KNOWLEDGE, PERCEPTION AND ACCEPTANCE OF CAESAREAN

SECTION AMONG PREGNANT WOMEN IN UBAKALA COMMUNITY

HEALTH CENTRE, UMUAHIA.

ELEKWECHI ESTHER CHINECHEREM

DEPARTMENT OF NURSING SCIENCE

FACULTY OF NURSING SCIENCES

ABIA STATE UNIVERSITY, UTURU.

MAY, 2024
KNOWLEDGE, PERCEPTION AND ACCEPTANCE OF CAESAREAN

SECTION AMONG PREGNANT WOMEN IN UBAKALA COMMUNITY

HEALTH CENTRE, UMUAHIA.

ELEKWECHI ESTHER CHINECHEREM

DEPARTMENT OF NURSING SCIENCE

FACULTY OF NURSING SCIENCES

ABIA STATE UNIVERSITY, UTURU.

IN PARTIAL FUFILMENT OF THE REQUIREMNT OF NURSING AND

MIDWIFERY COUNCIL OF NIGERIA FOR THE REWARD OF
“REGISTERED NURSE CERTIFICATE”.

MAY, 2024
 CERTIFICATION PAGE

This is to certify that this project by ELEKWECHI ESTHER CHINECHEREM

with the Examination Number ……………………… has been examined and
approved for the award of Registered Nurse Certificate.

……………………………. ……………………….
Mrs. Ukeagu N.C Date
(Project Supervisor)

……………………………. ……………………….
Mrs. Emeonye O. P Date
(Head of Department)

……………………………. ………………………
Chief Examiner Date
 DECLARATION PAGE
This is to certify that this research project titled “Knowledge, Perception and
Acceptance of Caesarean Section Among Pregnant Women in Ubakala Community
Health Centre, Umuahia,” was carried out by ELEKWECHI ESTHER
CHINECHEREM and is solely the result of my work except where acknowledged as
been derived from other person(s) or resources.

Examination Number …………………………….

Department …………………………….
Signature …………………………….
Date …………………………….
 ABSTRACT

The study was conducted to find out the Knowledge, Perception and Acceptance of Caesarean
Section among Pregnant Women attending the antenatal clinic at Ubakala Community Health
Centre, Umuahaia. Three specific objectives were formulated to guide this study which were to
ascertain the Knowledge, Perception and Acceptance. The review of Literature was based on the
above objectives and the appropriate theoretical review was applied. The cross-sectional survey
research design was used for the study and it consisted of 200 mothers seen at the health center
from October 2023- December, 2023. Random sampling technique of balloting without
replacement was used to draw the sample for the study and a self-structured questionnaire was the
instrument used for data collection and the participants were assessed on their perception and
acceptance. The results showed that a majority of 85.5% had good knowledge of caesarean section,
77.5% viewed the procedure as an acceptable mode of delivery and will accept it if indicated.
193(96.5%) had good perception of it. The main reasons why it was not accepted by some women
were: perception of denial of womanhood, pain, fear of death and high cost.

The high acceptance of CS could have resulted from mitigating the effect of cost. Rejecting a
procedure like CS can be catastrophic. Health education and antenatal counselling is suggested to
help in continuing to reduce the rejection of CS by antenatal women and increase the uptake.

KEYWORDS: KNOWLEDGE, PERCEPTION, ACCEPTANCE, CAESAREAN SECTION, PREGNANT WOMEN

 DEDICATION

This study is dedicated to God Almighty.

 ACKNOWLEDGEMENT

Firstly, I acknowledge the Almighty God, who granted me the strength, wisdom and knowledge to

successfully conclude this study.

My sincere appreciation goes to MRS UKEAGU N. C, my amiable supervisor for her persistent guidance in

ensuring the completion of this project. I would also like to appreciate the HOD of Nursing Sciences, Abia

State University, Uturu, DR (MRS) EMEONYE O. P and the other Lecturers of the department of Nursing

Science for the role they played in the completion of my course.

Lastly, I am forever grateful to my family. To my amazing parents MR AND MRS ELEKWECHI and to my

wonderful siblings, thank you for your unending support.

 Table of Contents

Title Page i

Cover Page ii

Certification iii

Declaration iv

Abstract v

Dedication v

Acknowledgement vi

Table of Content viii

List of Tables ix

List of figures x

CHAPTER ONE: Introduction

 Background to the Study

 Statement of the Problem
 Purpose of the Study
 Research Questions
 Significance of the Study
 Scope of the Study

CHAPTER TWO: Review of Related Literature

1. Conceptual Framework;
2. Theoretical Framework;
3. Empirical Studies on Attitude of Women Towards Cesarean delivery
4. Summary of Reviewed Literature.

CHAPTER THREE: Methods

 Research Design
 Area of the study
 Population for the Study
 Sample and Sampling Techniques
 Instrument for Data Collection
 Method of Data Collection
 Method of Data Analysis
CHAPTER FOUR: Results and Analysis of Data

 Results
 Analysis

CHAPTER FIVE: Discussion of Findings, Summary, Conclusions and Recommendations

 Summary
 Conclusions
 Recommendations
 Suggestions for Further Study

References

Appendices

Appendix A: Letter of introduction

Appendix B: Attitude to Cesarean Delivery Questionnaire

Appendix C: Correlations
 List of Tables

Tables
List of Figures
 CHAPTER ONE

INTRODUCTION

BACKGROUND TO THE STUDY

Maternal mortality represents the leading cause of death among the pregnant women in most
developing countries including Nigeria (WHO, 2016). Furthermore, it is estimated that one third of
all maternal deaths globally occur in just two countries, namely India and Nigeria. According to
UNFPA (2016), in 2010, India was accountable for about 20% of global maternal deaths (56,000)
and Nigeria, 14% (40,000). Meanwhile, disease, deformity and death are terms usually employed to
describe the experiences of a vast majority of sub-Saharan African women during pregnancy and
birthing (WHO, 2016).

Similarly, the majority of African women are often viewed as being at high risk of infections,
injury and death during pregnancy and the periods surrounding it (Izugbara and Ukwayi, 2017). In
recent time women in Nigeria have expressed worries about choices of childbirth especially the
issues surrounding vaginal birth. The joy of every woman is to deliver her baby normally. Some
decades ago the most available or preferred option for most women was vaginal birth. Some of the
women had their babies at home with traditional birth attendants but quite often with difficult
labour resulting from obstruction and the women died before any meaningful interventions. Today,
however, many babies have been delivered successfully through caesarean section. This success
story in not without criticism. Among women in the developing countries, caesarean section is still
being perceived as a ‘curse’ of an unfaithful woman (Adeoye and Kalu 2015).

The authors further assert that caesarean section is seen among weak women. In addition, caesarean
section is surrounded with suspicion, aversion, misconception, fear, guilt, misery and anger among
the women of South Western Nigeria (Adeoye and Kalu 2015). Furthermore, in most sub-Saharan
African countries including Nigeria, caesarean section is being accepted reluctantly even in the face
of obvious clinical indication (Adeoye and Kalu 2015). Despite the causes of maternal mortality
often obstetric in origin, underlying cultural factors and beliefs also affect access to and use of
health facilities and thus contribute to avoidable maternal deaths. Several studies have indicated
how local beliefs and practices impact general health and childbearing. Some of these beliefs have
been identified as contributing to the delays in accessing appropriate skilled help when
complications arise in labour (Okafor 2020).

It is necessary to note that the issue of vaginal birth is not only peculiar to developing countries but
also in some developed countries. Women still choose vaginal birth after having caesarean section
even in the case of post-dates slated for elective caesarean section (Clift-Mathews 2020). The
author further highlighted the fact that women desperately wished to go into labour before their
appointment dates because not giving birth vaginally was a sign of ‘failure’. In addition; vaginal
birth is something a number of women look upon as a rite of passage (Clift-Mathews 2020)
Obstetrics in modern America is a contentious subject in general (Ecker 2019). Usually childbirth
and action surrounding it whether medical or otherwise normally evoke strong emotions where
discussion is often framed ideologically as a matter of nature versus technology. Hence the issue of
caesarean section in particular is much contested issue (Ecker 2019). Even so, caesarean section
rates are on the increase as evident in a number of western countries such as the United States of
America and United Kingdom (McAra-Couper, Jones and Smythe 2018).

In 1985, following the increasing disparity rate among nations in the number of caesarean births,
the World Health Organization (WHO) set out to determine an optimal rate of 15 percent as ideal.
The postulated 15 percent by WHO would optimally prevent childbirth injuries and deaths. In
addition, many women and babies would avoid unnecessary and potentially harmful surgery
(Harvard magazine 2019). However, WHO has since modified this particular recommendation in
2009, stating that ‘the optimum rate is unknown but asserts that both very low and very high rates
of caesarean sections can be dangerous’.

In other words, the procedure should be done only when it is absolutely necessary. The editorial
team of Academic Research International of Harvard Magazine concluded that there is need for a
balance to be reached, that is, women should be allowed to have normal vaginal deliveries with as
little intervention as possible. However, at the same time, the families, obstetricians will be ready to
address any unexpected emergencies.

STATEMENT OF PROBLEM

Traditionally, Nigerian women are unwilling to have CS because of the general belief that
abdominal delivery is reproductive failure on their part regardless of the feasibility of vaginal birth
after CS and the decreasing mortality from Caesarean sections. Imperative to the average pregnant
woman irrespective of her level of education and parity therefore is CS. Available reports on
knowledge of CS among women are mainly from tertiary health facilities situated in the southern
parts of the country while little has been known about the Knowledge, Perception and Acceptance
of Caesarean section among pregnant women in Ubakala Community Health Center, Umuahia.

RESEARCH QUESTIONS

1. What is the level of knowledge of Caesarean section among pregnant women in Ubakala
Community Health Center, Umuahia?

2. What is the level of perception of Caesarean section among pregnant women in Ubakala
Community Health Center, Umuahia?

3. What is the level of acceptance of caesarean section among pregnant women in Ubakala
community Health Center, Umuahia?
SIGNIFICANCE OF THE STUDY

The findings from this study would be used in planning strategies towards improving the
knowledge, perception and acceptance towards CS in the community in order to possibly reduce the
delay in presentation to the health facility when CS is needed, improve utilization of this mode of
delivery and limit the avoidable maternal and fetal complications.

SCOPE OF STUDY

This study focused on assessing the level of knowledge, perception and acceptance of pregnant
women towards Caesarean section. It was carried out in Ubakala community Health Center,
Umuahia.

DEFINITION OF TERMS

Knowledge: this is the awareness of a particular fact or situation

Perception: is the process of recognizing and interpreting sensory stimuli.

Acceptance: in human psychology is a person’s assent to the reality of a situation, recognizing a

process or condition (often a negative or uncomfortable situation) without attempting to change it
or protest it.

Caesarean Section: also known as C-section or caesarean delivery is the use of surgery to deliver
one or more babies. A caesarean section is often necessary when a vaginal delivery would put the
baby or mother at risk.
 CHAPTER TWO

Review of Related Literature

Literatures abound on the attitude of women to C-delivery in both developed and developing
countries including Nigeria. The literatures for this study were therefore gathered from both local
and foreign sources. It was organized and presented under the following sub headings.

Conceptual Framework;

 Concept of knowledge, Perception, Acceptance, Cesarean Delivery, Mothers,

Antenatal Clinic and primary health center
 Demographic Factors Associated with Perception and Acceptance of Women
Towards Cesarean Delivery such as, age, previous mode of delivery, parity and
literacy level of both the woman and her partner

Theoretical Framework;

 Theory of Cognitive Dissonance (TCD);

 Theory of Reasoned Action (TRA);

Empirical Review

Summary of Reviewed Literature.

Conceptual Framework

Concepts of Knowledge, Perception, Acceptance, Caesarean delivery, antenatal clinic, mother

and primary health care Centre.

Attitude has been comprehended differently by different researchers and has been defined
conceptually and operationally. Eagly and Chaiken, (2015) identified two most distinct ways to
define attitude, this include: attitude as a set of readiness and attitude as effect and evaluation. He
described attitude as set of readiness as a mental and neural state of readiness, organized through
experience, exerting a directive dynamic influence upon a response to all objects and the situation
with which it is related. They also described attitude as effects and evaluation as a tendency or
predisposition to evaluate an object or symbol of that object in a certain way. Attitude as effect and
evaluation, consist of the following attributes; goodness and badness or desirable and undesirable
quality to an object. Fazio (2016) affirmed that it was conceived that all the definition of attitude
had the component of readiness or disposition to act. He therefore described attitude as mental and
neural states of readiness organized through experience exerting a directive dynamic influence
upon a response to all objects and situations with which it is related. Miller (2015) emphasized the
tripartite (three component) classification of attitude. They defined attitude as the tendencies to
evaluate an entity with some degree of favor or disfavor ordinarily expressed in cognitive,
affective, and behavioral responses and formed on the bases of cognitive, affective and behavioral
processes.
Eagly and Chaiken (2015) posited that attitude occupy the central position in the process of
transforming work requirement into efforts and thus have a profound influence on one’s behavior.
They maintained that attitude affects behavior by serving the four functions of an individual as
listed below: instrumental function, ego defensive function, value orientation function and
knowledge function. They explained that in instrumental function attitude serve as a means to reach
a desired goal or to avoid an undesired one. Instrumental attitudes are aroused by the activation
of need or cues that are associated with the attitude objects and arouse favorable or unfavorable feelings. For
example, most traditional people in India do not think the soft-drinks as very good for health. Their
propensity to cause acidity reinforces the attitude. He stated that the ego defensive function of attitude acknowledges
the importance of psychological thought. Attitudes may be required and maintained to protect the
person from facing threats in external world or from becoming aware of his own unacceptable
impulses. In other words, attitude help people to retain their dignity and self-image. The value
orientation function takes into account the attitudes, which are held because they express a person’s values
or enhance his self-identity. These attitudes arise by conditions that threaten the self-identity. For
example, most Indians are not very comfortable to purchase contraceptives openly. By their
advertisements, the marketers are trying to project the consumers that there is nothing bad if they purchase
them and get the advantages of safety and birth control. The knowledge function of attitude is based on a
person’s need to maintain a stable, organized and meaningful structure of the world. Attitudes that
provide a standard against which a person evaluates aspects of his world serve as the knowledge
function also. As explained above, these functions of the attitude influence an individual’s
interpretation of the information.
Park (2019) perceived attitude as more or less permanent ways of behaving acquired by
social interactions. He also noted that our success or failure in life depends upon our attitudes.
According to (Sunder, Adarsh & Pankaj, 2019), each society and indeed individuals has cultural
values, ideologies, and interests relating to health and health services which determines their
attitudes towards health services. Sunder, Adarsh and Pankaj, (2019), noted that there are some
beliefs values and ideologies that are inimical to survival and therefore indicates need for health
promoting changes in cultural pattern depending on the tolerability of the changes. When attitude is
linked to cesarean delivery, it is called attitude to cesarean delivery. Attitude to cesarean delivery in
the context of the present study refers to the way the pregnant mothers think or feel about C-
delivery which is expressed through their acceptance or non-acceptance of the procedure (C-
delivery) which may in turn lead to their death or survival. While the study conducted by Sunday-
Adeoye and Kalu (2015) aims at the determination of the perceptions of women in the southwestern
Nigeria on C-delivery and their views about other women who have had C-delivery in the past, this
study aims at finding out the attitude of pregnant mothers in Ubakala community Health Center
towards accepting C-delivery, mothers that undergo C-delivery and health workers that execute C-
delivery. The attitude of the women towards C-delivery according to previous mode of delivery,
age, literacy level and parity will also be explored.
Since the dawn of time, labour and birth through the vaginal passage have been an
inevitable consequence of pregnancy, a journey through to life, there was no alternative to vaginal
birth, except death (Pieter and Dongen, 2019). They further stated that in this new millennium,
women do have an alternative, one that has been provided by the wonders of modern technology -
women today have choice, something, that women in ages past did not have. That is the C-delivery.
 C-delivery is a surgical procedure for fetal delivery when vaginal delivery becomes
contraindicate (Gamble & Creedy 2020). Roberts, Algert and Douglas (2019) stated that initially,
C-delivery usually results in the death of the mother and the first recorded incidence of a woman
surviving a C-delivery was in the 1580 in Siegershausen, Switzerland, by Jakob Nufer who
performed it on his wife after a prolonged labor. According to Be-Hague, Victoria, and Burros
(2016), it requires regional (or rarely general) anesthetic to prevent pain, and then a vertical or
horizontal incision in the lower abdomen (laparotomy) to expose the uterus (womb), another
incision is made in the uterus (hysterectomy) to allow removal of the baby and placenta. They
affirmed that it was done in an ancient civilization upon the death of a pregnant woman who was
near full term in order to salvage the baby. They also noted that this operation subsequently
developed into a surgical procedure to resolve maternal or fetal complications not amenable to
vaginal delivery, for mechanical limitations for maternal or fetal benefit. Grobman, Gersnoviez, &
Landon (2020), affirmed that it was initially performed to separate the mother and the fetus in an
attempt to save the fetus of a moribund patient. According to (Dowling, 2019), on march 2000, Ines
Ramirez performed a C-delivery on herself and survived as did her son Orlando Ruiz Ramirez.

The C-delivery usually performed when a vaginal birth would put the baby or the mother’s
life or health at risk has evolved from a vain attempt to save the fetus to one in which physician and
patient both participate in the decision-making process, striving to achieve the most beneficial for
the patient and her unborn child (Njokanma, Egri-Okwarji, Nwokoro, Orebamjo, & Okeke, 2018,).
Currently, C-deliveries are performed for a variety of fetal and maternal indications. It has also
expanded to consider the patient’s wishes and preferences. Finger (2020) posited that in those
women who are having a scheduled procedure (elective C-delivery), the decision has already been
made that the alternate of medical therapy, that is, a vaginal delivery, is least optimal. For other
patients admitted to labour and delivery, the anticipation is for a vaginal delivery. Every patient
admitted in this circumstance is admitted with the thought of a successful vaginal delivery.
However, if the patient’s situation should change, a C-delivery (emergency C-delivery) is
performed because it is believed that the outcome may be better for the fetus, the mother, or both.

Most women prefer to give birth naturally (vaginal delivery) doctors also prefer this route as
it minimizes the amount of recovery time for the mother and is the natural way for a baby to make
his way into the world (Oliver, 2019). However, one may suddenly find herself being wheeled out
of the delivery room into the operating room if certain complications arise during labor. The
majority of C-deliveries are performed because of some difficulty arising during the labor and
delivery process. One may be pushing with all her might, but baby still refuses to make his or her
way down the birth canal. In cases like these, a C-delivery is often recommended. Yabroff (2019)
stated that during childbirth, doctors monitor the mother and the baby's progress. If the cervix stops
dilating (arrest of dilation) or if the baby is being stubborn about descending into the birth canal,
the doctor may feel a C-delivery is necessary. It is hard on both the mother and the baby if labor is
taking too long. To avoid extra complications, the doctor might suggest taking the baby out
abdominally. According to Yabroff (2019), most C-deliveries are performed because of slow labor.
Also, if the baby's heart beat suddenly becomes irregular a C-delivery could prevent her from
becoming too stressed. Yabroff (2019) further stated that the doctor will also keep an eye out for
other situations that may cause problems for mother and baby during labor. A prolapsed umbilical
cord could prevent the baby from getting the air and blood he needs to survive on his trip down the
birth canal. This will necessitate birthing baby through C-delivery. If the doctor suspects the
placenta may be tearing away from the uterus, a C-delivery will also be in order as this could
endanger the baby. He also outlined other factors that can lead to C-delivery thus, if the baby is too
large to fit down the birth canal and through the cervix, a C-delivery is probably the best option. If
the mother is diabetic, have placenta preavia or an outbreak of genital herpes, a C-delivery be will
be necessary to protect baby. If one is expecting multiple births, a C-delivery may also be elected.
Chong and Mongelli (2018) affirmed that C-delivery is performed for maternal indications,
fetal indications, or both. According to them, in some situations a C-delivery may be the only safe
option for mother and baby, for example when: the placenta lies so low in the uterus that it covers
the exit to the birth canal (cervix), this is called placenta previa. The obstetrician finds out that
baby's health is threatened due to lack of oxygen; there is vaginal bleeding and a natural delivery is
not about to happen; the umbilical cord falls forwards and the baby cannot be delivered easily (a
condition known as cord prolapsed. it becomes clear during labour that the mother will be unable to
deliver the baby herself also. In other situations a C-delivery may be considered the safest option
even though a vaginal birth is a possibility: if the baby is lying with its head upwards (breech
baby); if the mother is affected by high blood pressure or other illness, if the unborn baby is too
small or too weak to survive a natural birth; if the mother has had a cesarean birth before (although
it is possible for a mother who's had a C-delivery to have a vaginal delivery in a later pregnancy)
and in very rare cases, when the mother is so anxious about the delivery that a C-delivery is
considered. The leading indications for C-delivery according to (Finger, 2020) are previous
cesarean delivery, breech presentation, dystocia, and fetal distress. These indications are
responsible for 85 percent of all cesarean deliveries.

As with all types of abdominal surgery, a C-delivery is associated with risks of post-
operative adhesions, incisional hernias (which may require surgical correction) and wound
infections (Savage, 2019). If a C-delivery is performed under emergency situations, the risk of the
surgery may be increased due to a number of factors. The patient's stomach may not be empty,
increasing the anesthesia risk (Silver, Landon and Rouse 2018). Other risks include severe blood
loss (which may require a blood transfusion) and post spinal headache, the risk of placenta previa,
a potentially life-threatening condition, is only 0.13 percent after two C-deliveries but increases to
2.13 percent after four and then to 6.74 percent after six or more surgeries (Pai, Madhukar 2019).
The risks for the child are mostly skin lacerations Wet lung: retention of fluid in the lungs occurs
if not expelled by the pressure of contractions during labour.
However, medical science is now so advanced as to lower the risk so significantly that
women can consider elective C-delivery (Scott, 2019). He further stated that some C-deliveries are
planned (elective C-delivery) when a known medical problem would make labour dangerous for
the mother or baby but in most cases, doctors do C-deliveries because of problems that arise
during labor (emergency C-delivery). An elective C-delivery is safer and is performed one to two
weeks before the baby's due date to ensure the baby is mature before delivery. Awoyinka, Ayinde
& Omigbodun, (2018) noted that the safety of C-delivery has led to an upsurge in the number of
women being delivered in this way in the developed countries, however, despite the well-
documented record of safety, there is still a strong aversion of C-delivery by women in sub-
Saharan Africa, even in the presence of life-threatening indications. Paradoxically, in Africa,
 where more C-deliveries are needed to improve maternal and perinatal survival, its availability and
utilization are low (Dumont, De-Bernis, Bouvier-Colle, Bréart & Moma, 2019). Agumuo, (2018)
affirmed that in Nigeria, C-deliveries have been demonized. According to him, a good percentage
of women distaste the idea of going through the procedure. The level of aversion borders mainly
on ignorance and fanaticism. He stated that “in many cases, it is seen as if the woman is not
capable on her own to bring forth her baby, such a stigma most times forces women to try to do
the impossible even when their life is at stake. Onah, (2019) stated thus, “the problem has to do
with the societal perception of the entire thing in some village in those days, there’s a song women
used to sing whenever a woman put to bed, the natural way”. Level of jubilation that used to greet
any delivery that came through the natural procedure, tended to cast aspersions at any woman that
went through C-delivery. Onah, (2019) further stated that in general, Nigerians appear to view
childbirth as a natural, at times lengthy, phenomenon and as such it is not unusual to avoid
analgesia and medical intervention, such as C-delivery. In addition, family support in labour, home
births, squatting positions in labour and postnatal rest for 40 days are common African experiences
(Murray, Windsor, Parker, Tewfik, 2018). Despite the naturalness of the labour experience, the
study conducted by (Carmel,Yekini, Oyeye, Ogunleye, Greene & Higgins 2019), comparing birth
plan preferences among Irish and Nigerian women found that the Irish women had a preference for
medicalizing childbirth through electronic fetal monitoring, restrictive maternal positioning and
expecting attendance of a physician at delivery.
Many London obstetricians have a favorable attitude towards C-delivery, and some consider
it the best option for themselves or their spouses (Luthy, Malmgren, Zingheim & Leininger 2015).
Among most women in America, they are convinced that vaginal birth will distort and mutilate
their bodies and leave them gaping and incontinent, or they are simply frightened about what
doctors will do to them, and believe that C-delivery offers the safest birth for the baby and is a way
of avoiding pain (Turnbull, Wilkinson, Yaser, Carty, Svigos & Robinson 2017). They see vaginal
birth as ugly, agonizing – a form of torture- and enlist a surgeon to avoid this. These people have
come to believe that C-delivery is an improvement over nature. Thus (Agumuo 2018) stated “in
other climes, it is said that some mothers prefer to have their babies through C-delivery than going
through the labour process”. According to him, such mothers do not want to experience the pain
associated with normal child birth.
A mother is a woman who has raised a child, given birth to a child, and/or supplied the
ovum that united with a sperm which grew into a child (Leaper, Anderson and Sanders 2016).
Brocklehurst & Volmink (2017) defined mother as a female person who is pregnant with or gives
birth to a child. A pregnant mother is a woman carrying one or more offspring, known as a fetus or
embryo, in the womb. Pregnancy is one of the most important periods in the life of a woman, a
family and a society. Extraordinary attention is therefore given to the woman through antenatal care
by the health care systems of most countries.

ANC, also known as prenatal care, is the complex of interventions that a pregnant woman
receives from organized health care services. Bassavanthappa (2018) defined antenatal care as the
advice, supervision and attention a pregnant woman receives to ensure good health throughout the
period up to having a live healthy baby at the end of pregnancy. Antenatal care is one of the “four
pillars” of safe motherhood, as formulated by the Maternal Health and Safe Motherhood
Programme, Division of Family Health, of the World Health Organization (WHO) (WHO, 2016).
The package was devised to ensure that women should be able to go safely through pregnancy and
childbirth and have healthy infants, in other words, to prevent the dreaded outcomes of maternal
death, and prenatal and infant death. Taylor (2017) defined antenatal care as the clinical assessment
of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for
the mother and child. According to him, to achieve this objective, history and examinations are
complemented by screening and assessment using a combination of methods, including
biochemical, haematological, and ultrasound. He maintained that during antenatal clinic, efforts are
made to maintain maternal physical and mental wellbeing, prevent preterm delivery, anticipate
difficulties and complications at delivery, ensure the birth of live healthy infant, and to assist the
couple in preparation for parenting. Park (2019) affirmed that the primary aim of antenatal care is
to achieve at the end of the pregnancy a healthy mother and baby and the central purpose is to
identify “high risk” cases as early as possible and arrange for them skilled care. Enkin, Keirse and
Chalmers (2016), also noted that care should be centered on the pregnant woman and the aim
should be to keep her fully informed on the progress of her pregnancy and to provide her with
evidence-based information and support to make informed decisions.

According to Jewel & Young, (2019) there are large numbers of different interventions in
ANC and may be provided in approximately 12-16 ANC visits during a pregnancy. Villar (2018)
outlined that basic activities of antenatal care fall within three general areas, thus; screening for
health and socioeconomic conditions likely to increase the possibility of specific adverse outcomes,
providing therapeutic interventions known to be beneficial, and educating pregnant women about
planning for safe birth, emergencies during pregnancy and how to deal with them. According to
(Jewel & Young, 2019), antenatal visits in the second half of the pregnancy is very important in
ensuring the education of the woman regarding the rest of pregnancy and her delivery. He further
stated that contraception and plans for the birth should also be discussed from an early stage
especially with regards to sterilization or other permanent contraception in order to avoid
unnecessary duress under emergency conditions if an operative delivery is decided upon during
labour. Taylor (2017) noted that several factors are considered during antenatal clinic around 36-38
weeks including the past obstetric history such as previous C-delivery for lack of progress in
labour, fetal mal-presentation or malposition is also sought as it may also indicate a high likelihood
of operative delivery. This intervention produces a better result when it is done in an organized
health institution as in general hospitals.

According to WHO (2008), the primary health center is “a whole-of-society approach to

effectively organize and strengthen national health systems and bring services for health and
wellbeing closer to communities. It is regarded as the most inclusive, equitable and cost-effective
way to achieve universal health coverage.
 Demographic factors associated with knowledge, perception and acceptance of
Caesarean delivery among pregnant women.

Orji, Ogunniyi and Onwudiegwnu; (2016) posited that there is a general aversion to C-
delivery 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 (2017) affirmed
that Nigerian women are averse to C-delivery 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 C-delivery 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 2017). Another reason for doctors to recommend C-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 C-section. The delays
associated with these and other factors may have contributed to the high proportion of emergency
C-delivery (Filippi, Richard, Lange & Ouattara, 2017).
However certain factors such as poverty, religion, location, previous mode of delivery,
parity, literacy level and age have been seen to influence this attitude to C-delivery among pregnant
mothers. Poverty is a variable that has received consistent attention among researchers. Bolatito
(2017) stated that Poverty is a major cause of maternal mortality in developing countries, as it
prevents many women from getting proper and adequate medical attention due to their inability to
afford good antenatal and obstetric care. According to Henderson, McCandlish, Kumiega, Petrou
(2019), there has been records of extremely low C-delivery rates, particularly in developing
countries where these low rates are concentrated among the poor, when other segments of the
population seemingly have adequate or excessive use of it. In such cases, it means that the services
do exist; they just are not accessible to some in the population. Ezechi, Nwokoro, Kalu, Njokanma
and Okeke, (2018), noted that factors like poverty, ignorance, illiteracy, access difficulties and
culture plays a significant role in women’s refusal of C-delivery in developing countries. A study
conducted by Ezechi, Fasubaa, Kalu, Nwokoro, Obiesie, (2018) revealed that 66.5 percent of the
study populations were averse to C-delivery as a result of financial implications. In Chile, a
retrospective study among 540 puerperal women observed that those with private care available,
i.e. those of higher socioeconomic level, had a higher chance of undergoing C-delivery than those
attended in public clinic. The possible explanations for this include the kind of medical care and
hospital services, as well as the way in which the woman participates in the decision-making
process regarding the type of delivery.
 Location is another variable that has been identified by many researchers as a factor
influencing the attitude to elective C-delivery. Bassavanthappa (2018) affirmed that the rural areas
in most parts of India do not have facility for conducting even a normal delivery. He stated that in
India where still there is less accessibility of the emergency obstetric care in the rural sector, the
situation could be very different from that of the urban sectors. The women having a delivery
complication in the rural sector usually turns up into the places where the facilities are less and
virtually they are forced to go for normal delivery because of the absence of the equipments to
perform a C-delivery. Magadi, Diamond, Madise, & Smith (2018) noted that the delays in seeking,
accessing, and receiving quality care in health facilities also contribute to lower C-delivery rates
and increase risks of adverse outcomes. Religion has also attracted the attention of many
researchers as one of the factors influencing the attitude of women towards C-delivery. Porreco,
Thorp (2018) noted that reasons for refusal of C-delivery are grounded in religious views, fear of
surgical complications and cost. Emphasizing the influence of religion on the attitude of women to
C-delivery. Agumuo (2010) 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 general hospitals where they are registered, to allow an easy
procedure, they refuse. The influence of educational attainment on the attitude of women to C-
delivery is also a very important factor that could influence women’s attitude to C-delivery. A
study conducted by Aziken, Omo-Aghoja and Okonofua (2017) revealed among other findings that
women's low level of education was associated with women’s refusal of the procedure. Socio-
cultural factors could also be an important factor that influences women’s attitude to C-delivery.
WHO (2016) reported that in most African countries women may refuse surgery because of fear of
suffering and other cultural perceptions of womanhood (Ezechi, Fasubaa, Kalu, Nwokoro, &
Obiesie, 2018). 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 C-delivery 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. Parity is expected to play a very important
role on the attitude of women to C-delivery. Luthy, Malmgren, Zingheim and Leininger (2015)
stated that it is possible that multiparous women with previous vaginal deliveries are better
motivated to try vaginal delivery again. Nulliparity, on the other hand, has been associated with
acceptance of C-delivery.

Age is yet another factor that has been identified by researchers to influence the attitude of
mothers to cesarean delivery. According to Obikeze and Okeibunor (2019), the reproductive/child
bearing age ranges between 15- 49 years. However National Population Commission (NPC)
Nigeria Demographic and Health Survey (2019) noted that women in Anambra State tend to delay
pregnancy until a later age of 19 years and above. Rise in maternal age and specific risk factors
associated with it such as gestational diabetes and hypertension influences the decision making
concerning modes of delivery (Bayrampur and Heaman 2019). They further noted that there is
increased likelihood of cesarean birth acceptance among women of advanced maternal age.
However, Kolwek & Franzisk (2018) noted that despite risks that were found in various studies for
mothers of 35 years or older, they still prefer vaginal delivery.
 Pregnant mothers

Previous mode of delivery also influences the attitude of mothers to cesarean delivery.
Previously, obstetricians recommended that all women who had a cesarean delivery have the same
for all future deliveries (Berghella, Baxter, & Chauhan 2019). However, they further stated that this
Primary health care centre
is no longer the case but most women in the United States who have had one low transverse
cesarean delivery choose to(Antenatal
have a repeat
clinic) cesarean delivery, although these women could try to
have a vaginal delivery with the next pregnancy. According to them, between 60 and 80 percent of
women who try to deliver vaginally after a c-delivery are successful in delivering vaginally.
However, James (2020) noted that women who have a vaginal birth after cesarean (VBAC) have a
less than 1 percent chance that the uterus will rupture during delivery, which could affect the baby's
health. Aziken. Omo-AghojaCaesarean
and Okonofua
delivery (2017) found out in their study that past successful
vaginal and instrumental deliveries, were most likely to be associated with women's non-acceptance
of indicated caesarean section. Also Buyukbayrak and Lufti (2019) noted that the most common
reasons for choosing cesarean delivery by women in their study were fear of vaginal delivery, tubal
ligation demand, and previous cesarean section.

Positive attitude to Caesarean delivery has been criticized by women in many cultures
Negative attitude(Savage,
to C- 2019). Critics
of doctor-ordered cesareans
cesarean delivery worry factors;
Demographic that cesareans
age, are in some cases performed because they are
delivery
profitable for the hospital, because
parity, a quick
previous mode ofCaesarean is more convenient for an obstetrician than a
lengthy vaginal birth, or because
delivery anditlevels
is easier
of to perform surgery at a scheduled time than to respond
to nature's schedule and deliver a attainment
educational baby at anofhour
boththat is not predetermined. He further stated that
another reason for doctors to recommend
the woman C-delivery is money. According to him, in China,
and her partner
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 C-delivery.
Figure 1: The study’s conceptual model showing the relationships of the concepts reviewed; the
demographic factors like age, parity, previous mode of delivery and level of educational attainment
can lead to either positive or negative attitude towards cesarean delivery.
Theoretical Framework
Theory is an assumption or system of assumptions, accepted principles, and rules of
procedure based on limited information or knowledge, devised to analyze, predict, or otherwise
explain the nature or behaviour of a specified set of phenomena; abstract reasoning. Theories in
health education seek answers to the fundamental question of why people behave the way they do.
Theories are used to understand how and why people change their unhealthy behaviour to healthier
ones. The purpose of this section is to review the theories that are related to the attitude of women
towards C-delivery. The theoretical frame work for the study is based on the theory of cognitive
dissonance and theory of reasoned action.

Theory of cognitive dissonance (TCD).

According to Harmon-Jones and Mills, (2017), cognitive dissonance, is a concept put

forward by Leon Festinger, in which the main proposal is that each individual strives to maintain
consistency between their differing cognitions. Should a noticeable inconsistency arise, this will
produce a state of cognitive dissonance, which the individual experiences as uncomfortable and
attempts to correct. Cognitive dissonance is a theory of human motivation that asserts that it is
psychologically uncomfortable to hold contradictory cognitions (Chen, & Risen 2019). The theory
is that dissonance, being unpleasant, motivates a person to change his cognition, attitude, or
behavior. Stratton & Hayes (2018) posited that dissonance theory suggests that if individuals act in
ways that contradict their beliefs, then they typically will change their beliefs to align with their
actions (or vice-a-versa). Dissonance is reduced by adjusting one of the beliefs or attitudes involved
in the inconsistency, so that the conflict disappears
This theory could be used to analyze the attitudes of pregnant mothers towards C-delivery.
The importance of C-delivery cannot be overemphasized due to invaluable number of lives that
have been saved by this procedure. Though it has its own challenges especially in some developing
countries, where some personal and societal beliefs discourage women from giving birth through
this means and fear of risks involved in surgical procedures. Thus ( Awoyinka, Ayinde &
Omigbodun, (2018) noted that despite the well-documented record of safety, there is still a strong
aversion of C-delivery by women in sub-Saharan Africa, even in the presence of life-threatening
indications. In the face of all these challenges and benefits of C-delivery there are bound to be a
mental conflict (cognitive dissonance) but it is expected that women should reduce their aversion
towards C-delivery since it is the only option to save the life of the mother and baby when there are
complications. When an individual (a mother) holds a negative beliefs and ideas about C-delivery,
a new knowledge about the advantages of C-delivery from antenatal clinic will lead to mental
conflicts (that is cognitive dissonance) in the individual. The resolution of the conflicts leads to
modification of beliefs and attitude change and consequent positive attitude towards C-delivery.

The theory of reasoned action. (TRA)

The second theory, the theory of reasoned action (TRA), proposed by Fishbein (2015)
posited that the components of TRA are three general constructs: behavioral intention (BI), attitude
(A), and subjective norm (SN). TRA suggests that a person's behavioral intention depends on the
person's attitude about the behavior and subjective norms (BI = A + SN). If a person intends to
behave in a certain way, then it is likely that the person will do it. Behavioral intention measures a
person's relative strength of intention to perform a behaviour. Attitude consists of beliefs about the
consequences of performing the behavior multiplied by his or her valuation of these consequences ( Hale,
Householder, & Greene, 2019). Subjective norm is seen as a combination of perceived expectations
from relevant individuals or groups along with intentions to comply with these expectations. In
other words, "the person's perception that most people who are important to him or her think he
should or should not perform the behavior in question" (Fishbein, 2015).
To put the definition into simple terms: a person's volitional (voluntary) behaviour is
predicted by his/her attitude toward that behaviour and how he/she thinks other people would view
them if they performed the behaviour. A person's attitude, combined with subjective norms, forms
his/her behavioral intention. Attitude to this effect consists of beliefs about the consequences of
performing C-delivery multiplied by the woman’s valuation of these consequences. Subjective norm is the
perception that most people who are important to her think she should or should not perform the
procedure. The combination of the above will lead to the possibilities of adopting a favourable or
unfavourable attitude to C-delivery. To this effect, this theory will be used to analyze the attitude of
the mothers towards C-delivery from the attitudinal questions on C-delivery. It is expected that
women will adopt a positive attitude to C-delivery after the advantages must have been weighed
with the societal norm and opinion of significant others.
 Theory of cognitive dissonance Theory of reasoned action

Behavioural intention is predicted

Emotional state set up that result by attitude and advice of
from holding two inconsistent significant others.
cognitions.

Societal perception of C- New perception of C- Information Societal belief

delivery delivery from ANC about C-delivery about C-delivery
from ANC

Mental conflicts resulting

from contradictory ideas Decision making either for
information from ANC or
societal belief about C-
delivery.

Conflict resolution

Positive or negative
attitude to C-delivery

Figure 2. The study’s theoretical model derived from Leon Festinger’s theory of cognitive
dissonance and Ajzen’s theory of reasoned action. The interplay of theory of cognitive dissonance
and theory of reasoned action towards the attitude to C-delivery.
Empirical Studies on Attitude of Women towards Cesarean Delivery.

This section is concerned with a review of empirical studies carried out among pregnant
women attending ante-natal clinic in health institutions. It reviews literatures on demographic
factors influencing the attitudes of pregnant women towards C-delivery and other related studies.

Kolwek & Franzisk, (2018) carried out a study to investigate how pregnant women feel about
caesarean section and natural birth and whether a relation between maternal ages and preferred
mode of delivery exists. It was across-sectional study. The population of the study consisted of 534
pregnant women presenting themselves for prenatal diagnosis at the Clinic of Obstetrics and
Gynaecology of the University Hospital Schleswig Holstein, Campus Lueck (Germany). The
pregnant women mark their wishes in a questionnaire on birth expectations in a five point Likert
scale in a standardized questionnaire. Socio-demographic data were collected separately. Besides
the descriptive statistics, an inferential (t-test) statistics method was implemented to assess the age
groups, using SPSS 15.0. The level of significance was 5 %. The findings revealed that women
favour a natural birth and place high importance on the criteria physiology, birth experience and
personal support. Characteristics of the caesarean section viewed negatively include surgery and
pain. Pregnant women of advanced age (≥ 35 years) tend to view caesarean section slightly more
positive but there is insufficient evidence to support that their decisions diverge from younger
women’s views. The conclusion was that although special risks were found in various studies for
mothers of 35 years or older, they still prefer to give birth naturally.
Sunday-Adeoye and Kalu (2015) 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
300 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 300 consenting pregnant clients attending the antenatal clinic, the average C/S rate in
the hospital was 16.6%. Only 4 (1.4%) viewed C/S as very good and elected to undergo C/S.
Thirty-four (12.3%) considered C/S as bad and would reluctantly undergo the procedure. Two
hundred and twenty-five (81.2%) would accept C/S 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 C/S and the negative cultural perception of the people to C/S
reinforced this aversion.
A similar study was carried out by Saoji, Nayse, Kasturwar, and Relwani (2017) 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 (91.5%)
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.
Another study was conducted to evaluate the knowledge, attitude, perception and
acceptance of women toward labor analgesia and caesarean section, in a Medical College Hospital
in Udaipur, India by Naithani, Bharwal, Chauhan, Kumar, Gupta, and Kirti (2016) using a cross-
sectional research design. A semi-structured interview of 200 antenatal women to assess the
knowledge, attitude and perception regarding labor analgesia and caesarean section and to estimate
the correlation of awareness and acceptability with demographic variables. The data were analyzed
using Epi Info 6 and the Likert type scale (0 - 10), as also the chi square test, to calculate the
statistical significance. The findings revealed that when the option for cesarean section was offered,
73.50 percent of the women (n = 147; P = 0.008) refused and the most common reasons for refusal
were fear of operation (53.06%, n = 78) and delay in resuming household work (46.26%, n = 68).
Enabudoso, Ezeanochie, Biodun and Olagbuji (2017) 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 95% confidence limits. Their results
revealed that of the 139 parturient who participated in the study, 77 percent had one previous
caesarean delivery while 54.46 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 behavior change communication involving the community, improved postoperative pain
management, and better counseling especially on safety of the procedure.
Another study was carried out by Jeremiah, Enyidah and Fiebai (2017) to assess the attitude
of antenatal patients at a tertiary hospital in Southern Nigeria towards cesarean section. It was a
cross sectional study conducted among 400 clients seen at the University of Port Harcourt Teaching
hospital between 1st and 31st September 2016. 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, 68.5 percent favored
cesarean 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.
Högberg, Lynöe and Wulff (2016) carried out a study to examine public attitudes towards
maternal requests for C-delivery and its association with health care and birth experiences in the
counties of Stockholm and Vasterbotten in Sweden. In addition, this study attempts to ascertain
whether gender, age and residence influence these attitudes. It was a cross-sectional population
survey with a postal questionnaire. Equal numbers of women and men between 20 and 80 years of
age were used. Using descriptive statistics and content analysis, the following results were
obtained. Of the 1,066 women (53%) who responded, two-thirds stated that a C/S should be
decided on for medical reasons and by a doctor. One-third considered that a woman, without
persuasion, should decide herself about mode of delivery and should be free to choose a C/S. These
respondents used arguments such as women's rights, bodily integrity and childbirth fear. The results
were associated with low trust in health care, women being young or middle aged, urban living and
having no children. Low trust in health care was associated with experiences of insecurity,
vulnerability and perceived maltreatment. Conclusion: Public norms towards women's own
decision making on mode of delivery are associated with younger age, lower trust in health care
and urban living. Antenatal care will encounter more parents asking for a C/S and demanding that
health professionals provide an ethically appropriate informed consent process. Considering the
risk of violating young women's trust if not respecting her wish, it seems reasonable that making
decisions whether or not to perform a C/S is part of shared decision making.
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 1,588 pregnant women. The data were analyzed using Epi Info 6.
Of the women questioned, 84.1% opted for vaginal delivery, whereas only 15.9% 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 labour 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.
A study was carried out by Nusrat, Nisar, and Ahson (2019) to determine the knowledge,
attitude and preferences of pregnant women towards vaginal and caesarean delivery at antenatal
clinic of Obstetrics and Gynecology Department, Isra University Hyderabad Sindh, from August
2017 to February 2018. Four hundred and forty-six women who have attended the antenatal clinic
during the study period were interviewed after taking informed consent. The information regarding
socio-demographic, obstetric history, knowledge and attitude statements towards vaginal and
caesarean delivery, the source of their knowledge, information regarding willingness to accept
caesarean delivery as a primary mode of delivery for current pregnancy and the reasons for chosen
preferences were recorded on questionnaire. All data were analyzed by using SPSS v.12. Cluster
scores for knowledge and attitude statements, mean±SD were calculated. The mean±SD age was
26.54±5.08 years. Among other findings, the study revealed that the mean attitude score was
21.99±3.12 for vaginal delivery and 8.78±4.47 for caesarean delivery. It shows that 304 (68.1%)
women regarded vaginal delivery as a natural and accepted mode of delivery. Three hundred and
fifty-seven (80%) women refused to accept caesarean delivery as primary mode of delivery in
current pregnancy, common reason given was fear of operation. Only 89 (20%) accepted it and the
main reason for acceptance was doctor’s advice. They concluded that women in their setup have
low level of knowledge regarding modes of delivery and positive attitude towards vaginal delivery.
They recommended that there is a need for a program to increase women’s understanding about
different modes of delivery.
Danso, Schwandt, Turpin, Seffah, Samba, Hindin (2019) conducted a study to determine
Ghanaian women's preferred mode of delivery and opinion of caesarean section after caesarean
section in two teaching hospitals in Ghana: Komfo Anokye Teaching Hospital, Kumasi, and Korle-
Bu Teaching Hospital, Accra. It was a cross sectional study of women who recently delivered by
caesarean section prior to hospital discharge. The respondents were 154 patients who delivered by
caesarean section between the 1st and 31st August, 2017. Of the 154 initiating the interview, 151
completed, and 145 had complete data. . The pregnant women were specifically asked what their
current preference for delivery was. Pearson's Chi-square test and logistic regression for
multivariate analysis were performed with a 5% significance level. The findings revealed that the
majority of women interviewed indicated that they preferred vaginal delivery (55%). The
conclusion is that Ghanaian women with experience of caesarean section prefer vaginal delivery.
A study was carried out by Adageba, Danso, Adusu-Donkor, and Ankobea-Kokroe (2018),
to determine the awareness and perceptions of and attitudes towards caesarean delivery among
antenatal clinic (ANC) attendants in a Ghanaian teaching hospital. It was a cross-sectional study. A
13-point structured questionnaire containing items on demographic characteristic and assessment of
knowledge of, perceptions and attitudes towards caesarean delivery was administered to 347
women attending the hospital's antenatal clinic from 1 st December to 31st December, 2017. The data
were analysed using Epi-Info, version 6. Variables were described and analysis of variance and
Pearson tests were applied to find out any significant relationship between variables. P values less
than 0.05 were considered as significant.
Among other findings, the study revealed that vaginal delivery was preferred by 296 (93.3%) while
11 (3.5%) preferred planned caesarean delivery; the remaining 10 (3.2%) were undecided.
Although 164 (51.7%) perceived it as being dangerous to the mother and baby, 287 (90.5%) were
willing to undergo the operation when indicated; 19 (6%) would refuse the operation even when
indicated. Almost all the women, 311 (98.1%), wanted caesarean section to be part of client
education at the antenatal clinic and 314 (99.1%) wanted to be informed about the specific
indication before surgery. They recommended that client education is necessary to address some
concerns on safety of and indications for the operation.
Obiechina, Ezeama, & Ugboaja (2018) carried out a study in the context that Caesarean
section is very central to the practice of safe obstetric, especially in emergency obstetric care.
Frequent review of trends, indications, methods and complications is necessary to ensure safety.
The objective is to determine the patients’ characteristics, indications, techniques and complications
of caesarean section done in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria over a
five year period. The case files of all patients who had caesarean section in the Hospital between
1st January, 2014 and 31st December, 2017 were retrospectively analysed. Parameters assessed
include parity, booking status, nature of surgery, indications for surgery, complications and
maternal outcome. The findings revealed that there were 2,847 deliveries within the review period
with 535 caesarean sections done, giving an incidence of 18.8%. 76.9% of the patients were booked
for antenatal care at the hospital while 23.1% were unbooked and were attended to as emergencies.
72.8% of the operations were emergency sections while 27.2 % were electively done. The main
indications for the emergency procedures were poor progress/cephalopelvic disproportion
(52.90%), obstructed labour (15.10%) and fetal distress (11.72%) while repeat caesarean sections
accounted for the majority (66.7%) of elective cases followed by placenta praevia. Most of the
surgeries were done as emergencies and none was carried out by a junior registrar. The morbidity
and mortality rates were higher on those done in emergencies.
Nira & Pradhan (2017) conducted a study to evaluate the knowledge and attitude of
Nepalese women towards mode of delivery and caesarean on demand. Hospital based cross
sectional descriptive study where 200 pregnant women after 37 completed weeks of gestation were
recruited randomly and interviewed, and their answers were analyzed using Epi-info version 3.5.1
software. The results revealed among other findings that of the 200 interviewed pregnant women,
vaginal delivery was the preferred mode of delivery in 93 per cent and 7 per cent preferred
caesarean delivery. Only 35 per cent of the interviewed women believed that women should have
the right to demand a caesarean section Conclusion: Knowledge assessment of two hundred women
regarding the mode of delivery clearly indicates the need for strengthening counseling aspect of
antenatal care and awareness programme regarding mode of delivery. In Nepal, on demand
caesarean section is not provided in the University Teaching Hospital. However, one third of
women still felt that women should have the right to choose caesarean section on demand.
Aziken, Omo-Aghoja and Okonofua (2017) carried out a study to determine the perceptions
and attitudes towards caesarean section [C/S] among women attending maternity care at the
University of Benin Teaching Hospital in Nigeria. The population of the study consisted of 413
consecutive women, attending antenatal care in the hospital, who were interviewed with a
structured questionnaire that solicited information on their socio-demographic characteristis, their
previous pregnancy and delivery history, and their knowledge and attitudes towards C/S. Among
other findings, the study revealed that only 6.1% were willing to accept C/S as a method of
delivery, while 81% would accept C/S if needed to save their lives and that of their babies. Up to
12.1% of women would not accept C/S 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. They recommended that there is a need for programmmes to
increase women's and community understanding and perceptions of C/S as a method of delivery in
Nigeria.
Chigbu and Iloabachie (2017) carried out a study to investigate the prevalence, aetiology
and outcomes of caesarean section refusal in pregnant women. The setting is University of Nigeria
Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria. It was prospective controlled study. A
total of 62 Nigerian women who declined elective caesarean section were used for the study. The
data entry, validation and analysis were by EPI info software version6. The results are as follows
the prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons
for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal
delivery and inadequate counseling. Outcomes were significantly worse among women who
refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%,
P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001).
Koken, Cosar, Sahin, Tolga, Arioz, Duman & Aral (2017) carried out a study to assess the
attitudes of healthcare providers and the public in Turkey towards mode of delivery and C- delivery
on demand. A written questionnaire was given to female healthcare providers and women from the
general public, and their answers were analyzed using SPSS 15.0 statistical software. A total of 329
female healthcare providers and 347 women from the public group completed the survey. In
response, 48.1% of healthcare providers and 69.6% of the public group chose vaginal delivery as
the preferred mode of delivery (P<0.001). Some 45.3% of healthcare providers and 20.6% of the
public group had undergone a C-delivery without any medical indications (P<0.001). In addition,
37.8% of healthcare providers and 36.2% of the public group believed that women should have the
right to a C-delivery on demand. The conclusion is that in the two groups studied the preference for
C-delivery is higher in Turkish healthcare providers than in the public population. In both groups
the attitude towards C-delivery on demand is high.
Ezechi, Fasubaa, Kalu, Nwokoro, Obiesie (2018) conducted a study to examine the reason
for aversion to caesarean section among pregnant Nigerian women receiving antenatal care at
Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria and Havana Specialist Hospital,
Lagos Nigeria. Structured questionnaires were administered to pregnant women receiving antenatal
care in both hospitals. The response to questions on their knowledge, attitudes and reason for
aversion to caesarean section and experience of patients who have had caesarean section were
analyzed using EPI info software version6. Among other findings, only 28.9% accepted caesarean
section on doctor's advice, 71.1% will not accept caesarean delivery for any reason. 26.8% of the
patients that have had previous caesarean section prefer to die while attempting vaginal delivery
than to have a repeat caesarean section. Reasons for refusing caesarean section were essentially that
of sense of reproductive failure after caesarean section (81.2%) and financial implication (66.5%).
It also shows that education and social class has little or no effect on the aversion to caesarean
section in our environment. The recommendation is that meaningful attempt at solving the problem
of caesarean aversion must go beyond the confines of hospital wards to the communities since it is
deep-rooted in culture.

Summary of Literature Review

The key concepts in this study have been variously defined by different authors. These were
attitude, cesarean delivery, mother, antenatal care and primary health centers. Following from these
definitions, the researcher linked attitude to cesarean delivery and defined it (attitude to cesarean
delivery) as the feelings which predispose pregnant mothers to respond either positively or
negatively towards C-delivery.

The theories reviewed include the theory of cognitive dissonance and theory of reasoned
action. The theory of cognitive dissonance looks at the emotional state set up when two
simultaneously held attitudes or cognitions are inconsistent or when there is a conflict between
belief and overt behavior. The resolution of the conflict is assumed to serve as a basis for attitude
change, in that belief patterns are generally modified so as to be consistent with behavior." The
theory of reasoned action looks at person’s attitude towards behavior as well as the subjective
norms of the influential people and groups that could influence the attitudes.

The literature reviewed also showed that some demographic factors may have the tendency
to influence the attitude of pregnant mothers towards cesarean delivery. These factors include
poverty, location, age, parity, literacy level, and religion. Many studies on perception of and
attitude to cesarean deliveries have helped in understanding people’s views and thinking about C-
delivery. The literature also revealed that many authors have attempted to predict the attitude of
mothers to C-delivery based on their demographic characteristics.

The literature review also shows that related studies have been carried out both locally and
internationally. However, among all the related studies that are reviewed in this work, none has
been done in Ubakala Community Health Center, which is the location of the present study and
none tended to capturing the peculiar background of the area of the study thereby justifying the
need to carry out this study in Anambra state.
 CHAPTER THREE

Methods

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.

Research Design

The cross-sectional survey research design was used for the study. According to Levin
(2006), cross sectional survey design when simply put, provides a snapshot of a situation in a
population, and the characteristics associated with it at a specific point in time. This study also
involved the collection, analysis and interpretation of data which Osuala (1987) described that is
better done by cross-sectional survey research design. The design was considered appropriate for
the study because the information was collected directly from the respondents.

Area of the Study

The location of this study was Ubakala Community Health Center, Umuahia South LGA,
Abia State. It was established on the 2 nd of December, 1962 and it operates on a 24 hours basis. It
was licensed by the Nigerian Ministry of Health. It is registered as a primary health care center. The
services offered are: Antenatal care(ANC), Immunization, HIV/AIDS Services, Family Planning,
Non-Communicable Diseases, Nutrition etc.

Population for the Study

The population for the study consisted of all the mothers registered for antenatal clinics at
Ubakala Community Health Center, Umuahia during the study period.

Sample and Sampling Techniques

Respondents were selected during each clinic day by simple random sampling using
balloting. Verbal consent with a right to opt-out was obtained after assurance of confidentiality. A
pool of 300 lottery papers were made earlier, 150 had ‘YES’ written on them and 150 had ‘NO’
written on them. The women who chose ‘YES’ were recruited for the study and those who chose
‘NO’ were not selected.

Inclusion Criteria

Women who attended Ubakala community health center during the study period from October,
2023- December, 2023.
Exclusion Criteria

The women who did not consent to the study.

Instrument for Data Collection

A structured interviewer administered questionnaire was used to obtain information about socio-
demographic characteristics, reproductive profile, knowledge, perception and acceptability of
Caesarean section.

The questionnaire had 7 questions about knowledge of Caesarean section. Each correct answer was
scored 1, and each wrong answer was scored 0. Marks obtained by each participant was divided by
total score of 7 and multiplied by 100. A score of 50% and above was considered a good
knowledge and a score of less than 50% was considered a poor knowledge.
There were 8 questions about perception with yes or no options, a correct answer was scored 1 and
each wrong answer was scored 0. The marks obtained was divided by total of 8 and multiplied by
100. A score of 50% and above was considered a good perception and a score of less than 50% was
considered a poor perception. The minimum sample size calculated was 150 using a sample size
formula of a cross sectional study using a Proportion of women that had aversion to CS from
previous study, which is 11.6%. The minimum sample size was further increased by 35% attrition
value to 200.

Validity of the instrument.

The researcher secured validity of the instrument used for the instrument by formulating and
submitting the constructed questions to her project supervisor and other research based lecturers for
scrutinizing, edification, and corrections to ascertain that the questionnaire suites the level of the
respondents and in line with research questions as its content covers the scope of the study avoiding
ambiguity. The supervisor and other research based lecturers effected some corrections and these
were reflected into the final copy of the questionnaire, hence, the face and content validity of the
instrument was ensured before the instrument was distributed.

Reliability of the instrument.

The reliability co-efficient were established using the test-retest method. Copies of the
questionnaire was administered to mothers in Federal Medical Center, Umuahia, with the same
feature of the target population and after two weeks, another 11 copies were distributed to the same
people which was not part of the study population, thereby re-testing them and the reliability index
of the instrument. The scores that were obtained from the two tests were correlated using
spearman-correlation co-efficient formula in order to find out their reliab
Method of Data Collection

With permission from the chief Nursing Officer at the community health center, a structured
interviewer administered questionnaire was used to obtain information about the socio-
demographic characteristics, reproductive profile, knowledge, perception and acceptance of
Caesarean Section. The questionnaire had 7 questions about knowledge of caesarean section. Each
correct answer was scored 1, and each wrong answer was scored 0. Marks obtained by each
participant was divided by total score of 7 and multiplied by 100. A score of 50% and above was
considered a good knowledge and a score of less than 50% was considered a poor knowledge.
There were 8 questions about perception with yes or no options, a correct answer was scored 1 and
each wrong answer was scored 0. The marks obtained was divided by total of 8 and multiplied by
100. A score of 50% and above was considered a good perception and a score of less than 50% was
considered a poor perception. The minimum sample size calculated was 150 using a sample size
formula of a cross sectional study using a Proportion of women that had aversion to CS from
previous study, which is 11.6%. The minimum sample size was further increased by 35% attrition
value to 200.

Method of Data Analysis

The information obtained was analyzed using SPSS version 21. Tables and figures were used for
data presentation. The information obtained was analyzed using SPSS version 21. Chi- square test
was used to determine association and a p-value <0.05 was considered significant.
 CHAPTER FOUR
Results and Analysis of Data

This chapter presents and discusses the findings of the study on attitude of mothers attending
antenatal clinics at Ubakala Community Health Center, Umuahia, towards caesarean delivery. Two
hundred of the questionnaires were distributed, and all two hundred were returned representing
100% percent return rate. They were filled correctly and therefore used for the study. Two hundred
respondents were interviewed during the three-month period of the study. The socio-demographic
characteristics of the respondents were shown on table 1. The age ranged from 18-39 with a mean
of 26.88 +/- 4.73 years. All were married. Parity ranged from 1-7 and 50 (25%) of the clients are
nulliparous, and 115 (57.5%) are housewives. Most of the clients had tertiary level of education
135 (67.5%).

Table 1: Socio-demographic characteristics of respondents (n=200).

Characteristics Number Percentage
Age
<20 14 7.0
20-24 44 22.0
76 38.0
25-29 51 25.5
30-34 15 7.5
35-39
Occupation
Housewife 115 57.5
Civil servant 48 24.0
Petty trader 29 14.5
Artisan 8 4.0
Educational status
Informal 13 6.5
Primary 13 6.5
Secondary 39 19.5
Tertiary 135 67.5
Educational status of husband
Informal 6 3.0
Primary 5 2.5
Secondary 31 15.5
Tertiary 158 79.0
Occupation of husband
Artisan 15 7.5
Business 51 25.5
Civil servant 134 67.0

Majority of the respondents 104(52.0%) got information from friends and relatives. Among the
participants, 171(85.5%) had good knowledge of Caesarean section, while 29(14.5%) had poor
knowledge.
 Figure 1: Source of information.

Knowledge was significantly associated with age (p=0.005), educational status (p=0.009) and
husband education (p=0.038). The younger patients had better knowledge than the older patients.
The participants and their husbands with higher level of educational are more likely to have better
knowledge of caesarean section.

Table 2: Factors associated with knowledge.

Poor Good
P
Factors knowledge n knowledge n χ2
value
(%) (%)
Age (years)
<20 0 (0.0) 14 (100)
20-24 2 (4.5) 42 (95.5)
25-29 16 (21.1) 60 (78.9) 17.298 0.002
30-34 5 (9.8) 46 (90.2)
35-39 6 (40.0) 9 (60.0)
Occupation
Artisan 0(0.0) 8(100)
Civil servant 9(18.8) 39(81.2)
2.467 0.482
Housewife 17(14.8) 98(85.2)
Petty trader 3(10.3) 26(89.7)
Marital status
Married 29(14.5) 171(85.5)
Educational status
Informal 0(0.0) 13(100)
Primary 3(23.1) 10(76.9)
12.057 0.009
Secondary 0(0.0) 39(100)
Tertiary 26(19.3) 109(80.7)
Educational status of
husband
Informal 0(0.0) 6(100) 7.725 0.038
Primary 3(60.0) 2(40.0)
Secondary 6(19.4) 25(80.6)
Tertiary 20(12.7) 138(87.3)
Occupation of husband
Artisan 3(20.0) 12(80.0)
0.693 0.729
Business 6(11.8) 45(88.2)
Civil servant 20(14.9) 114(85.1)

In the study, 193(96.5%) had good perception of CS and perception. Good perception was higher
among younger only 7(3.5%) had poor perception.

Age (P = 0.006), religion (P = 0.0001) and husband’s

occupation (P =.002) were significantly associated with

Table 3: Factors associated with Perception.

Poor Good
P-
Factors perception perception χ2
value
n(%) n(%)
Age(years)
<20 3(21.4) 11(78.6)
20-24 0(0.0) 44(100)
11.095 0.006
25-29 4(5.3) 72(94.7)
30-34 0(0.0) 51(100)
35-39 0(0.0) 15(100)
Occupation
Artisan 0(0.0) 8(100)
Civil servant 0(0.0) 48(100)
3.793 0.238
Housewife 7(6.1) 108(93.9)
Petty trader 0(0.0) 29(100)
Educational status
Informal 0(0.0) 13(100)
Primary 0(0.0) 13(100)
2.127 0.433
Secondary 3(7.7) 36(92.3)
Tertiary 4(3.0) 131(97.0)
Educational status of
husband 0(0.0) 6(100)
Informal 0(0.0) 5(100)
Primary 2(6.5) 29(93.5) 1.758 0.547
Secondary 5(3.2) 153(96.8)
Tertiary
Occupation of husband
Artisan 2(13.3) 13(86.7)
Business 5(9.8) 46(90.2) 15.155 0.002
Civil servant 0(0.0) 134(100)
The majority, 155(77.5%) of the respondents will accept CS if indicated while 45(22.5%) would
not accept CS. Among those that viewed CS as an unacceptable mode of delivery, the reasons
given are as follows; denial of womanhood 21 (10.5%) painful procedure 16 (8.0%) it is
expensive 15 (7.5) fear of death 11 (5.5%) fear to be mocked by other women 5 (2.5%) and CS
done in the interest of the doctor 3 (1.5%)
 CHAPTER FIVE

Discussion of Findings, Summary, Conclusions and Recommendations

Discussion

Caesarean section is one of the oldest procedures in obstetric practice and may be a necessary end in
the termination of pregnancy to abort or minimize complications to the mother, fetus or both. In the
developing countries, caesarean section utilization has been observed to be low. A significant
contributor to this comparatively lower caesarean section rate is thought to be due to negative
perception and perception of the procedure by pregnant women and their families. The discussion of
findings of the study on knowledge, attitude and practice of breastfeeding amongst mothers in Abia
State University Teaching Hospital, Aba was organized in relation to the research questions presented
in the study.

RESEARCH 1

Level of knowledge of caesarean section among pregnant women in Ubakala Community Health
Centre, Umuahia.

With improvement in the number of pregnant women attending antenatal clinic in developing countries
including Nigeria, health education during the clinic period on modes of delivery should be able to
correct misconceptions and myth about caesarean section. Table 2 in our study shows that the majority
of our respondents 171(85.5%) had good knowledge about Caesarean section. The high knowledge of
the respondents may be a product of their educational status; most of them had tertiary level of
education. Likewise, in a study from North-East Nigeria majority (80.3%) had knowledge about
caesarean section. This is similar to a study from the South-West Nigeria where all the participants had
knowledge of caesarean section. Furthermore, a similar study conducted in Niger Delta Tertiary facility,
majority (86.0%) had knowledge on caesarean section and will support and accept it if offered. In
another study in Irua, Delta state 83% were aware of the surgery. In a study by Oshimi et al; 93.8%
were aware of Caesarean section while 40.9% had adequate knowledge. Some of the questions were
technical for a patient who is not a health personnel explaining the lower level of knowledge. In a study
conducted in India, knowledge was classified, with 8.7% having high knowledge, 26.2% adequate,
47.7% low and 17.4% had no knowledge. In a study by Faremi in Ondo state, 17.2% had good
knowledge, 36.0% had fair knowledge and 46.8% had poor knowledge.
Since all the respondents were recruited from the antenatal clinic, it is expected that the main source of
information, would be from the clinic. However, majority 104 (52.0%) got information from
friends/relatives (figure 1). This is similar to the finding from a study done in North-Eastern Nigeria
where 49% of the respondents got information from friends and relatives. This may be a reflection of
the poor health education in our antenatal clinics.

Our study shows significant association age, educational status of respondents and their husbands with
knowledge of Caesarean section (Table 2). Knowledge of caesarean section was higher in the younger
women. Participants with higher high level of education or those whose husbands had high level of
education had better knowledge of CS. Oshimi et al demonstrated that there was no association
between socio-demographic characteristics and knowledge of Caesarean section.

RESEARCH QUESTION 2

Level of Perception of Caesarean Section Among Pregnant Women in Ubakala Community

Health Center, Umuahia.

Findings from the study showed that perception was better with older age group and husbands
occupation (Table 3). This is similar to the study conducted by Panti et al, where 96.5% of the
respondents recorded a good perception. However, the respondents in a study conducted in Lagos State
and in Cape Coast of Ghana, among pregnant women, were found to have a poor perception of CS.
Respondents from a study in Jos, Nigeria also thought it was a safe procedure while 40% of those in
Ghana thought it was dangerous procedure and that women would die after the procedure.

RESEARCH QUESTION 3

Level of Acceptance of Caesarean Section Among Pregnant Women in Ubakala Community

Health Center, Umuahia.

Majority (77.5%) of our study participants would accept Caesarean section if indicated and more
women were ready to encourage friends or relatives to accept the procedure. Similarly, in Irua, Edo
state, 81.5% of the women would accept CS when indicated. This is in contrast with findings from a
study carried out in two hospitals in Ile-Ife and Lagos where 81.2% of the respondents showed aversion
to caesarean delivery. In the study from Birnin Kudu acceptance was 99%. In a study on women who
had previous CS, 69.2% would accept repeat of the procedure if necessary. In Ibadan Bello et al found
acceptance to be 65.5%. In an Indian study, 91.5% would agree to caesarean section if it’s necessary to
protect their baby’s health. Most studies agree that the reasons for aversion for CS are not just because
of associated maternal and fetal hazards but mostly due to traditional beliefs and practices. In our study,
reasons for not accepting the surgery are mainly, perception of denial of womanhood, pain, high cost
and fear of death. Similarly, in the study carried out in Edo state, most of those who would refuse the
surgery felt its denial of womanhood. Most of the women with aversion for CS in the study from Ile-Ife
and Lagos view it as a reproductive failure. In a study among women with previous CS, those who
would not accept repeat surgery had fear of death and pain. The reasons were mainly family preference
for vaginal delivery, fear of death and cost of CS. Similar findings were made by Chigbu and Iloabachie
in Enugu, South-East Nigeria.

Among the women who viewed CS as an unacceptable mode of delivery, most felt that their
womanhood would have been lost. Majority of respondents have negative perception on Caesarean
section in a study conducted in Irua, Edo state. In another study conducted in a missionary hospital in
Edo state, majority of the respondents have negative perception on Caesarean section the reasons were
mainly family preference for vaginal delivery, fear of death and cost of Caesarean section. Similar
findings were made by Chigbu and Iloabachie in Enugu, South-East Nigeria. In the study conducted in
Ile-Ife and Lagos where 81.2% of the respondents showed aversion to caesarean delivery, most of the
respondents viewed it as a reproductive failure. would not accept were mainly due to fear of death and
pain. This is in contrasts to a finding from a similar study at Ebonyi state university teaching hospital,
where fear of death from the procedure was the commonest reason for aversion to caesarean section.

Summary

This study was aimed at determining the perception and acceptance of caesarean section among
pregnant women at the antenatal clinic of Ubakala Community Health Center, Umuahia.
A cross-sectional research design was used for the study. The population for the study was 300
pregnant mothers and a simple random sampling technique was used to select the sample, the process
produced a sample of 200 mothers.
A structured questionnaire was the instrument for data collection: the instrument was validated and
proven to be reliable. The questionnaires were distributed to the 200 respondents with a 100% retrieval
rate. Data was analyzed using tables, a pie chart and criterion mean.
Conclusions

Based on the findings and discussions of the study, the following conclusions were attained.
1. The findings affirm previous suspicion that a significant number of mothers have
unfavourable attitude towards cesarean delivery.
2. Age did not influence the mother’s attitude towards cesarean delivery.
3. Mother’s parity status had little or no effect on their attitude towards cesarean delivery.
4. Mother’s level of education did not influence their attitude to cesarean delivery.
5. Mother’s previous mode of delivery also had little or no effect on their attitude to
cesarean delivery.

Recommendations
 Based on the findings, discussions and conclusions, the following recommendations were made.

1. More scientific research should be conducted on the demographic factors that influence the
perception and acceptance of women towards cesarean delivery.
2. A challenge to health care personnel would be to provide better information for pregnant
women during antenatal period about cesarean deliveries, their indications, advantages and
adverse consequences.
3. Community health education about the benefits of cesarean delivery when indicated at primary
care level is needed for the women’s and community’s understanding of the necessity of
cesarean delivery. This will go a long way to reduce the number of women declining cesarean
delivery and the morbidities and mortalities associated with such an action and improve the
pregnancy outcome.
4. Health planners need to recognize that the objective of the Safe Motherhood Initiative to reduce
maternal mortality cannot be realized if the mothers are ignorant of the necessity of cesarean
delivery as a life-saving procedure.

Suggestions for further studies

In view of the limitations of the study, a research of the same should be carried out putting into
consideration the sample size and sort of instrument used to collect data.
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 Appendix A

Letter of introduction

Abia State Unversity,Uturu,

Department of Nursing Sciences,

Abia State,
Nigeria,
10th October, 2023.

Dear respondent,
I am a student of the above mentioned school carrying out an investigation on the Knowledge,
Perception and Acceptance towards Caesarean Delivery by Mothers Attending Antenatal Clinic in
Ubakala Community Health Centre, Umuahia.

Your cooperation is being solicited to candidly respond to the statements and sets of questions
below. Your responses will be treated in confidence and will be solely used for the purpose of this
study. Your name and address do not need to be indicated on the questionnaire rather respond to the
questionnaire items and return completed copy to the researcher or her assistants. The result of this
study will be used strictly for research purposes.

I sincerely appreciate your willingness to co-operate in this exercise.

Yours faithfully,

ELEKWECHI ESTHER CHINECHEREM

Student.
 APPENDIX B

QUESTIONNAIRE

Abia State Unversity,

Uturu,
Department of Nursing Sciences,
Abia State,
Nigeria,
10th October, 2023.
Dear respondent,
I am a student of the above School, carrying out a research study on “Knowledge, Perception and
Acceptance of Caesarean Section among pregnant women in Ubakala Community Health Centre,
Umuahia”.
I therefore request your cooperation in filling the necessary information needed by this questionnaire
which is for academic purpose. Please note that your name is not required as all information will be
treated with utmost confidentiality.

Yours faithfully,
ELEKWECHI ESTHER CHINECHEREM
Student
 Appendix C

Attitude to Cesarean Delivery Questionnaire

Directions; tick [√] on the appropriate responses as applied to you.

SECTION A:

1. What is your age bracket?

a. 15-25 years
b. 26-35 years
c. 36 years and above
2. How many pregnancies have you had before this one?
a. None
b. 1 pregnancy
c. 2-3 pregnancies
d. More than 3 pregnancies
3. What is your highest educational attainment?
a. No formal education
b. Primary school [FSLC]
c. Secondary school [WAEC]
d. Tertiary institution [OND, NCE, HND, BSc, MA/M.Sc/M.Ed, Ph.D
4. What is your husband’s highest educational attainment?
a. No formal education
b. Primary school [FSLC]
c. Secondary school [WAEC]
d. Tertiary institution [OND, NCE, HND, BSc, MA/M.Sc/M.Ed, Ph.D]

5. What is your occupation?

a. Artisan
b. Civil servant
c. housewife
d. Petty trader
6. What is your husband’s occupation?
a. Artisan
b. Business
c. Civil servant
d. Health Practioner
 SECTION B

Instructions: (A) Below are attitudinal statements. 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, D =DISAGREE AND SD=

STRONGLY DISAGREE.

ATTITUDE OF WOMEN TOWARDS ACCEPTING SA A D SD

CESAREAN DELIVERY
7. Caesarean delivery is acceptable to me provided that
the decision concerning mode of delivery is taken
without considering the views and advice of
significant others (parents, husbands, religious
leaders, in-laws and friends).
8. Caesarean delivery is a necessary option to save the
lives of the mother and baby when pregnancy poses
a great threat to their lives and should be accepted
whenever it is indicated.
9. Caesarean delivery is unacceptable to me because it
is expensive
10. Caesarean delivery should not be accepted by
anyone because God’s promise to His children is
safe natural/vaginal delivery.
11. Caesarean delivery is acceptable to me because it
makes me not to experience the pains of natural
child birth.
ATTITUDE OF THE WOMEN TO THOSE WHO UNDERGO SA A D SD
CESAREAN DELIEVRY
12. Those who undergo cesarean delivery are lazy
women who are not capable of bringing their babies
on their own.
13. All pregnant women are at risk of pregnancy
complications which can be resolved by cesarean
delivery.
14. Women who deliver by cesarean are those who are
attacked by evil spirit.
 15. Those who undergo cesarean delivery are not
necessarily as a result of any personal wrong doing.

16. I believe that those who undergo cesarean delivery

are usually unfaithful (adulterous) women

ATTITUDE OF WOMEN TOWARDS HEALTH WORKERS SA A D SD

WHO PERFORM CESRAEN DLIVERY

17. Most of the doctors who perform cesarean delivery

are not competent enough to carry out the procedure.

18. Doctors recommend planned or elective cesarean

delivery because waiting for normal delivery may
result in more serious complications.
19. Doctors recommend cesarean delivery because of
monetary gains from performing the operation.
20. Doctors who perform cesarean operation should be
appreciated for saving lives

21. Doctors recommend cesarean delivery because it is

more convenient for them to perform surgery than to
respond to a lengthy vaginal delivery.