correspondence: Professor F.E. Okonofua, Department of Obstetrics and Gynaecology, U.B.T.H, P.M.B. 1111, Benin City, Edo State, Nigeria. E-mail:
wharc@hyperia.com

(Received 8 December 2005; accepted 4 September 2006)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2007 Taylor & Francis
DOI: 10.1080/00016340600994950

Women’s Attitudes towards caesarean section in Nigeria
CS in Nigeria, and the reasons that women are
averse to the procedure. Such data would be relevant
for designing programs aimed at increasing women’s
uptake of CS, an important intervention necessary to
reduce maternal mortality in the country. The aim of
this study was to determine women’s perceptions
and attitudes towards CS in a tertiary center in
Southern Nigeria. We believe the results of the study
will contribute towards identifying strategies for
improving the acceptability and uptake of CS, and
reducing maternal morbidity and mortality in
Nigeria.
Materials and methods
The study was conducted at the University of Benin
Teaching Hospital (UBTH), a tertiary hospital in
Benin City, Southern Nigeria. Benin City is a
cosmopolitan city of
/1 million inhabitants, and is
the headquarters of Edo State, one of the 36 states in
federal Nigeria. The UBTH provides tertiary ob-
stetrics services to Edo State, as well as to several
surrounding States.
The study was conducted using quantitative and
qualitative methods. In the quantitative study, a
convenient sample of 413 women attending antena-
tal clinic at the UBTH were interviewed with a
structured questionnaire. All women who attended
the clinic during the period March
August 2003
were approached for interview, and only those who
agreed to participate in the study were interviewed.
Written informed consent was obtained from each
woman; they were assured of confidentiality of
information obtained, and no actual names were
identified in the questionnaire.
The questionnaire obtained information on the
women’s socio-demographic characteristics, their
past and current obstetric history, and their knowl-
edge and perceptions of different methods of deliv-
ery (including CS). The questionnaire also included
questions that explored women’s willingness to
accept CS in their current pregnancies if indicated,
and the reasons for their chosen preferences. The
questionnaires were essentially self-administered,
after full explanation of the relevant sections by
clinic staff. However, for non-literate women, the
questions were explained by clinical staff in the local
language, who also assisted them in completing the
questionnaire. The questionnaires were pre-tested
and validated among pregnant women in the hospital
before use. Clinic staffs were also debriefed on the
correct mode of administering the questionnaire
before commencement of the study.
Data from the survey were entered into a compu-
ter database using the EPI INFO Software. They
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43
were analysed with univariate and bivariate statistics,
to provide an understanding of women’s knowledge
and pattern of acceptance of various modes of
delivery, including CS. Differences in rates of
responses between sub-groups were compared using
Chi-square test with Yates correction, as appropri-
ate. Thereafter, the data were transformed into
SPSS Pc/, and unconditional logistic regression
was performed to identify the factors that predict the
likelihood of women refusing CS when needed for
safe delivery. The independent variables included in
the model were women’s education, religion, past
methods of delivery and sources of information.
We also conducted focus group discussions with
pregnant women and in-depth interviews with wo-
men undergoing CS in the hospital. Five focus group
discussions [FGDs] were conducted, each consisting
of 8
10 pregnant women. The FGDs explored
women’s knowledge and perceptions of various
methods of delivery, as well as their understanding
of reasons that women prefer different methods of
delivery. In particular, we elicited information on
cultural beliefs in the community that may hinder or
encourage the use of various forms of delivery, and
how these influence women’s acceptance of caesar-
ean delivery.
In-depth interviews were held with 5 women who
recently underwent CS in the hospital. The women
were questioned in an open-ended manner, on their
understanding of the reasons for the CS, why they
accepted the operation, their experiences with the
operation, their partners’ attitudes towards the
operation, and whether or not they would accept
the operation if asked in a future pregnancy. The
interviews were necessary to document women’s
current actual experiences, and their coping me-
chanisms following indicated CS.
A well-trained team, versed in the local language
and culture, conducted both the FGDs and the in-
depth interviews. All discussions were conducted in
the local language or Pidgin English as appropriate,
and audiotaped. They were then transcribed and
analysed for both content and form. The results were
triangulated with those obtained from the quantita-
tive study to make inferences about the socio-
cultural perceptions and attitudes towards CS in
the community.
Results
A total of 413 respondents completed the question-
naire. Their mean age was 24.0 (range 14
43) years,
with their parity ranging from 0 to 7 (median 2).
Only 2 (0.5%) women did not have formal educa-
tion, while 34 (8.2%), 197 (47.7%) and 169
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44 M. Aziken et al.

(40.9%) had primary, secondary and tertiary educa- Table II. Logistic regression with odd ratios and confidence
intervals for women’s likelihood to refuse caesarean section
tion, respectively. The educational backgrounds of
when offered as a method of delivery.
11 (2.7%) respondents were not stated.
Four of the respondents (0.9%) reported not
Odd 95% Confidence
practicing any form of religion, while 93 (22.5%) Variables ratio interval
were Catholics, 57 (13.8%) were Protestants, 198
(47.9%) were Pentecostals, while only 8 (1.9%) were Educational status
Moslems. The religions of 53 (12.8%) respondents Nil 3.6 1.12
11.53
Primary 3.2 1.50
6.85
were not stated. Secondary 1.7 1.08
2.57
All the respondents reported that they have heard
Rc: Tertiary
of caesarian section and were able to identify CS Religion
(among 4 options) as ‘delivery by operation through None 0.54 0.09
3.00
the abdomen’. Regarding their sources of informa- Catholic 0.43 0.10
1.84
tion, 99 (24%) reported that they obtained the Protestant 0.58 0.13
2.58
Pentecostal 0.78 0.19
3.23
information from doctors, 232 (52.2%) obtained it
from nurses, while 39 (9.4%) were told by their Rc: Islam
Mode of last delivery
friends. The source of information about CS was not
SVD 3.59 1.44
8.92
reported by 43 (10.4%) of the women. Forceps/vacuum 20.66 1.95
218.65
Among the study population, only 25 (6.1%) said
Rc: CS
they would have CS by choice, mainly for fear of Outcome last pregnancy
labour pain and concern about the baby’s safety. By Baby went home with mother 0.47 0.14
1.58
contrast, 246 (59.7%) reported they would accept it ENND 1.25 0.15
10.69
if the doctor said so, while 338 (81.8%) would Rc: FSB
accept caesarian delivery if their life or that of the Previous CS
fetus was in danger. Fifty (12.1%) would not accept No 3.79 1.80
8.00
CS under these 3 instances. The reasons they gave Rc: yes
included fear of death, pain associated with CS, Sources of information
Nurse at ANC 0.69 0.30
1.57
concern about being seen as a failure, husband’s Nurse elsewhere 2.05 0.88
4.75
disapproval, CS not being part of culture/custom, Friends 1.91 0.91
4.00
friends would laugh, and cost (Table I). There was Rc: Doctor
no statistically significant difference between
the respondents who would accept CS by choice Rc, reference category.
and those who would not, with regards to mean
age (29.49/3.6 versus 29.29/4.5; p /0.77), parity Table II. Women without formal education were
(1.79/1.4 versus 1.69/1.4; p /0.61 and gestational nearly 4 times more likely to refuse CS than those
age (289/6.1 versus 26.49/6.8; p /0.2548) at the with tertiary education (OR 3.6; CI 1.12
11.53).
time of the interview. Similarly, women with primary education were 3
Logistic regression was carried out to determine times more likely to refuse CS than those with
the factors which predict the likelihood of women tertiary education (OR 3.2; CI 1.5
6.85). However,
refusing indicated CS. The results are presented in there were no significant differences between women
with secondary and tertiary education in the re-
sponses to this question.
Table I. Reasons for not accepting caesarean section as a mode of
delivery in the cohort of women. Other risk factors for refusal of indicated CS were
previous successful vaginal delivery (OR 3.6; CI
Variables No. (%) 1.44
8.92), previous forceps delivery (OR 20.7; CI
1.95
218), and women not having had a previous
Fear of death 123 (31.7) CS (OR 3.79; CI 1.8
8.0). By contrast, women’s
Fear of pain 113 (29.1)
religious affiliation and the sources of information on
Cost 78 (19.8)
Seen as a failure 28 (7.2) the method of delivery did not affect women’s
Off custom/culture 7 (1.8) acceptance of CS.
Friends would laugh 6 (1.5)
Husband disapprove 6 (1.5)
Religion 86 (20.8) Results of FGDs and in-depth interviews
Thirty-four women gave more than one reason for not accepting During FGDs, women listed the methods of delivery
CS. known to them as normal vaginal delivery, ‘delivery

Women’s Attitudes towards caesarean section in Nigeria
by operation’, forceps delivery, ‘delivery by hand’,
use of pitocin injection and induction. However,
when asked which women preferred, the unanimous
answer was vaginal delivery. The most common
reasons given for preference of vaginal delivery
ranged from the pains associated with caesarean
delivery, the scar left in the abdomen after the
procedure, and the loss of lives often associated
with CS. By contrast, normal vaginal delivery was
perceived to be safer for women, to be less expensive
and to be natural. The curtailment of the reproduc-
tive potential of women undergoing CS was also
mentioned. According to a 25-year-old woman:
‘With normal delivery the woman can deliver as
many children as possible but with CS the number of
children a woman can have is limited’.
The consensus was that women sometimes under-
stood the reasons given by health providers for CS.
Some of the reasons mentioned by women them-
selves included prolonged labour, ‘to save the life of
the mother and the baby’, and ‘the baby being in the
wrong position in the womb’. However, the women
reported that illiterate women were less likely to
understand these reasons compared to women with
formal education. One woman commented as fol-
lows: ‘Most women do not understand the reason for
CS, especially illiterate women and mother in-laws.
The illiterate ones often feel that doctors are not
patient enough to deliver the baby normally’.
Overall, the feeling among the FGD participants
was that women generally do not like CSs. It was felt
that if women are allowed to push during delivery
and with prayers, they will deliver successfully.
Those who fail to deliver through the normal process
are those who did not pray hard or who did not
consult a native doctor before labour. The impres-
sion was that most pregnant women often consulted
faith healers before embarking on labor, for rituals to
be performed to ensure normal delivery and to
prevent CS. It was felt that only women who did
not consult faith healers before going into labour
would experience difficulties in labour.
Focus group participants reported a belief in the
supernatural as the main determinant of the out-
come of labour pervades the entire community. It
was reported that women who failed to deliver
normally are often accused of being witches or
having been unfaithful to their husbands. Conse-
quently, they are often asked to confess their sins
before community elders.
Participants were asked why women who had
consulted oracles and performed necessary rituals
before the onset of labour sometimes fail to deliver
normally. In such instances, the perception was that
doctors were not patient enough to ‘fix drips’ that
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45
would ensure normal delivery. They retorted that
this was for monetary gains, as doctors often charge
a lot of money for CSs compared to normal delivery.
Interviews were conducted with 5 women who
were recovering from recent CSs in the hospital. The
women were interviewed on their experiences of CS
at the time of their discharge from the hospital. The
reasons for the CSs reported by the women were
cephalopelvic disproportion, prolapse of the umbili-
cal cord, prolonged premature rupture of mem-
branes, fetal distress and maternal hypertension
and placenta praevia. The reasons tallied with the
reasons listed by the doctors in the case notes.
As to why they accepted the operation, the women
gave the following reasons: ‘to save my life and that
of the baby’; ‘I agreed because I attempted delivery
before with other hospitals, but with the same
problem’; ‘I accepted because I felt they were right’;
‘I accepted because my scan revealed fetal distress
and I wanted to save the life of my baby’; and ‘I
accepted because I wanted to save my life first, and
felt (the problem) was going to kill the baby’. Thus,
the need to save the life of the women and their
babies were the major reasons for accepting CS.
They also appeared to have had confidence in the
results of the clinical investigations conducted by the
health providers.
When asked their experiences of the current
operation, they gave varied answers as follows:
This is the second operation I am having and I
have never had any complication from it. But my
husband has not been happy with these repeated
operations.
I actually do not have complications but my vision
is blurred. Also I feel psychologically bad since I
am supposed to deliver normally like others.
I had minor pains, psychologically demoralised,
and my husband is not happy about it.
No complication or psychological problem at all.
Although I have no complication, I feel bad
because I have never had CS before. This is my
fifth child, with CS; I do not know why the baby
decided to come out at the 7th month.
Thus, there was evidence of some regret in some of
the women for having undergone the operation;
many were concerned about the reactions of their
husbands. However, when specifically asked as to
whether they regret having had the operation, the
women responded that they did not, since mothers

46 M. Aziken et al.
and the babies were alive. They all reported that
their husbands were not happy that they had to be
delivered by CS.
As to whether they will have the operation if
requested for them in future pregnancies, all replied
that they have no option but to accept. One woman
replied in greater detail as follows: ‘I do not have any
option, I will accept it because I understand that
once you have done the operation once or twice,
there is a high probability for you to have it again.’
The overall impressions of two women about CS
based on their experience are as follows:
Normal delivery is good because it was ordained
by God but with CS, the pains from the stitches
will be there and the constant fear of getting
pregnant again, which will result in another CS, is
there.
Delivery by operation is not bad, although people
do frown at it.
Discussion
The results of this study indicate that 6.1% of
pregnant women were willing to accept CS as a
primary method of delivery. This finding is similar to
a recent Swedish report that indicated that 8.2% of
women will accept CS as a primary method of
delivery (9). Pregnant women, mostly in developed
(and some developing) countries, are increasingly
requesting caesarean delivery for reasons ranging
from the need to eliminate labor pains, the safety of
their baby, and desire to avoid sub-standard intra-
partum care (3,6
8). By contrast, the results in-
dicate that 59% of the women are willing to accept
CS if indicated, with up to 81% willing to accept it if
they or their babies are at risk of death. This suggests
that the need to preserve their safety and that of an
infant is the major determinant of women’s accep-
tance of CS in Nigeria.
It was of interest that as much as 19% of women
would still reject CS, even at the risk of their lives or
that of their babies. The latter situation contrasts
with the Western world, where it is exceedingly rare
that women do not choose a caesarean delivery when
the obstetrician recommends it. This is because of
their improved understanding of the role and safety
of CS (5,6). The results of logistic regression
revealed that low level of women’s education, pre-
vious successful vaginal or instrumental delivery and
not having had a CS increased the likelihood that
women would reject an indicated CS. This was
further collaborated by the focus group discussions,
where participants specifically mentioned the lack of
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maternal education as a factor likely to reduce the
acceptance of CS.
Some reasons given by women for not accepting
CS included fear of death and pain, which is clearly a
reflection of their ignorance of the present state of
improved safety of anaesthesia and management of
post operative pain. Cost as a reason for not
accepting CS was given by 19.8% of the women.
Other reasons, such as being laughed at by friends,
husband’s disapproval, and the notion that delivery
by CS is not culturally acceptable, testify to the low
level of understanding of women about the need and
justification for CS.
The real reasons for refusal of CS were captured in
the focus group discussions and in-depth interviews,
where perceptions relating to reliance on faith and
the supernatural to see women through labor were
reported. There was very little understanding of the
physiology and mechanisms of labor that could
warrant CS. Rather, women believed that failed
spontaneous vaginal delivery was due to lack of
prayers for supernatural intervention or an offence
committed by the woman earlier in life. Recourse to
supernatural divination would then appear to be the
solution, rather than delivery by CS. Overall, low
maternal education reduces the risk perception of
the real extent of these problems and accentuates the
belief in supernatural methods to relieve the diffi-
culties of labor.
In Enugu, Southeastern Nigeria, Iloabachie (11),
and Egwuatu and Ezeh (5), reported similar findings
indicating low perception and acceptance of indi-
cated CS by women with a low level of education.
The results of this study suggest a need for specific
health education of women and the community to
reduce the level of beliefs about superstitions as
causes of adverse pregnancy and labour outcomes,
and increase women’s access to evidence-based
methods of safe delivery, including CS. In particular,
such education can be structured to increase wo-
men’s use of antenatal services, where more specific
antenatal preparation of women has been found to
enhance positive attitudes towards CS (12).
The scale of this problem can be better imagined
when it is recognised that this was a hospital-based
study, and targeted women who were motivated to
access formal health services for antenatal care and
delivery. It is plausible that completely different
results would be obtained if the study were to focus
on women in the community, and those who use
informal providers of maternity services. We believe
that a community-based study will reduce the
proportion of women willing to accept indicated
CS, and expose more reasons for the low acceptance
of CS in the community. This is because the fear of

Women’s Attitudes towards caesarean section in Nigeria
CS is one of the commonest reasons often proffered
by women for not utilising formal maternity services
(10), as a result of the various socio-cultural factors 2.
reported in this study. Thus, we believe that any
interventions to address these problems must not
only focus at the institutional level to provide specific 3.
antenatal education and counseling, but must also
focus at the community level to provide broad-based
4.
community education and empowerment.
In conclusion, this study reveals low acceptance of
indicated CS by women at a tertiary hospital in 5.
Southern Nigeria due to women’s low understanding
of the nature of the problem and adverse socio- 6.
cultural and religious factors. Previous reproductive
experience, such as previous stillbirth or neonatal
7.
death, and previous CS influence the level of
acceptance of CS among Nigerian women. There
is an urgent and critical need for programs to 8.
increase women’s and community understanding
and perceptions of CS in Nigeria.
Acknowledgements 9.
We are grateful to Becky Tita of the Women’s Health
and Action Research Center, for assistance with data
10.
analysis.
11.
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