CHAPTER 2:

LITERATURE REVIEW.

INTRODUCTION

The chapter elaborates the research which has already been done on pregnant women's attitudes
and understanding regarding caesarean sections. Various factors have been implicated to affect
the uptake of C- section not only in Nakuru county but also worldwide. Demographic and
obstetric characteristics being one of implications has shown significant effect on how pregnant
women uptake the C-sections. The summary of the chapter's main points from the literature
review in the section; knowledge, attitude and perception on cesarean section.
KNOWLEDGE ON CESAREAN SECTION.
Knowledge on cesarean section is the understanding, information and skills acquired through
experience, study, education or observation of a cesarean section procedure. Knowledge of
society surrounding CS may have a significant role in the decision-making process of pregnant
women accepting to undergo the procedure women who have undergone CS tend to have more
knowledge and confidence in their decision-making regarding the procedure for subsequent
deliveries. Women’s knowledge about CS is also strongly influenced by the information
provided by healthcare providers. Women who have received more detailed explanations about
CS and its risks and benefits tend to have a better understanding and knowledge of CS
(Elsherbiny,2019). Women’s knowledge about CS varies depending on their cultural
background, beliefs, personal experiences and availability of information
A study was carried out at the University of cape Coast Hospital a standardized questionnaire
was used to assess the knowledge, attitudes and views of 412 pregnant women about cesarean
sections. There were two categories for overall knowledge: inadequate (50%) and adequate
(50%). The 412 responders all knew what a caesarean section was. However, just 39.6% of the
respondents felt they had enough information. The majority of the women (94%) chose vaginal
birth as their preferred method of delivery over cesarean section. Despite the fact that 40%
thought a high number of women having CS may passaway,95.7%were willing to undergo CS.
Caesarean section is still being viewed as an abnormal means of delivery by some women in
developing countries (Qazi, Akhtar, Khan & Khan, 2013). Although know-edge of women
towards CS is changing, there is still wide knowledge gap between the developed count-tries and
the developing countries. Some sociocultural factors hinder the acceptance of CS. According to
African communities, it is traditionally believed that achieving adagial delivery portrays the
woman’s power and ability but a pregnant woman who delivers through is seen as being lazy.
Women refuse CS for fear of being abandoned by their husbands and in-laws and are accused of
taking the easy way out. This phenomenon leads to low acceptability of the procedure among
African women, even in the face of obvious clinical justification. Many women perceive the
process of not giving birth vaginally as a sign of ‘failure’. A lot of them perceive vaginal birth as
a right route of passage hence most of them crave for it (Robinson-Bassey & Uchegbu, 2017).
The knowledge of society surrounding CS may have a significant role in the decision-making
process of pregnant women accepting to undergo the procedure.
In Usmani danfodiyo Teaching Hospital, respondents of a study stated the reasons for not
accepting CS as; perception of denial of womanhood, pain, high cost and fear of death and pain.
In a study conducted in Jos, Nigeria, while some women feared CS because thought it could
harm the mother, others thought it could harm the baby and cause pain during and after the
procedure. The study conducted in Lagos showed that the majority of the respondents would not
undergo a CS even if medically indicated. Most of them believed CS to be very dangerous. 94%
of respondents of a study conducted in Cape Coast of Ghana among pregnant women preferred
vagina delivery over CS, stating that it was safer, natura and had less pain after delivery and
early discharge. Another study showed that among its respondents, women who had up to four
antenatal visits had higher odds of utilizing CS compared to those who did not attend antenatal
clinics due to the health education provided.
The lack of knowledge about CS by women in the developing countries has led to
underutilization of the procedure compared to the large burden of obstetric morbidity requiring
resolution by CS (Qazi et al., 2013).
ATTITUDE AND PERCEPTIONON ON CESAREAN SECTION.
Attitude towards cesarean section is a settled way of thinking or feeling towards cesarean section
reflected by an acceptance or a decline of undertaking the procedure. Perception on the other
hand is the process by which an individual interprets and make sense of cesarean section in order
to create a coherent understanding of the procedure. A reflection of the process of birth is always
important to all health care providers. When a woman understands the process of birth, then it
would automatically impose a positive attitude to maternal role. A study conducted by UK stated
that most women in developing countries see Caesarean Section as abnormal means of child
birth. In some part of Africa, the number of caesarean section cases are still low since most
people perceive this mode as an abnormal mode of delivery. Hence, evidence show that CS in
countries like Burkina Faso and Niger in sub- Sahara Africa is as low as 2%. In this countries
woman see CS as being a very weak woman and also unfaithful. The attitudes of women towards
caesarean section can vary based on their own personal experiences, cultural beliefs and
HealthCare provider recommendations. Some women may have a positive attitude towards
caesarean section because they believe it is safe method of childbirth, while others may have a
negative perception due to longer recovery time and potential complications. In some cultures,
Caesarean section may be stigmatized viewed as an inferior form of childbirth compared to
delivering vaginally. Some women may prefer caesarean section due to predetermined medical
conditions such as placenta Previa and previous caesarean section delivery. Other factors may
include fear of labor pain, convenience of the desire to schedule the birth of their baby. However,
other women may have a negative attitude towards caesarean section due to potential
complications such as infections, blood loss of wound dehiscence. Additionally, some women
may feel that caesarean section may take away the naturalness of childbirth, even if the
procedure is medically necessary. It is important for healthcare providers to understand the
individual attitudes of their patients towards caesarean section delivery and to provide the
necessary information to support them in making informed decisions. Informed decision making
must consider the medical risks, lifestyle choices and potential long- term outcomes for both
mother and child. Thus, it is important to provide information and support women to feel
informed and empowered in making decisions about childbirth (Naemi R, Hossieni F,
Khadivzadeh, Ľ, 2019). According to Adeoye et al., (2011) CS is seen in women who are
unfaithful. Women who delivered by Caesarean section are seen as weak as undergoing a
Caesarean section in traditional times displays failure (Mboho, Christine & Heather, 2011).
Maybe, it could this could be due to the fact that it is surrounded by fear, being suspicious,
misconceptions, guiltiness, anger and misery (Adeoye et al., 2011). Also, Ugwu et al., (2015) in
a study observed that women refuse Caesarean section because of restricted number of children,
being abandoned by loved ones and financial implications of the surgery.
2.5 ROSENSTOCK’S CONCEPTUAL FRAMEWORK (1950)
The main focus of this study’s framework is on evaluating pregnant women’s attitudes,
knowledge and perceptions of cesarean sections at Nakuru Referral and Teaching Hospital. To
explain preventive health action, many people use the health belief system of Rosen Stock.
This health belief model was developed in 1950s by a group of United States Public Health
Service Social Psychologists that wished to elaborate why a small number of people participated
in programs helpful in preventing disease. The model postulates behaviors to seek health, is
promoted by how the individual perceives the risk caused by the problem and the benefit of the
actions undertaken to curb the risk. The health belief model is focused on assessing health
behavior of persons by examining their perceptions and attitudes to the diseases and negative
outcomes to some actions.
ADAPTATION OF HEALTH BELIEF MODEL TO CAESAREAN SECTION SOURCE:
ROSENSTOCK (1950)

Obstetric characteristics.
 Age; women of
reproductive age
 Educational level
 Marital status: single or
married
 Race
 parity

UPTAKE OF
CESAREAN
LEVEL OF KNOWLEDGE SECTION
 Health care workers
 Myths and misconception

ATTITUDE AND PERCEPTION

 Perceived barriers e.g.,
expensive, painful.
 Social support.
 Culture
 Perceived severity e.g.,
effect on work and social
life.