Knowledge, attitude and perception of cesarean section among pregnant women attending antenatal clinic at Babcock University Teaching Hospital, Ilishan-Remo, Ogun State

Abstract Background: While the rate of Cesarean Section (CS) has been increasing in developed countries, the same cannot be said about developing countries, especially Nigeria. Despite the various indications of CS that may arise, the CS rate in Nigeria has remained as low as 2.7% as against the 15% acceptable upper limit according to the World Health Organization. The level of knowledge, perception, and attitude toward CS among pregnant women have been found to significantly influence the women’s decision to utilize this life-saving means. Hence, the researchers conducted this study among pregnant women attending the antenatal clinic at Babcock University Teaching Hospital (BUTH), Ogun State, to assess their level of knowledge, perception and attitude toward CS. Methodology: A descriptive cross-sectional design was utilized. A questionnaire designed by the researchers was used to collect data from 200 respondents, and the data were analyzed with Statistical Package for the Social Sciences version 25. Results were reported with frequencies, mean scores and percentages. Results: Findings of the study showed that 78.5% had a high level of knowledge of CS, 67.5% had a good perception of CS, and 93% had a positive attitude toward CS. Around average (52.5%) considered CS a safe procedure, and 78.5% would agree to have CS if medically indicated. The majority (76.5%) believed that opting for a CS could save the life of the mother or the child. Discussion: In conclusion, the findings of this study show that although majority of the respondents had good knowledge and perception of CS, and were willing to accept CS when medically indicated, around one-third had poor perception of CS and around two-tenths would not agree to have it if medically indicated. Hence, nurses and other stakeholders are thus encouraged to always include CS lessons in antenatal teachings to ensure that every woman is knowledgeable enough to accept CS, especially when medically indicated.


Introduction
Cesarean Section (CS) is usually indicated, in situations where a vaginal delivery would put the baby or mother at risk [1], such as pelvic abnormalities, cardiac conditions, fetal distress, malpresentation of the fetus, infection, abnormal placentation or situations in which vaginal birth is generally contraindicated [2].Otherwise, the American College of Obstetricians and Gynecologists recommended that primary cesarean section should be safely prevented [3,4].WHO reported that Nigeria accounts for 34% of maternal deaths worldwide, and the risk of having maternal death in Nigeria is 1 in 22 as against 1 in 4900 in developed countries [5].Another study conducted in Ogun State, Nigeria, reported that the leading contributory factors of maternal deaths include inadequate human resources for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referral services [6].
The trend of acceptability and the rate of CS has been on the increase in developed countries in the past two decades.According to Martin et al. [7], in 2019, the CS rate in the United States was 31.9%.In most European countries, one-third of the women are delivered by CS [8].In Australia, there was a high cesarean rate of about 34% in 2016 [9].Report from The Lancet data from WHO and the United Nations Children's Fund shows that in 2013, CS in Venezuela was 52.4%; in 2014, it was 55.5% in Egypt, and as of 2015, it was 53.1% and 55.5% in Turkey and Brazil respectively [10].When the data were examined by region, the researchers found that CS birth rates in 2015 were: 4.1% in West and Central Africa, 6.2% in Eastern and Southern Africa, 29.6% in the Middle East and North Africa, 18.1% in South Asia, 28.8% in East Asia and the Pacific 44.3% in Latin America and the Caribbean, 27.3% in Eastern Europe and Central Asia, 32% in North America, 26.9% in Western Europe [10].
Meanwhile, in developing countries, the rate of CS has remained on the low side.In Ethiopia, for example, the CS rate, according to a systematic review, was 29.55% [11].In Nigeria, the rate was 1.8% in 2008 [12] and 2.7% in 2018 [12], whereas the upper limit of the eight critical thresholds of CS, according to WHO, is 15% [13].The WHO estimated that in 15.5% of pregnancies in Nigeria, a CS is medically necessary, based on rates of fistula incidence.However, CS is being underutilized in Nigeria [14].Lower rates were recorded in northern Nigeria, while higher rates were recorded in the south [15].In Enugu, there is an overall underutilization of cesarean section, especially in rural areas where only 5.55% of all births are delivered via cesarean section [14,16].
CS is perceived as an abnormal means of delivery by some women in developing countries.This negative view and perception of CS by women in developing countries has led to gross underutilization of the procedure compared to the large burden of obstetric morbidity requiring resolution by CS [17].In a study among Yoruba women of southwestern Nigeria, CS was viewed with suspicion, aversion, misconception, fear, guilt, misery and anger [18].Some other women perceived it as something for weak women, while others considered it a curse [18].In Usmanu 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 [15].In a study conducted in Jos, Nigeria, while some women feared CS because they thought it could harm the mother, others thought it could harm the baby and cause pain during and after the procedure [19].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 [20].94% of respondents of a study conducted in Cape Coast of Ghana among pregnant women preferred vaginal delivery over CS, stating that it was safer, natural and had less pain after delivery and early discharge [21].
Inadequate knowledge and poor perception of CS greatly impact the attitude and acceptance of CS among pregnant women [17].The respondents in a study conducted in Ghana had poor knowledge of CS and thus had poor acceptance of CS [22].In the study conducted at Usmanu Danfodiyo Teaching Hospital, 85.5% of the respondents had good knowledge, and 77.5% of them would agree to a CS if indicated [15].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 [23].Other factors affecting CS acceptance include residence in rural areas, lack of husband/partner's formal education, birth order, women's low level of education and past successful vaginal deliveries [23,24].A study by Maduka and Enaruna in 2022 reported that 46% of their respondents refused to have a repeat CS if medically indicated, stating postoperative pain and discomfort, being labeled a failure, and fear of death as their reasons [25].
A study conducted among women living in a Obogun village of Ogun state reported that 51.9% of the women earned less than the minimum wage of #30,000 monthly, 35.1% had tertiary education, and 41.6% were traders [26].Apart from this, there is minimal data and research on CS in Ogun state and across Nigeria.Also, the low rate of CS in the country prompted the researcher to conduct this study.Hence, the study aims to assess the knowledge, attitude, and perception of CS among the pregnant women attending the antenatal clinic at Babcock University Teaching Hospital, Ilishan-Remo, Ogun state.

Research design, sampling and participants
A descriptive cross-sectional design was adopted for the study.The sample size for this study was the 200 pregnant women attending the antenatal clinic in Babcock University Teaching Hospital, Ilishan Remo, Ogun state, at the time of data collection.Data on the number of clinic attendees was obtained from the clinical attendance register.All the 200 pregnant women attending the antenatal clinic at Babcock University Teaching Hospital at the time of data collection were selected for the study in accordance with the total sampling method [27,28].The total sampling method justifies the selection of all members of a population if the population is small (below 300) and well-defined [29].The respondents of this study fell into this category as there were just 200 of them attending the antenatal clinic at the facility during the data collection period and were all pregnant as required by the study.Furthermore, they were all willing to participate in the research.

Instrument for data collection
A questionnaire designed by the researcher was used as an instrument of data collection.It consisted of four sections: demographic variables, knowledge of cesarean section, perception of cesarean section and attitude toward cesarean section.The knowledge section contains nine questions with a 'Yes/No' response.A correct answer was scored 1 point, while an incorrect answer was scored 0. The highest obtainable score was 9, while the least obtainable score was 0. The total of each respondent's scores was converted to percentage.The knowledge score of participants below 50% was categorized as poor, the knowledge score of participants between 50%--70% was categorized as average, and the knowledge score above 70% was categorized as good [30].
The section on respondent's perception contained 13 questions, on a five-point Likert scale ranging from 1 to 5 per question.Total obtainable scores were 65 as the highest and 5 as the lowest.The total score of each respondent was converted into percentages.The perception score below 50% was considered poor, while the perception score above 50% was considered good [30].
The section on respondents' attitudes contained seven questions also on a five-point Likert scale with scores ranging from 1 to 5. Total obtainable scores were 35 as the highest and 5 as the lowest.The total score of each respondent was also converted into percentages.An attitude score below 50% was considered negative, while an attitude score above 50% was considered positive [30].

Validity and reliability of the instrument
Validity of the instrument was ascertained by two nursing professors, one midwife and a research analyst.They evaluated the questionnaire and deemed it valid for data collection.
The reliability of the instrument was tested using a total of 20 respondents attending antenatal clinic in Olabisi Onabanjo Teaching Hospital.The Cronbach's alpha reliability coefficient was calculated to be 0.755.Hence, the instrument was considered reliable.

Procedure for data collection
A letter of introduction was obtained from the School of Nursing, Babcock University, which was taken to the management of Babcock University Teaching Hospital, Ilishan Remo, Ogun State to obtain permission to conduct the study.The nurse in charge of the antenatal clinic was met and necessary information was obtained.
The respondents were given full information about the purpose and significance of the study.Informed consent was obtained before the questionnaires were administered.The respondents were made anonymous as no identification detail was requested or recorded.The researcher, however, stayed close to the respondents to ensure that the questionnaires were completed correctly.The questionnaires were then retrieved after completion.

Method of data analysis
The data was processed and analyzed using Statistical Package for the Social Sciences (SPSS) version 25.The data was presented in frequency tables.The three research questions were answered using descriptive statistics of mean, standard deviation and percentages.

Ethical consideration
Ethical clearance to conduct this study was first obtained from the Babcock University Health Research Ethics Committee (BUHREC) following which permission to collect data was obtained from the management of Babcock University Teaching Hospital.After that, permission was sought from each participant after they had been informed about the research and consents were obtained from them.They were allowed to voluntarily agree to participate and were assured that their refusal to participate would not affect them.Right to privacy, autonomy, benevolence, non-maleficence, and respect for each subject were maintained throughout the research study.

Socio-demographic data
The result from Table 1 reveals that 50% of the respondents were between the ages of 25-35 years, and the majority (70%) of them were Christians.Also, the analysis shows that 61% of the respondents were Yoruba, the majority (74%) were married, 44.5% were employers, and 68% of them had their previous deliveries through the vagina.More findings are presented in detail in Table 4.1.

Knowledge of pregnant women toward Cesarean section
Of the 200 respondents recruited for the study, about 89.5% of the respondents knew that a woman could have a vaginal delivery after CS.The majority (91.5%) thought it was normal for a woman to give birth through CS, and 73% of the respondents thought CS limits the number of children.Furthermore, about the majority (80%) of the respondents knew that a woman's health determines the mode of delivery, and 86% affirmed that CS is done when complications arise.53.5% did not think that mothers recover faster after CS, and only 27.5% think CS is safer for the baby (See Table 2).
Based on the predetermined scoring of the level of knowledge, 78.5% of the respondents were found to have a good level of knowledge, while 12% had an average level of knowledge.

Perception of pregnant women toward Cesarean section
Responses of the respondents in this section were categorized into Strongly Agree (SA), Agree (A), Undecided (U), Disagree (D) and Strongly Disagree (SD).The analysis shows that the majority (D − 32%, SD − 23.5%) of the respondents did not agree that women who deliver through CS would miss an important life experience.While 33.5% of the respondents were undecided about whether CS enhances a more affectionate mother-baby relationship, the majority (D − 22%, SD − 14.5%) disagreed.Also, 30% of the respondents strongly disagreed A larger number of the respondents (SD − 29.5%, D − 19%) disagreed that having a CS automatically means one must have CS for subsequent pregnancies.The majority (A − 42%, SA −34.5%) agreed that CS could prevent the mother and baby's death.Most respondents (D − 31.5%,SD − 16.5%) also disagreed that having a CS could make mothers less confident about their ability to give birth (See Table 3).
Based on the above responses, with a score of 50-100, 67.5% of the respondents were judged to have a good perception of CS.

Attitude of pregnant women toward Cesarean section
Responses of the respondents in this section were also categorized into Strongly Agree (SA), Agree (A), Undecided (U), Disagree (D) and Strongly Disagree (SD).About 74% (A − 40.5%, SA − 33.5%) of the respondents agreed that it is their right to choose a CS.The majority (D − 30%, SD − 34.5%) also disagreed that CS was an abnormal mode of delivery.
While 28.5% of the respondents strongly agreed that cesarean section was not an accepted mode of delivery in their culture or religion, about 34.5% strongly disagreed.About 78.5% (A − 42%, SA − 36.5%) agreed they would undergo a CS if indicated.The majority of the respondents (73.5%) disagreed that cesarean section could be embarrassing and 29.5% strongly agreed that they considered CS as a way of reducing maternal and infant mortality, and 51% of them agreed that CS was expensive (See Table 4).
Based on the above responses, with a score of 50-100, 93% of the respondents were judged to have a positive attitude toward CS.

Discussion
This study was conducted to assess the knowledge, attitude, and perception of CS among the 200 pregnant women attending the antenatal clinic at the time of data collection.
The findings of the study showed that the majority of the respondents had good knowledge of CS.This is in congruence with the findings of two previous studies by Panti et al. and Abazie & Abdul-Kareem [15,20], where more than half of the respondents also had good knowledge of CS.It is, however, different from the findings of the study conducted in Northern Ghana by Afaya et al. [22], where the majority of their  12) 11(5.5)Husbands should be the one to give consent for cesarean section 12(6) 61 (30.5) 20( 10) 59(29.5)48(24) Cesarean section could make mothers feel less-confident in their ability to give birth.28( 14) 37(18.5)39(19.5)63(31.5)33(16.5)Key: SA: strongly agree; A: Agreed; U: undecided; D: disagreed; SD: strongly disagree.[21] and in India by Sultana et al. [31] where 60.4% and 55.4% of the respondents had inadequate knowledge respectively.The differences could be due to the higher level of education of respondents as the majority of respondents in this study had up to the tertiary level of education, while the majority of the respondents of the studies conducted in Ghana [21,22] had low or no formal education.Abazie and Abdul-Kareem [20] also showed in their study that the level of education was significantly associated with knowledge of CS.
The majority of the respondents of this study also displayed a good perception of CS, similar to the study conducted by Panti et al. [15], where 96.5% of the respondents recorded a good perception.However, respondents in the studies conducted in Lagos state of Nigeria and Cape Coast of Ghana, among pregnant women [20,21], were found to have a poor perception of CS.Respondents of this study believed CS to be a safe procedure.Respondents in Jos, Nigeria [19] also thought CS was a safe procedure, while 40% of those in Ghana [21] thought it was a dangerous procedure and that women would die after the procedure.Furthermore, similar to the perception of respondents in Northern Ghana [22], the majority of the respondents in this study also perceived that a vaginal birth could still be achieved after a previous CS.
This study also shows that majority of our respondents had good attitudes toward CS.Majority were willing to undergo CS if medically indicated and did not think it embarrassing.In similar studies, while the respondents preferred to give birth per vagina, over 50% of them agreed to do a CS if medically indicated [19,21,22].In Sultana et al.'s, even though the respondents had inadequate knowledge about CS, about 70% were more willing to do a CS than to have a vaginal delivery [31].However, respondents in Lagos State [20] had poor attitudes toward CS, so much that 68.5% were unwilling to undergo CS even if medically indicated.Furthermore, the respondents of our study believed they had the right to request for CS, as did women in India [31], who believed that a woman had the right to choose her mode of delivery.
Furthermore, it is important to note that nurses and midwives can utilize the antenatal clinics to address gaps in knowledge, perception and willingness to undergo CS if needed.This is important as a previous study observed that pregnant women in Nigeria were satisfied with the antenatal care received from nurses [32].Similarly, this can be an avenue to dispel myths regarding CS, as a previous study among pregnant women in Nigeria found that some African cultures forbid women from undergoing CS [33].Additionally, it is crucial to note that first-time mothers can face psychological issues during their treatment [34], which can influence their willingness to undergo CS and their experience after the procedure.Thus, the antenatal clinic can also be an avenue to address these issues.Also, as mobile phones have been reported to be helpful in supporting pregnant women psychologically [32], and as psychological benefits have been reported among women through mHealth alongside high mobile phone usage among Nigerian women [35,36], mHealth can also be considered as a tool for addressing gaps in knowledge, attitude and willingness to undergo CS.
In conclusion, the findings of this study show that majority of the respondents had good knowledge of CS, had good perceptions and were willing to accept CS when medically indicated.However, around onethird had poor perception of CS and around twotenths would not agree to have it if medically indicated.Hence, nurses should always include lessons on CS in antenatal teachings to ensure that every woman is knowledgeable enough to accept CS, especially when medically indicated.

Strengths and limitations of the study
As little was known about the CS acceptance rate in Ogun State, the study has added to the limited body of evidence on the knowledge, attitude and perception of pregnant women in Ogun State about CS.However, the study has some limitations.As the study was conducted in just one center, it is difficult to generalize to Nigeria's entire southwest or other geopolitical zones.Similarly, the data collection was based on self-report; social desirability bias might play out, wherein participants respond in a manner favourably perceived by others.These limitations should be taken into consideration when interpreting the findings.

Recommendation for further studies
We recommend that further studies collect data on the number of respondents who had a previous vaginal birth and previous CS to explore the relationship between these variables and the level of knowledge, perception and attitude of the respondents.Also, we recommend conducting further research to explore other determinants of CS acceptance, such as financial capacity, availability and accessibility, and misconceptions about the procedure.

Table 1 .
Socio-demographic characteristics of the respondents.

Table 2 .
Knowledge of pregnant women toward Cesarean section.32%, SA − 20.5%) agreed that CS was a safe procedure.(D-35.5%,SD − 37.5%) disagreed that CS would reduce a woman's dignity.37.5% could not decide whether CS would prevent mother and child bonding.38% preferred CS over the pain of vaginal delivery.

Table 3 .
Perception of pregnant women toward Cesarean section.

Table 4 .
Attitude of pregnant women toward Cesarean section.JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE respondents (48%) had only fair knowledge and of the studies conducted among pregnant women in Cape Coast of Ghana by Prah et al.
Key: Strongly Agree SA; A: Agreed; U: undecided; disagreed D; and SD: strongly disagree.THE