European Journal of Cardiovascular Medicine

Caesarean section (CS) is a commonly performed surgical procedure worldwide, used in the delivery of infants through an incision in the abdominal and uterine walls [1]. It is often considered a life-saving intervention in cases of complicated pregnancies, such as fetal distress, breech presentation, placenta previa, or maternal health issues like preeclampsia[2]. However, the overuse of caesarean sections has raised concerns about maternal and neonatal health, as well as the socio-economic implications for families.

The increasing global CS rates have prompted discussions about the factors influencing its widespread use. According to the National Family Health Survey (NFHS-5), more than one-fifth of deliveries in India are via caesarean section, with a notable rise in rates, particularly in urban and private healthcare settings. In Andhra Pradesh, where this study was conducted, the CS rate stands at 42.4%, significantly exceeding the World Health Organization's recommended rate of 15% (Shams-Ghahfarokhi & Khalajabadi-Farahani, 2016) [6].

Several factors contribute to the rising number of CS deliveries, including socio-economic status, education levels, maternal age, and healthcare practices. Cultural attitudes, fear of labor pain, financial incentives, and perceived safety concerns also play significant roles in shaping the decision-making process regarding delivery methods (Al-Rifai et al., 2020) [1]; (Suwanrath et al., 2021) [2]. Despite these influences, maternal knowledge, attitudes, and perceptions about CS remain underexplored, especially in rural and semi-urban settings. Studies from countries such as Iran have shown that women's preferences towards CS are often shaped by both personal and societal factors (Siabani et al., 2019) [3]; (Zamani-Alavijeh et al., 2018) [7]. Additionally, perceptions regarding labor pain management and the role of healthcare providers influence women's delivery choices (Ghamgosar et al., 2024) [4].

A systematic review and meta-analysis on the prevalence, causes, and complications of CS in Iran highlights the impact of healthcare practices on the increased rates of caesarean deliveries (Rafiei et al., 2018) [5]. Understanding these factors is essential for addressing the rising rates of CS and improving maternal and neonatal health outcomes globally.

This study aims to evaluate the knowledge, attitudes, and perceptions of pregnant women attending the antenatal clinic at KIMS Medical College, Amalapuram, regarding caesarean section. By assessing these factors, we aim to better understand the drivers of CS decisions and highlight the need for educational interventions to improve informed decision-making and reduce unnecessary caesarean sections.

Study Design

This study was a hospital-based, cross-sectional design conducted at the antenatal clinic of KIMS Medical College, Amalapuram. The purpose was to assess the knowledge, attitude, and perception of pregnant women towards caesarean section (CS).

Study Participants

The study involved 110 pregnant women attending the antenatal clinic during the study period (July 2024 to September 2024). Inclusion criteria were pregnant women aged 15 years and above, who were mentally competent and available during data collection. Women in labor or those unconscious or mentally incapacitated were excluded from the study.

Sampling Technique

A convenience sampling method was used to select participants. This approach allowed for the inclusion of women who were available and willing to participate during the study period.

Data Collection Procedure

Data was collected through a structured questionnaire administered to participants in the Telugu language. The questionnaire was divided into three sections:

Socio-demographic Information: Age, marital status, education level, employment status, and place of residency.

Obstetric History: Age at first marriage, gravida, parity, abortion history, and method of first delivery.

Knowledge, Attitude, and Perception Towards CS: Questions related to participants' knowledge of CS, attitudes towards its use, and their perceptions of CS outcomes (e.g., cost, recovery, post-operative issues).

Ethical Considerations

The study was approved by the Institutional Ethics Committee of KIMS Medical College, Amalapuram. Informed consent was obtained from all participants before data collection, ensuring confidentiality and voluntary participation.

Data Analysis

The collected data was entered into Microsoft Excel 2016 for initial processing. IBM SPSS Software was used for statistical analysis. Descriptive statistics (frequencies, percentages) were computed to summarize the socio-demographic characteristics, knowledge, attitude, and perception of the participants. Data were presented in tables and figures to illustrate key findings.

Socio-Demographic Characteristics

A total of 110 pregnant women participated in this study. The majority (55%) of the participants were aged between 22-29 years, followed by 21.5% aged 15-21 years, and 14.3% aged above 29 years. The marital status of the participants showed that 98% were married, while 2% were divorced (Table 1).

Table 1: Socio-Demographic Characteristics of Participants

Regarding education, 57.8% of the participants had completed secondary education, while 23.4% had only attended primary school, and 13.6% were graduates. In terms of employment, 71% of participants were employed, whereas 29% were unemployed. The study further found that 75% of the participants resided in rural areas, with 58% living in nuclear families (2-4 members), and 39% in larger families of 5-7 members (Table 1).

Obstetric History

The majority of participants (57%) had married between the ages of 19-23 years, while 15% had married between 14-18 years, and 28% had married after 23 years. 45% of the participants were in their second or third pregnancy (gravida 2-3), while 34% had been pregnant four or more times. In terms of parity, 46% of women had at least one prior delivery, while 24% had no previous deliveries (Table 2).

Table 2: Obstetric History of Participants

A significant proportion (72%) of the participants had never had an abortion, whereas 18% had experienced one abortion, and 10% had two or more abortions. With regard to their first delivery, 77% of participants had a vaginal delivery, while 23% had undergone a caesarean section (Table 2).

Knowledge of Caesarean Section

All participants (100%) had heard of caesarean section, but only 23% had undergone the procedure. Among those who had undergone caesarean section, 56% had undergone one CS, while 44% had undergone two or more. The majority (92%) had undergone CS for medical reasons, while 8% had undergone it for non-medical reasons (Table 3).

Table 3: Knowledge of Participants on Caesarean Section

In assessing their knowledge:

63% of participants believed that maternal health determines the mode of delivery, while 37% disagreed. 69% believed that mothers recover after a caesarean section, while 31% believed otherwise. 33% stated that normal delivery is possible after a previous caesarean section, whereas 67% believed it was not. 87% of participants believed that CS saves the life of the baby, and 84% believed that it saves the life of the mother (Table 3).

Figure No:1.  Knowledge of Participants on Caesarean Section

Overall, 62% of the participants demonstrated good knowledge about caesarean section, while 38% had poor knowledge.

Attitudes Towards Caesarean Section

In terms of attitude, 80% of participants stated that they were willing to undergo a caesarean section if medically indicated, while 14% were unwilling, and 6% remained undecided. The majority (87%) believed that caesarean section should be performed when normal delivery is not possible, whereas 10% disagreed, and 3% were undecided.

Interestingly, 67% of the participants disagreed with the notion that caesarean section should be a woman's choice without medical indications, while 28% supported the idea. Additionally, 72% of the participants rejected the notion that CS should be preferred due to labor pain, whereas 22% believed that avoiding pain is a valid reason for CS (Table 4).

Table 4: Attitude of Pregnant Women Towards Caesarean Section

Regarding the postnatal impact, 54% of participants believed that pain after CS makes nursing difficult, while 40% disagreed, and 16% were undecided. Additionally, 79% agreed that CS increases hospital stay, whereas 18% disagreed, and 3% were undecided (Table 4).

Figure No:2. Attitude of Pregnant Women Towards Caesarean Section

Overall, 59% of the participants held a positive attitude towards CS, while 41% had a negative attitude.

Perceptions of Caesarean Section

Regarding perception, 78% of the participants believed that CS is more expensive than normal delivery, while 16% disagreed, and 6% were undecided. 71% of participants believed that CS causes long-term back pain, whereas 22% disagreed, and 7% were undecided (Table 5).

Table 5: Perception of Pregnant Women Towards Caesarean Section

100% of participants acknowledged that CS leaves a permanent scar, and 65% disagreed with the notion that CS decreases a woman’s dignity, while 11% believed that it does. 26% of the participants agreed that CS increases the risk of infection, while 60% disagreed, and 14% were undecided. Additionally, 66% of participants were undecided about whether prenatal exercises reduce the need for CS, while 18% agreed, and 15% disagreed (Table 5).

Figure No:3. Perception of Pregnant Women Towards Caesarean Section

Overall, 61% of the participants had a positive perception of CS, while 39% had a negative perception.

The findings of this study provide valuable insight into the knowledge, attitudes, and perceptions of pregnant women regarding caesarean section (CS) at KIMS Medical College, Amalapuram. Overall, the results indicate that while a majority of participants possess good knowledge and demonstrate positive attitudes towards CS, there remain several areas where misconceptions or lack of awareness persist.

Knowledge of Caesarean Section

A significant 62% of participants exhibited good knowledge about CS, which is relatively high compared to previous studies in similar settings. The majority of women recognized the life-saving potential of CS for both mother and child, with 87% acknowledging its role in saving the life of the baby and 84% for the mother. This finding aligns with studies in other settings, where awareness of the medical benefits of CS is high among pregnant women, particularly regarding the safety it offers in complicated deliveries (Zamani-Alavijeh et al., 2018) [7]. However, the study also highlighted areas of uncertainty, especially regarding the possibility of normal delivery after a CS. While 33% of participants believed that vaginal delivery was possible after a CS, a significant portion (67%) did not. This misconception could be attributed to a lack of education or fear surrounding vaginal birth after caesarean (VBAC), a topic that is often not sufficiently addressed during prenatal care (Gandau et al., 2019) [8]. This finding underscores the need for more comprehensive counseling regarding VBAC and the risks associated with multiple CS deliveries.

Attitudes Towards Caesarean Section

The study found that 59% of participants held a positive attitude towards CS. This is in line with other research, which suggests that many women prefer CS when it is medically necessary, particularly in the context of avoiding labor pain and complications during vaginal delivery. The 80% who expressed a willingness to undergo CS if medically indicated further demonstrates the acceptance of CS as a necessary intervention for maternal and fetal health. Interestingly, 67% of participants disagreed with the idea that women should have the autonomy to choose CS without medical necessity, indicating a more conservative view about the procedure. This reflects a broader cultural context where CS is still perceived as a major surgical intervention, and its elective use is often discouraged (Ashimi et al., 2013) [9]. These findings highlight the importance of ensuring that pregnant women are not only aware of the advantages of CS but also educated on its potential risks and when it is truly necessary.

Perceptions of Caesarean Section

The participants' perceptions towards CS were generally positive, with 61% having a favorable view. However, concerns about the physical consequences of CS, such as 71% of participants believing that it causes long-term back pain, indicate that more information is needed on the long-term recovery and health outcomes associated with CS. Similar perceptions have been documented in other studies, where women often report concerns about post-surgical pain and the recovery process after CS (Maitanmi et al., 2023) [10]. Another critical finding was the perception of the high cost of CS, with 78% of participants believing it is more expensive than normal delivery. This aligns with studies that suggest financial constraints, particularly in low and middle-income countries, can be a significant deterrent for women when choosing the mode of delivery (Aziken et al., 2007) [11]. Addressing these financial concerns through policy reforms, better insurance coverage, and financial counseling could help reduce barriers to accessing necessary healthcare services.

while there is general awareness and positive attitudes towards CS, areas such as VBAC knowledge, long-term consequences of CS, and the financial burden need to be addressed to improve maternal healthcare. Educational initiatives targeting these concerns could contribute to a more informed and empowered approach to delivery choices among pregnant women. These findings are consistent with those of other researchers in similar settings (Begum et al., 2018) [12], (Keshk et al., 2024) [13], and (Yaqoub et al., 2022) [14].

Limitations and Future Directions

Although this study provides valuable insights into the knowledge, attitude, and perception of pregnant women towards CS, there are limitations to consider. The use of convenience sampling limits the generalizability of the results, and the study was conducted in a single setting, which may not fully represent the broader population of pregnant women across different regions. Future research could explore larger, more diverse samples, including women from urban and rural settings, to provide a more comprehensive understanding of the factors influencing CS decisions.

Additionally, further studies should investigate the role of healthcare professionals in shaping women's decisions regarding CS. In some cases, the decision to undergo CS is influenced by medical staff recommendations, which can either reinforce or challenge women’s existing knowledge and perceptions. Therefore, the involvement of healthcare providers in patient education and decision-making processes is crucial in ensuring informed and evidence-based choices.

This study demonstrates that pregnant women generally possess good knowledge and positive attitudes toward caesarean section (CS). However, there are misconceptions, particularly regarding the possibility of vaginal delivery after CS and the long-term effects of the procedure. The findings highlight the need for targeted educational interventions that address these misconceptions and promote informed decision-making. Providing comprehensive information about the benefits, risks, and alternatives to CS, while considering cultural and financial concerns, will empower women to make safer childbirth choices. Moreover, the involvement of healthcare professionals in counseling and educating pregnant women is crucial to ensure that decisions regarding delivery methods are based on accurate knowledge and medical necessity, ultimately reducing unnecessary CS rates.

1. Al-Rifai, R.H., et al. "Knowledge and Preference Towards Mode of Delivery among Pregnant Women in the United Arab Emirates: The Mutaba'ah Study." Int J Environ Res Public Health, vol. 18, no. 1, 2020, p. 36. doi:10.3390/ijerph18010036.
2. Suwanrath, C., et al. "Why Do Pregnant Women Prefer Cesarean Birth? A Qualitative Study in a Tertiary Care Center in Southern Thailand." BMC Pregnancy Childbirth, vol. 21, no. 1, 2021, p. 23. doi:10.1186/s12884-020-03525-3.
3. Siabani, S., et al. "Attitude of Pregnant Women Towards Normal Delivery and Factors Driving Use of Caesarian Section in Iran (2016)." Biopsychosoc Med, vol. 13, 2019, p. 8. doi:10.1186/s13030-019-0149-0.
4. Ghamgosar, F.D., et al. "Iranian Mothers' Perceptions of Contextual Factors Helping Them Manage Pain in Labor." BMC Pregnancy Childbirth, vol. 24, no. 1, 2024, p. 809. doi:10.1186/s12884-024-07012-x.
5. Rafiei, M., et al. "Prevalence, Causes, and Complications of Cesarean Delivery in Iran: A Systematic Review and Meta-analysis." Int J Reprod Biomed, vol. 16, no. 4, 2018, pp. 221-234.
6. Shams-Ghahfarokhi, Z., and F. Khalajabadi-Farahani. "Intention for Cesarean Section Versus Vaginal Delivery Among Pregnant Women in Isfahan: Correlates and Determinants." J Reprod Infertil, vol. 17, no. 4, 2016, pp. 230-239.
7. Zamani-Alavijeh, F., et al. "Contributing Factors of Pregnant Women's Beliefs Towards Mode of Delivery: A Cross-sectional Study from Iran." Matern Health Neonatol Perinatol, vol. 4, 2018, p. 9. doi:10.1186/s40748-018-0077-1.
8. Naa Gandau, B.B., et al. "Maternal Perceptions about Caesarean Section Deliveries and Their Role in Reducing Perinatal and Neonatal Mortality in the Upper West Region of Ghana; A Cross-sectional Study." BMC Pregnancy Childbirth, vol. 19, no. 1, 2019, p. 350. doi:10.1186/s12884-019-2536-8.
9. Ashimi, A., et al. "Knowledge and Attitude of Pregnant Women to Caesarean Section in a Semi-Urban Community in Northwest Nigeria." J West Afr Coll Surg, vol. 3, no. 2, 2013, pp. 46-61.
10. Maitanmi, B.T., et al. "Knowledge, Attitude and Perception of Cesarean Section Among Pregnant Women Attending Antenatal Clinic at Babcock University Teaching Hospital, Ilishan-Remo, Ogun State." J Matern Fetal Neonatal Med, vol. 36, no. 2, 2023, p. 2278019. doi:10.1080/14767058.2023.2278019.
11. Aziken, M., L. Omo-Aghoja, and F. Okonofua. "Perceptions and Attitudes of Pregnant Women Towards Caesarean Section in Urban Nigeria." Acta Obstet Gynecol Scand, vol. 86, no. 1, 2007, pp. 42-47. doi:10.1080/00016340600994950.
12. Begum, T., et al. "A Qualitative Study to Explore the Attitudes of Women and Obstetricians Towards Caesarean Delivery in Rural Bangladesh." BMC Pregnancy Childbirth, vol. 18, no. 1, 2018, p. 368. doi:10.1186/s12884-018-1993-9.
13. Keshk, E.A., et al. "Knowledge and Attitude Toward Modes of Delivery and Possible Complications Among Women in Al-Baha Region, Saudi Arabia." Cureus, vol. 16, no. 5, 2024, e59988. doi:10.7759/cureus.59988.
14. Yaqoub, R.M., et al. "Awareness and Knowledge of Caesarean Section Complications Among Women in Jeddah, Saudi Arabia." Cureus, vol. 14, no. 12, 2022, e32152. doi:10.7759/cureus.32152.