Project – Factors Influencing Cesarean section Among Pregnant Women: A Study of Selected Primary Healthcare Centres in Ibadan, Oyo State.

CHAPTER ONE

GENERAL INTRODUCTION

1.1 Background to the Study

Caesarean section (CS) is a surgical procedure through which a baby is delivered by making incisions in the mother’s abdomen and uterus. It is an important component of modern obstetric care and is performed when vaginal delivery is considered unsafe or when a medical condition requires surgical delivery to protect the health or life of the mother, the baby, or both. Caesarean section may be planned before labour or performed as an emergency when complications develop during pregnancy or childbirth. According to the World Health Organization (WHO, 2015), caesarean section can prevent maternal and newborn deaths when medically indicated, but increasing the rate of the procedure does not necessarily improve outcomes for the entire population. The procedure must therefore be guided by the individual clinical circumstances of each pregnant woman rather than by a predetermined target. This distinction is important because caesarean section is neither inherently undesirable nor automatically preferable to vaginal delivery. Its appropriateness depends on a careful assessment of maternal health, fetal condition, obstetric history, pregnancy complications, and the availability of safe surgical and postoperative care. Understanding the factors influencing caesarean section is consequently essential to improving maternal healthcare and ensuring that women receive the most appropriate mode of delivery.

Caesarean section has become increasingly common across many countries, although substantial differences exist between and within regions. The increase reflects a combination of medical, demographic, socioeconomic, organisational, and cultural influences. Some caesarean deliveries are necessary because of complications such as obstructed labour, fetal compromise, placenta praevia, and certain abnormal fetal presentations. Other decisions may be influenced by previous caesarean delivery, maternal age, pregnancy-related conditions, preferences concerning childbirth, and the clinical judgement of healthcare professionals. Betrán et al. (2016), in their global analysis of caesarean section trends, documented substantial increases in caesarean delivery rates across countries and highlighted the need to understand the reasons for variation in its use. Similarly, the WHO (2018) emphasised that caesarean section rates are shaped by complex interactions among women, healthcare providers, health facilities, health systems, and social and cultural circumstances. These findings indicate that the factors influencing caesarean section cannot be adequately explained by medical conditions alone. Investigating the procedure requires consideration of both clinical indications and the circumstances in which women seek and receive maternity care.

Medical and obstetric conditions constitute major determinants of the decision to perform a caesarean section. These conditions may include obstructed labour, fetal distress, placenta praevia, breech presentation, multiple pregnancy in selected circumstances, hypertensive disorders of pregnancy, and certain maternal or fetal complications that make vaginal delivery unsafe. A previous caesarean section may also influence the mode of delivery in a subsequent pregnancy, although the appropriate option depends on the previous uterine incision, the reason for the earlier operation, the woman’s preferences, and the facility’s capacity to manage labour safely. Sandall et al. (2018), in a review of the consequences of caesarean section for women and children, explained that the procedure can be lifesaving when necessary but may also carry short- and long-term risks. These considerations make accurate diagnosis, appropriate clinical assessment, and evidence-based decision-making essential. Primary healthcare centres may provide antenatal assessment and identify complications that require referral to hospitals with comprehensive emergency obstetric and surgical services. Examining the medical and obstetric factors associated with caesarean section among women attending selected primary healthcare centres in Ibadan can therefore help clarify how pregnancy characteristics and referral processes relate to the eventual mode of delivery.

Socioeconomic and demographic characteristics may influence women’s exposure to pregnancy-related risks, their access to antenatal care, and their ability to obtain appropriate obstetric services. Maternal age, educational attainment, household income, employment, marital circumstances, place of residence, and health insurance coverage may affect how women seek, understand, and use maternity services. For example, education may influence a woman’s ability to understand health information and participate in discussions about delivery options, while financial resources may affect access to transport, diagnostic investigations, specialist consultations, and emergency care. However, the relationship between these characteristics and caesarean section is not uniform across populations. Boatin et al. (2018), in a systematic review of the use of the Robson classification system in low- and middle-income countries, demonstrated the importance of systematically examining obstetric populations and their characteristics when interpreting caesarean section rates. The WHO (2018) also recognises that social and economic circumstances may interact with health-system arrangements and clinical practices to influence the use of caesarean section. In Ibadan, examining the socioeconomic and demographic profiles of women who undergo caesarean delivery may help identify patterns that are relevant to maternal health planning, health education, and equitable access to appropriate obstetric care.

Women’s beliefs, previous childbirth experiences, perceptions of pain, and concerns about maternal or infant safety may influence their preferences concerning the mode of delivery. Some pregnant women may fear labour pain, complications during vaginal delivery, or the possibility of emergency intervention, while others may prefer vaginal delivery because of concerns about surgery, recovery, or future pregnancies. Family members, community expectations, religious or cultural interpretations, and information obtained from friends or social media may also shape attitudes towards childbirth. However, a woman’s preference does not necessarily determine whether a caesarean section is performed, because the final decision should involve appropriate clinical assessment and informed discussion between the woman and her healthcare team. The WHO (2018) recommends context-sensitive educational interventions and support for women, particularly where fear of childbirth or anxiety may contribute to requests for caesarean delivery without a clear medical indication. The organisation also emphasises the importance of respectful communication and meaningful participation in decisions about childbirth. These considerations suggest that understanding maternal knowledge, attitudes, fears, and preferences may provide valuable insight into the factors associated with caesarean section among pregnant women in Ibadan.

Health-system characteristics can influence the identification of pregnancy complications, the timing of referral, the availability of obstetric services, and the decisions that ultimately determine the mode of delivery. Relevant factors include the availability of trained healthcare personnel, antenatal monitoring, referral protocols, access to emergency transport, the capacity of receiving hospitals, clinical guidelines, and communication between primary and secondary healthcare facilities. The WHO (2018) identifies organisational practices and differences in healthcare-provider behaviour as important considerations in understanding variation in caesarean section rates. Furthermore, the WHO (2017) recommends the Robson classification as a standard approach to categorising women into obstetric groups for monitoring and comparing caesarean section rates. Such approaches can help health facilities understand which groups contribute most to their caesarean deliveries and support appropriate clinical audit. Primary healthcare centres are particularly important because they often provide initial antenatal services, health education, risk assessment, and referral for women who need higher-level care. Although most primary healthcare centres do not perform caesarean operations themselves, the information gathered from women attending them can help identify factors associated with referral and subsequent delivery outcomes. It is therefore important to examine how service availability, referral practices, and maternal healthcare experiences relate to caesarean section among women receiving care through selected centres in Ibadan.

In Nigeria, maternal healthcare is provided through a combination of primary healthcare centres, general hospitals, specialist facilities, and private healthcare institutions. Primary healthcare centres are important for antenatal registration, routine maternal monitoring, health education, identification of pregnancy risks, and referral to facilities with appropriate obstetric capabilities. Nevertheless, women may experience differences in access to antenatal services, emergency transportation, specialist assessment, and affordable maternity care. These differences may affect when obstetric complications are recognised and how delivery decisions are made. The National Population Commission (NPC) and ICF (2019), in the Nigeria Demographic and Health Survey 2018, provide nationally representative information on maternal healthcare utilisation and delivery-related indicators, offering an important basis for understanding reproductive health patterns in Nigeria. However, national estimates cannot automatically explain the factors influencing caesarean section among women attending particular healthcare facilities in Ibadan. Local patterns may differ according to the characteristics of the women served, the referral networks available, the clinical conditions encountered, and the organisation of maternity services. Consequently, this study seeks to examine the factors influencing caesarean section among pregnant women receiving care through selected primary healthcare centres in Ibadan, Oyo State. By considering medical and obstetric history, socioeconomic characteristics, maternal knowledge and preferences, and health-system factors, the study aims to generate local evidence that may assist healthcare professionals and maternal health planners in improving antenatal counselling, referral arrangements, and access to appropriate delivery care.

1.2 Statement of the Problem

Caesarean section is an essential obstetric intervention when medical conditions make vaginal delivery unsafe, but its use requires careful assessment because unnecessary surgery may expose women and their babies to avoidable risks. Although the procedure can prevent maternal and newborn deaths when appropriately indicated, it may also be associated with surgical complications, infection, longer recovery, and implications for subsequent pregnancies. Sandall et al. (2018) reviewed the short- and long-term consequences of caesarean delivery and highlighted the importance of considering both its benefits and potential adverse outcomes. The WHO (2015) similarly emphasised that caesarean section should be provided to women who need it rather than used to achieve a predetermined population-level rate. The public health problem is therefore two-sided: some women may undergo caesarean delivery when it is not medically necessary, while others who require the procedure may face delays or inadequate access to safe surgical care. In Nigeria, understanding the circumstances surrounding caesarean delivery is important for improving maternal and newborn outcomes. However, the extent to which particular clinical, socioeconomic, cultural, and health-system factors influence caesarean section among women attending selected primary healthcare centres in Ibadan requires specific investigation.

The decision to perform a caesarean section may be influenced by medical conditions, previous obstetric experiences, maternal age, pregnancy complications, and the availability of appropriate clinical services. Socioeconomic characteristics such as educational attainment, household income, employment, and access to health insurance may also affect antenatal attendance, the timing of referral, and the ability to obtain specialist care. However, the contribution of these factors may differ across populations and healthcare settings. Boatin et al. (2018) demonstrated the importance of classifying and analysing obstetric populations systematically when investigating caesarean section use in low- and middle-income countries. Without such context-specific assessment, it may be difficult to determine whether observed caesarean deliveries primarily reflect clinical need, differences in the characteristics of women receiving care, or variations in access to maternity services. For selected primary healthcare centres in Ibadan, there is a need to investigate how medical and obstetric histories interact with socioeconomic circumstances to influence caesarean section. Addressing this problem may help distinguish factors

Another problem concerns the possible influence of maternal knowledge, fear of childbirth, family expectations, healthcare-provider communication, and the organisation of maternity services on caesarean section. Women may hold different beliefs about the safety of vaginal delivery and caesarean surgery, and some may experience anxiety because of previous delivery complications or fear of labour pain. At the same time, delays in identifying complications, limited access to skilled personnel, inadequate transport, and weaknesses in referral arrangements may affect whether women receive timely and appropriate obstetric care. The WHO (2018) recognises that non-clinical factors, including women’s beliefs, provider practices, and organisational arrangements, can influence caesarean section rates. It recommends approaches that support informed decision-making, evidence-based clinical guidelines, and appropriate monitoring of caesarean section practices. Nevertheless, the relevance and relative importance of these factors may vary across communities and facilities. It is therefore necessary to investigate the knowledge, attitudes, preferences, and healthcare experiences of women attending selected primary healthcare centres in Ibadan, alongside the service-related factors that may influence referral and delivery decisions.

Although international and national publications provide important information about caesarean section, general findings cannot automatically establish the factors influencing the procedure among women attending particular primary healthcare centres in Ibadan. The Nigeria Demographic and Health Survey 2018 provides national evidence on maternal healthcare utilisation, while the WHO’s recommendations address clinical monitoring, women’s preferences, and organisational factors associated with caesarean section (NPC & ICF, 2019; WHO, 2018). However, these sources do not replace a focused investigation of the women served by the selected centres in the study area. A facility-specific study is needed to examine the relative contribution of medical and obstetric history, socioeconomic characteristics, maternal knowledge and preferences, and health-system factors to caesarean section. Such evidence may help identify relevant gaps in health education, antenatal risk assessment, referral practices, and access to appropriate maternity services. The present study therefore seeks to investigate the factors influencing caesarean section among pregnant women associated with selected primary healthcare centres in Ibadan, Oyo State, with a view to providing findings that can support context-sensitive maternal healthcare planning and improve access to safe, evidence-based delivery care.

1.3 Objectives of the Study

The main objective of the study is to examine the factors influencing caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

The specific objectives are to:

1. Examine the influence of medical and obstetric factors on caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

2. Determine the influence of socioeconomic and demographic factors on caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

3. Assess the influence of maternal knowledge, attitudes, and preferences regarding childbirth on caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

4. Investigate the influence of healthcare-service factors, including antenatal care, referral practices, and access to obstetric services, on caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

1.4 Research Questions

The following research questions will guide the study:

1. What medical and obstetric factors influence caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State?

2. How do socioeconomic and demographic factors influence caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State?

3. To what extent do maternal knowledge, attitudes, and preferences regarding childbirth influence caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State?

4. How do healthcare-service factors, including antenatal care, referral practices, and access to obstetric services, influence caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State?

1.5 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no statistically significant relationship between the selected medical, socioeconomic, maternal-related, and healthcare-service factors and caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State.

1.6 Significance of the Study

The study is expected to be useful to pregnant women, healthcare professionals, primary healthcare administrators, policymakers, public health practitioners, and future researchers.

1.6.1 Pregnant Women

The study may help identify factors that influence delivery decisions and highlight the importance of informed discussions about the benefits, risks, and indications for caesarean section. Its findings may support improvements in antenatal health education, enabling women to better understand pregnancy-related complications and the importance of timely referral when specialist care is required.

1.6.2 Healthcare Professionals

Midwives, nurses, community health practitioners, and other maternal healthcare professionals may benefit from a better understanding of the medical, socioeconomic, cultural, and service-related factors associated with caesarean section. The findings may inform antenatal counselling, risk assessment, communication with pregnant women, and referral practices.

1.6.3 Primary Healthcare Centre Administrators

Administrators of the selected centres may use the findings to identify areas where antenatal services, record keeping, health education, and referral coordination require improvement. The study may also provide information to support collaboration between primary healthcare centres and hospitals with comprehensive emergency obstetric services.

1.6.4 Oyo State Health Authorities and Policymakers

The study may provide local evidence to inform maternal healthcare planning and the allocation of resources for antenatal care, emergency referral systems, and health education. It may also support the development of context-appropriate policies that improve access to necessary caesarean delivery while promoting evidence-based clinical decision-making.

1.6.5 Public Health Practitioners

Public health practitioners may use the findings to design health education interventions addressing maternal knowledge, perceptions of childbirth, and awareness of obstetric complications. The study may also help identify socioeconomic barriers that require targeted community-based interventions.

1.6.6 Future Researchers

The study may contribute to the literature on maternal healthcare utilisation and determinants of caesarean section in Nigeria. It may serve as a basis for further research comparing facilities, examining regional differences, or investigating the effectiveness of antenatal education and referral interventions.

1.7 Scope of the Study

The study focuses on factors influencing caesarean section among pregnant women attending selected primary healthcare centres in Ibadan, Oyo State, Nigeria.

Geographical scope: The research will be conducted in selected primary healthcare centres located within Ibadan. The specific centres and their locations will be determined during the sampling process.

Content scope: The independent variables include medical and obstetric factors, socioeconomic and demographic characteristics, maternal knowledge and preferences, and healthcare-service factors. The outcome variable is caesarean section, including whether a woman has undergone the procedure or has a documented history of caesarean delivery, depending on the final study design and eligibility criteria.

Population scope: The study population will comprise eligible pregnant women attending antenatal services at the selected primary healthcare centres. Depending on the chosen design, women who have recently delivered may also be included to provide information on their actual mode of delivery.

Methodological scope: The study may adopt a descriptive cross-sectional design using structured questionnaires and, where ethical approval and permission are obtained, relevant maternal health records. Descriptive statistics and appropriate inferential techniques, such as chi-square tests and logistic regression, may be used depending on the outcome variable and the data collected.

Important methodological consideration: Because many primary healthcare centres do not perform caesarean operations, the study should distinguish between women currently receiving antenatal care, women referred for specialist obstetric care, and women whose actual mode of delivery is known. This distinction will help ensure that the study measures caesarean section accurately rather than treating antenatal attendance alone as evidence of the eventual delivery method.

1.8 Limitations of the Study

The study may encounter limitations related to access to maternal records, recall of previous pregnancy experiences, and the availability of information about deliveries that occurred at other facilities.

First, some women may not remember all details of previous pregnancies or complications, which could affect the accuracy of their responses. The researcher may reduce this limitation by using clear questions and checking available records where permission is granted.

Second, some primary healthcare centres may not have complete records of women who were referred elsewhere for delivery. This may limit the ability to verify the final mode of delivery for every participant.

Third, the study may be affected by differences in the characteristics of women attending the selected centres, including age, parity, socioeconomic status, and previous obstetric history. The researcher should account for relevant differences during analysis where the sample size and data permit.

Finally, a cross-sectional study can identify associations between selected factors and caesarean section but may not establish definitive causal relationships. Findings should therefore be interpreted in line with the study design, sampling procedure, and quality of the available data.

1.9 Operational Definition of Terms

Caesarean Section: A surgical procedure involving incisions in the mother’s abdomen and uterus to deliver a baby.

Factors Influencing Caesarean Section: The medical, obstetric, socioeconomic, demographic, maternal-related, and healthcare-service characteristics that may be associated with whether a woman undergoes caesarean delivery.

Pregnant Women: Women who are currently pregnant and eligible to participate in the study according to its inclusion criteria. If women who have recently delivered are included, they will be defined separately in the methodology.

Primary Healthcare Centres: Facilities providing first-contact healthcare services, including routine antenatal care, maternal health education, basic pregnancy monitoring, and referral for higher-level obstetric care when necessary.

Medical and Obstetric Factors: Clinical characteristics such as maternal health conditions, previous caesarean delivery, parity, pregnancy complications, and fetal presentation that may influence delivery decisions.

Socioeconomic and Demographic Factors: Characteristics such as age, educational attainment, income, employment, marital status, and other relevant social or economic circumstances.

Maternal Knowledge and Preferences: A woman’s understanding, beliefs, attitudes, fears, and preferences concerning caesarean section and vaginal delivery.

Healthcare-Service Factors: Characteristics of the healthcare system, including antenatal attendance, availability of skilled personnel, referral practices, transport arrangements, and access to facilities capable of performing caesarean delivery.

Mode of Delivery: The method through which a baby is delivered, principally vaginal delivery or caesarean section.

Ibadan, Oyo State: The geographical setting in southwestern Nigeria in which the selected primary healthcare centres for this study will be located.

Project – Factors Influencing Cesarean section Among Pregnant Women: A Study of Selected Primary Healthcare Centres in Ibadan, Oyo State.