Predisposing Factors for Women’s Preference of Caesarean Section in Lafia Metropolis, Nasarawa State, Nigeria

to the goals of the study. A systematic random sampling technique was used to select the participants. Every nth woman (where n is a predetermined interval) was selected from the list until the sample size is met. The calculation of this interval was done by multiplying the total number of eligible women by the inverse of the desired number of those to be sampled. Women within the reproductive age (18 -45 years) who had undergone a caesarean section and who indicated preference for the procedure were included. Those people who have incomplete medical records or are not willing to participate were excluded. 3.6 Methods of Data Collection The self-administered questionnaire was adopted here with the closed ended question pattern. The questionnaire consists of two parts A and B. part A focused on the personnel demographic characteristic of the respondent, such as name, sex, age etc. while part B bothers on substantive issues of the research work. The questionnaires were completed by the member of the public in Lafia metropolis representing the sample size of the study. 3.7 Methods of Data Analysis Based on the research work, the method of data analysis collected from the questionnaires were recorded on frequency table and analysed using the frequency distribution and percentages. The percentages were used to show the demographic statistic and formula of the responses using statistical package for social sciences version 22, data collected were subjected to Parsons Moment Correlation statistical analysis for testing the study hypothesis. 4.0 Data Presentation, Analysis and Discussion of Findings 4.1 Socio- Demographic Attributes of Respondents A total of 176 respondents took part in this study. Table 4.1.1 presents the socio-demographic characteristics of the participants, including gender, age, marital status, occupation, education level, and religion. 4.1.1 Socio- demographic attributes of respondents Table 4.1.1: Socio- demographic attributes of respondents Variables Frequency Percentage Age 18-25 38 21.6 26-32 86 48.9 33-41 29 16.5 42 and above 23 13.1 Marital Status Married 138 78.4 Divorced 10 5.7 Widowed 28 15.9 Occupation Trader 31 17.6 Civil Servant 42 23.8 Students 39 22.2 Farmer 64 36.4 Level of Education No formal education 21 11.9 Primary 33 18.7 Secondary 46 26.1 Tertiary 76 43.2 Religion Christianity 91 51.7 Islam 82 46.6 Africa Religion 3 1.7 Source: Field work, 2024 The table above outlines the distribution of the respondents by age, which is a significant percentage of the participants 48.9% were between the age of 26-32 years followed by 21.6% of age between 18- 25 years, 16.5% of 33-41 year of age, 16.9% of 32-38 year of age, and 13.1% of age 42 years and above. The data also shows that out of the total number of respondents, which is 176, 78.4% are married, 15.9% are widowed and 5.7% are divorced. Additionally, from the table, the occupations of the respondents include farmers making up 36.4%, followed by civil servants which makes up 23.8%, students were 22.2% and traders 17.6%. This is an indication of the importance of farming in the study area. With respect to education, 43.2% of the respondents have degree certificate, 28.1% had completed their secondary school, 18.7% has first school leaving and 11.9% have no formal education. In terms of religion, 51.7% of the respondents were Christian, 46.6% were Muslims, and 1.7% practiced African traditional religion. 4.2 Influence of Maternal Age on Preference of Caesarean Section Table: 4.2 Distribution of respondents by maternal age influence women preference of caesarean section Statement Yes No Not certain Do you think that advanced maternal age increases a woman's likelihood of preferring a caesarean section? 107 (60.8%) 38 (21.6%) 31 (17.6%) Are younger pregnant women less likely to prefer caesarean deliveries compared to older women? 110 (62.5%) 34 (19.3%) 32 (18.2%) Would you say that older first-time mothers frequently opt for caesareans section due to fears about labour and vaginal birth? 118 (67.0%) 33 (18.8%) 25 (14.2%) Do you think that some women view caesarean sections more positively as they age? 121 (68.8%) 28 (15.9%) 27 (15.3%) Do women in their late 30s or 40s typically have a higher preference for caesarean section compared to those in their 20s? 133 (75.5%) 26 (14.8%) 17 (9.7%) Source: Fieldwork, 2024 Table 4.2 shows that majority of the respondents i.e. 60.8% agreed advanced maternal age increase a woman's chances of going for a caesarian section while 21.6% disagreed and 17.6% were not sure. In addition, 62.5% of the respondents agreed that young women who are pregnant less likely to prefer caesarean deliveries than old women, 19.3% were against the statement and 18.2% were unsure. Moreover, 67.0% of the respondents said that old first time mothers often choose caesarean section due to fear of labour and vaginal birth, 18.8% disagreed and 14.2% were not sure. Likewise, 68.8% agreed that some women look upon caesarean sections more favorably as they get older while 15.9% disagreed and 15.3% were unsure. Lastly, 75.5% of the people replied that women in their late 30s or 40s usually have a greater preference of caesareans section for babies perpetually than women in their 20s. 14.8% of people didn't agree with that and 9.7% are confused whether this is true or false. These findings point to a widespread perception that maternal age has a major role in influencing women's preferences for caesarean section. 4.3 Previous Birth Experiences and Women Preference of Caesarean Section Table: 4.3 Distribution of respondents by previous birth experiences and women preference of caesarean section Statement Yes No Not Sure Woman's previous birth experiences impact her preferences for future delivery modes? 99 (56.3%) 41 (23.3%) 36 (20.4%) Women who had positive experiences with prior vaginal births less likely to prefer caesarean sections 105 (59.6%) 39 (22.2%) 32 (18.2%) Traumatic previous births have any effect on a woman's subsequent delivery preferences? 115 (65.3%) 34 (19.3%) 27 (15.3%) Previous uncomplicated vaginal birth leads to lower preference for caesarean section in future pregnancies 135 (76.7%) 27 (15.3%) 14 (8.0%) Women who experienced postpartum complications like excessive bleeding after a vaginal delivery often prefer a caesarean section for their next birth? 123 (69.9%) 29 (16.5%) 24 (13.6%) Women with a history of multiple previous caesarean sections to prefer caesarean delivery for their subsequent pregnancies 141 (80.1%) 19 (10.8%) 16 (9.1%) Source: Fieldwork, 2024 The study looked at whether women who have had bad experiences with prior births would lean more toward caesarians. Table 4.3 shows that 56.3% of respondents agreed that the past birthing experiences of a woman influenced her preferences for methods of future delivery, whereas a total of 23.3% of the respondents did not agree with this assertion and 20.4% were unsure about it. Moreover, 59.6% of respondents agreed that women who have positive experiences due to previous vaginal births have less tendency to go for caesarians, while 22.2% disagreed, and 18.2% were unsure. In addition, 65.3% of the respondents agreed that previous traumatic births affect a woman's later decision on delivery, but 19.3% of the respondents disagree with this statement, and 15.3% of the respondents are unsure. When asked whether a previous uncomplicated vaginal delivery lowers the probability to opt for a caesarean section for future pregnancies, 76.7% of the respondents agreed, 15.3% disagreed, and 8.0% were uncertain. Furthermore, most of them, 69.9%, agreed women who experienced postpartum problems, such as excessive bleeding after a vaginal birth, often will prefer caesarean, while 16.5% disagree and 13.6% are uncertain. Finally, 80.1% of the respondents agreed that women with a history of multiple caesarean sections have tendency to prefer caesarean delivery in future deliveries, 10.8% of the respondents disagreed and 9.1% were not sure. 4.4 Income Level and Women Preference of Caesarean Section Table: 4.4 Distribution of respondents by income level and women preference of caesarean section Statement Yes No Not Sure Women with higher income levels are more likely to prefer caesarean section 101 (57.4%) 39 (22.2%) 36 (20.4%) Wealthier women, are caesarean sections sometimes viewed as a status symbol and more modern option 116 (65.9%) 35 (19.9%) 25 (14.2%) Are poor women universally more averse to caesareans due to the higher costs involved 127 (72.1%) 33 (18.8%) 16 (9.1%) Income level play a role in shaping women's attitudes towards caesarean section? 123 (75.0%) 31 (17.6%) 13 (7.4%) Women with a higher income level have access to private doctors who are more willing to perform caesarean sections? 138 (78.4%) 27 (15.3%) 11 (6.3%) Source: Fieldwork, 2024 Table 4.4 shows that majority of respondents which are 57.4% agreed or disagree that women with the higher income level preference caesarean section and 22.2% agreed and 20.4% were not sure. Additionally, 65.9% agreed that wealthier women occasionally view caesarean sections as a status symbol and a more modern option with 19.9% disagreeing and 14.2% not sure. Furthermore, 72.1% of respondents agreed that the poorer women are more averse to caesareans because of the higher cost involved, 18.8% of respondents disagreed and 9.1% don't know. Similarly, 75.0% agreed that income level has a say in the attitude of women towards caesarean sections (17.6% disagree) and 7.4% were not sure. Finally, 78.4% of the respondents agreed that women who have a more income level have the access to the private doctors who have a more willingness to perform caesarean sections, while 15.3% disagreed and 6.3% were uncertain. 4.5 Discussion of Findings 4.5.1 Maternal age influence women preference of caesarean section The data in Table 4.2 shows the strong perception of the respondents regarding the effect of maternal age in shaping the preference of women for delivery through caesarean section (CS). Most of the respondents think that the older the mother, the greater the tendency to prefer CS. This perception falls in line with a number of studies. For example, Bayrampour and Heaman (2020) found that advanced maternal age is associated with greater preference for CS especially among first time mothers. Additionally, 62.5% of respondents are in favour of the concept that pregnant younger women are less likely to favour caesarean deliveries than older women. This is in line with findings from Mazzoni et al (2022) who found a positive relationship between maternal age and CS preference in a systematic review and meta-analysis. Furthermore, many respondents think that older first-time mothers often choose empowered delivery as they have fears about labour and vaginal delivery. This is consistent with research completed by Cooke, Mills, and Lavender (2012) which found fear of childbirth was an important factor that contributes to older women's preference for CS. Moreover, a majority of the respondents agree that women tend to have more positive views of caesarean sections as they increase in age. This perception is partly echoed by research conducted by Karlstrom, Nystedt, Johansson and Hildingsson (2021) who found older women often perceived CS to be a safer option for the mother and baby. The maximum percentage of the respondents that agreed with any of the statements was 75.5% with the statement that women in their late 30s or 40s have more preference on CS than those in their 20s. This is in line with the results of Herstad, Klungsoyr, Skjaerven, Tanbo, Forsen, Abyholm and Vangen (2022), who found that maternal age >=35 years is significantly associated with preference of CS. 4.5.2 Previous Birth Experiences and Women Preference of Caesarean Section The data shown in Table 4.3 implies very strongly among the respondents that past birth experiences play a significant role in shaping women's preferences for caesarean section (CS) in subsequent pregnancies. A majority of the respondents say that a woman's past experience with childbirth affects her preferences for future methods of delivery. This perception is justified by the correspondence of several studies such as the one of Karlstrom et al. (2021), who identified that previous experiences of childbirth were an important determinant on women's preferences and deliveries. The ideas relating to the likelihood of women who experienced positive with previous vaginal deliveries to the use of caesarean sections are supported by the majority of respondents. This finding is in line with the research findings by Hildingsson et al. (2013), who found that women who had positive previous birth experiences were more likely to opt for vaginal birth in subsequent pregnancies. A large majority of the respondents feel that having traumatic previous births impacts future delivery preferences of a woman. This perception is similar to the results obtained by Storksen, Garthus-Niegel, Adams, Vangen and Eberhard-Gran (2015), who found an association between negative birth experiences, in particular fear or trauma, and CS preferences in future pregnancies. The largest proportion of the respondents agree that previous uncomplicated vaginal birth causes reduced preference for caesarean section in the future. This is in line with findings reported by Mazzoni et al. (2022) who stated that women who had previous vaginal births were less likely to opt to CS compared to women who have no prior experience. A majority of the respondents would believe that women who suffered from postpartum complications such as excessive bleeding after a vaginal delivery often would prefer a caesarean for their next delivery. This perception is supported to a certain degree by research from Ecker, Chen, Cohen, Riley and Lieberman (2021), who found that previous complications during childbirth could influence preferences for the method of future delivery. The greatest agreement (80.1%) is with the statement that women who have a history of multiple previous caesarean sections like caesarean delivery for their subsequent pregnancies. This is consistent with results from Guise, Eden, Emeis, Denman, Marshall, Fu and McDonagh (2020) who found a greater preference for repeat CS among women who had previous CS for their subsequent births. 4.5.3 Income Level Women Preference of Caesarean Section The data in Table 4.4 indicates a very strong perception in the group of the respondents that income level affects women's preference for caesarean section (CS). A majority of the respondents believe that women with high income levels are more likely to prefer caesarean section. This perception is supported by several studies, Ronsmans, Holtz and Stanton (2016) for one, finding that CS rates were higher among women from wealthy households in many low- and middle-income countries. A majority of the respondents agree that among the cool women, caesarean sections are sometimes seen as status symbol and more modern. This perception is in accordance with findings from Behague, Victora and Barros (2022) which reported that in certain contexts, CS was considered to be associated with higher social status and thought to be a sign of quality care. A significant majority of the answers appear to be that poor women have a universal aversion to caesareans because of the high costs involved. While this perception makes sense, it's important to note that things begin to vary in the relationship between income and CS preference. For example, Leone, Padmadas, and Matthews (2018) analysis showed that in some countries, the rate of CS increased with wealth but that this was not the case for all countries. Three quarters of the respondents (75.0%) believe that income level plays role in determining women's attitude towards caesarean section. This perception is supported in various studies such as Feng, Xu, Guo and Ronsmans (2012) who found that there was an association between socioeconomic factors, including income, and CS rates in China. The strongest agreement among respondents (78.4%) is women who enjoy a better income level have access to private doctors who are more willing to perform caesarean section. This perception is supported by the research of Potter, Berquo, Perpetuo, Leal, Hopkins, Souza and Formiga (2021) who found that private sector physicians in Brazil were more likely to perform CS when compared to their counterparts in the public sector. 5.0 Summary of Findings, Conclusion and Recommendations 5.1 Summary of Findings The aim of the study was to study the predisposing factors which may affect women's preference to Caesarean sections (C-sections) in Lafia metropolis, Nasarawa State, Nigeria. The study aimed to find out how maternal age influences the preferences of women towards C-sections. It was found that younger women (ages 18-25) and women in the 26-32 age bracket had differing preferences, it was perhaps found that older women were more inclined to opt for the C-section due to perceived obstetric risks. The aim of the research was to investigate the circumstances that lead to the choice of a C- section, focusing on the past experiences with childbirth. Women who had prior birth experiences with negative or traumatic outcomes were more likely to want their babies delivered by C-section in their subsequent pregnancies, since they were a safer choice for the baby. The research examined the influence of socioeconomic status, especially income, on women's preferences for C-sections. Higher income levels, because wealthy women could have access to better healthcare services and C-sections may be seen to be a more desirable choice. Overall, the research therefore demonstrated the distinct contribution of various individual, sociocultural, and healthcare system-related factors as causes of the rising preference of C-sections by women in the Lafia metropolis. Younger women may be less likely to choose surgical delivery, whereas older women are often aware of the increased obstetric risks associated with delivery, and they may be more likely to choose C-sections. This implies that age-related perceptions and experiences are important in decision-making as it relates to methods of delivery. Past childbirth experiences of women play a major role in determining their preferences of C-sections. Women who had complications or a traumatic experience during their previous births were more likely to opt for C-sections when they are expecting a baby again. This further drives the importance of psychological and emotional factors in maternal healthcare. 5.2 Conclusion The study concluded that there is a clear positive correlation between income levels and the preference for C-sections among women of Lafia metropolis of Nasarawa state. Women who are more financially privileged have access to healthcare services and select C-sections, knowing them to be more controlled and safer. This points to the need for addressing socioeconomic disparities in mismatch of maternal healthcare access and education. 5.3 Recommendations 1. Healthcare providers ought to carry out educational programs that focus on the implications of maternal age on pregnancy and delivery. These programs should seek to inform women (particularly those in younger age brackets) about the risks and benefits of different modes of delivery, including those of a C-section. This can help women to make informed decisions based on their individual circumstances and experience (circumstances). 2. It is necessary to offer psychological help and counselling to women who have had bad or traumatic childbirth experiences. Healthcare facilities should set up support groups and counselling services that can help these women process their experiences and understand their options as far as future deliveries are concerned. This can help to dampen the fear that comes with childbirth and may hopefully curb the tendency towards unnecessary C-sections. 3. Policymakers should focus on better access to quality maternal healthcare services for women belonging to different income levels. This includes increasing access to affordable healthcare options, particularly for low-income women, and making sure that all women have wide-blooded information about their delivery options. Community outreach programs can also be developed to teach women in lower socioeconomic groups about safe delivery practices, the potential risks of C-sections. References Abbasi, S., Seyedtabaei, S. M., Nasiri, M., & Jahani Shurab, N. (2020). Socio-cultural factors associated with women's preference for cesarean section: A qualitative study. urnal of Environment and Public Health, 4(2), 1-10. Ajenifuja, K. O., Adepiti, C. A., & Ogunniyi, S. O. (2020). Caesarean section in a semi-urban specialist hospital in Nigeria: a six-year analysis. Tropical Journal of Obstetrics and Gynaecology, 37(1), 59-63. American College of Obstetricians and Gynaecologists (2019). Advanced maternal age. Retrieved from https://www.acog.org/womens-health/faqs/advanced-maternal-age American College of Obstetricians and Gynecologists (2019). Practice bulletin no. 205: Vaginal birth after caesarean delivery. Obstetrics and Gynecology, 133(2), 110-127. Ayres-de-Campos, D., Sousa, P., Costa-Santos, C. (2016). Previous caesarean section and preferences for elective delivery: A survey of women's choices in Portugal. Acta Obstetricia et Gynecologica Scandinavica, 95(2), 234-241. Bayrampour, H., & Heaman, M. (2020). Advanced maternal age and the risk of cesarean birth: A systematic review. Birth, 37(3), 219-226. Behague, D. P., Victora, C. G., & Barros, F. C. (2022). Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ, 324(7343), 942-945. Betran, A. P., Ye, J., Moller, A. B., Zhang, J., Gulmezoglu, A. M., & Torloni, M. R. (2023). The increasing trend in caesarean section rates: global, regional and national 90-2022. PloS one, 11(2), 148-343. Behague, D. P., Victora, C. G., & Barros, F. C. (2022). Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population- based birth cohort study linking ethnographic and epidemiological evidence. BMJ, 324(7343), 942-945. Behague, D. P. (2022). Infant feeding practices and maternal subjective goals: a mixed methods study among low-income women in Rio de Janeiro, Brazil. Population Review, 41(1). Boerma, T., Ronsmans, C., Melesse, D. Y., Barros, A. J., Barros, F. C., Juan, L. & Victora, C.G. (2018). Global epidemiology of use of and disparities in caesarean sections. The Lancet, 392(10155), 1341-1348. Bohren, M., Oladapo, O.T. & Tunçalp, O. (2018). Deciding on interventions to help maximise uptake of caesarean sections in low- and middle-income countries: A population–level geospatial modelling study. PLoS Medicine, 15(10), e1002679. Bokosi, M., Munthali, G., Kachale, F., & Chatipedze, B. (2022). Factors associated with preference for caesarean section delivery among women in Lilongwe District, Malawi: A cross-sectional study. BMC Pregnancy and Childbirth, 22(1), 1-9. Caughey, A. B., Sundaram, V., Kaimal, A. J., Cheng, Y. W., Gienger, A., Little, S. E. & Shaffer, B. L. (2018). Maternal and neonatal outcomes of elective induction of labour. Evidence Report/Technology Assessment, (176), 1-257. Cooke, A., Mills, T. A., & Lavender, T. (2012). Advanced maternal age: Delayed childbearing is rarely a conscious choice: A qualitative study of women's views and experiences. International Journal of Nursing Studies, 49(1), 30-39. Ecker, J. L., Chen, K. T., Cohen, A. P., Riley, L. E., & Lieberman, E. S. (2021). Increased risk of cesarean delivery with advancing maternal age: indications and associated factors in nulliparous women. American Journal of Obstetrics and Gynaecology, 185(4), 883-887. Edmonds, J. K., Yee, L. M., Dibble, S. L., Hillemeier, M. M., Gourevitch, R., & Munoz, A. (2017). Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical centre: a retrospective cohort study. BMC Pregnancy and Childbirth, 17(1), 1-10. Ezechi, O. C., Fasubaa, O. B., Kalu, B. E., Nwokoro, C. A., & Obiesie, L. O. (2022). Caesarean section: why the aversion? Tropical Journal of Obstetrics and Gynaecology, 21(2), 164- 167. Fagevik Olsén, M., Hildingsson, I., & Alehagen, S. (2019). Does maternal age influence the likelihood of intrapartum interventions during childbirth? A nationwide Swedish cohort study. BMC Pregnancy and Childbirth, 19(1), 1-9. Faisal, I., Matinnia, N., Hejar, A. R., & Khodakarami, Z. (2014). Why do primigravida request caesarean section in a normal pregnancy? A qualitative study in Iran. Midwifery, 30(2), 227-233. Feng, X. L., Xu, L., Guo, Y., & Ronsmans, C. (2012). Factors influencing rising caesarean section rates in China between 1988 and 2008. Bulletin of the World Health Organization, 90, 30-39A. Fenwick, J., Staff, L., Gamble, J., Creedy, D. K., & Bayes, S. (2020). Why do women request caesarean section in a normal, healthy first pregnancy?. Midwifery, 26(4), 394-400. Furtado, S. P., & Firie, A. (2019). Vaginal birth after caesarean section. British Journal of Midwifery, 27(8), 505-510. Garthus-Niegel, S., Von-Soest, T., Vollrath, M. E. (2013). The impact of subjective birth experiences on post-traumatic stress symptoms: A longitudinal study. Archives of Women's Mental Health, 16(1), 1-10. Gibbons, L., Belizán, J. M., Lauer, J. A., Betrán, A. P., Merialdi, M., & Althabe, F. (2020). The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report, 30. Grzybowski, S., Stoll, K., Kornelsen, J., & Kuziemsky, C. (2021). Distance matters: a population based study examining access to maternity services for rural women. BMC Health Services Research, 11(1), 147. Guise, J. M., Eden, K., Emeis, C., Denman, M. A., Marshall, N., Fu, R. & McDonagh, M. (2020). Vaginal birth after cesarean: new insights. Evidence Report/Technology Assessment, (191), 1-397. Haines, H., Pallant, J., Karlström, A., & Hildingsson, I. (2011). Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery, 27(4), 560-567. Herstad, L., Klungsoyr, K., Skjaerven, R., Tanbo, T., Forsen, L., Abyholm, T., & Vangen, S. (2022). Maternal age and emergency operative deliveries at term: a population-based registry study among low-risk primiparous women. An International Journal of Obstetrics & Gynaecology, 119(13), 1572-1580. Hildingsson, I., Radestad, I., Rubertsson, C. (2013). Few women wish to be delivered by caesarean section. Sexual & Reproductive HealthCare, 4(2), 61-66. Hildingsson, I., Johansson, M., Karlstrom, A., & Fenwick, J. (2012). Factors associated with a positive birth experience: an exploration of Swedish women’s experiences. International Journal of Childbirth, 2(3), 153-164. Hotimsky, S. N., Rattner, D., Venancio, S. I., Bógus, C. M., & Miranda, M. M. (2022). Childbirth and fear: the perspective of obstetric nurses and obstetricians in a public maternity in São Paulo. Revista Brasileira Saude Mater. Infant, 2, 53-63. International Institute for Population Sciences. (2023). National Family Health Survey (NFHS- 4), 2015-2023. http://rchiips.org/nfhs/NFHS-4Reports/India.pdf [34] Ikeako, L. C., Ogbonna, C., & Ezegwui, H. U. (2016). Influence of formal maternal education on the use of maternity services in Enugu, Nigeria. Journal of Obstetrics and Gynaecology, 26(1), 30-34. Jenabi, E., Fereidooni, J., & Khaki, S. (2020). Fear, anxiety and adverse natal experiences as mediators between maternal beliefs and preference for caesarean delivery. BMC Pregnancy and Childbirth, 20(1), 1-11. Kamal, P., Dixon-Woods, M., & Kurinczuk, J. J. (2017). Maternal obesity and caesarean section: A systematic review and meta-analysis of bias-adjusted evidence. Paediatric and Perinatal Epidemiology, 31(5), 474-490. Karlstrom, A., Nystedt, A., Johansson, M., & Hildingsson, I. (2021). Behind the myth – few women prefer caesarean section in the absence of medical or obstetrical factors. Midwifery, 27(5), 620-627. Karlstrom, A., Nystedt, A., Johansson, M. (2021). The meaning of a very positive birth experience: Focus groups discussions with women. BMC Pregnancy and Childbirth, 11(1), 1-9. Karlstrom, A., Radestad, I., Eriksson, C., Rubertsson, C., Nystedt, A., & Hildingsson, I. (2015). Cesarean section without medical reason, 1997 to 2006: a Swedish register study. Birth, 42(5), 492-498. Keag, O. E., Norman, J. E., & Stock, S. J. (2018). Long-term risks and benefits associated with caesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS medicine, 15(1), 100-249. Kozhimannil, K. B., Trinacty, C. M., Busch, A. B., Huskamp, H. A., & Adams, A. S. (2021). Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatric Services, 62(6), 619-625. Kozhimannil, K. B., Attanasio, L. B., & Yang, Y. T. (2013). Caesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32(3), 527-535. Leone, T., Padmadas, S. S., & Matthews, Z. (2018). Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries. Social Science & Medicine, 67(8), 1236-1246. Llana, A., Arpin, J. & Bacci, A. (2019). Understanding drivers of caesarean section in Nicaragua: A mixed methods analysis. Heliyon, 5, e02523. Litorp, H., Mgaya, A., Mbekenga, C. K., Kidanto, H. L., Johnsdotter, S., & Essen, B. (2014). Fear, blame and transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting. Social Science & Medicine, 143(2), 232-240. Litorp, H., Mgaya, A., & Kidanto, H. L. (2010). Obstetric near-miss and deaths in routine care at the Muhimbili National Hospital, Dar es Salaam, Tanzania: a cross-sectional study. BMC Pregnancy and Childbirth, 10(1), 1-7. Lumbiganon, P., Laopaiboon, M., Gulmezoglu, A.M. (2020). Method of delivery and pregnancy outcomes in Asia: The WHO global survey on maternal and perinatal health 2007-08. The Lancet, 375(9713), 490-499. Maharlouei, N., Rezaianzadeh, A., Hesami, E., Moradi, F., Mazlooman, R., Joulaie, H., Rezaianzadeh, Z., & Lankarani, K. B. (2019). The preference of Iranian pregnant women for caesarean delivery and its causes: A systematic review and meta-analysis. Journal of Preventive Medicine and Holistic Health, 5(1), 1-11. Maharloukou, N., Moalaee, M., Ajdari, S., Zarei, M., & Lankarani, K. B. (2019). Maternal age and other reproductive factors in preference for cesarean delivery among pregnant women. International Journal of Women's Health and Reproduction Sciences, 7(4), 441- 448. Martin, J. A., Hamilton, B. E., Osterman, M. J. K., & Driscoll, A. K. (2023). Births: Final data for 2022. National Vital Statistics Reports, 70(2), 1-51. Mazzoni, A., Althabe, F., Liu, N. H., Bonotti, A. M., Gibbons, L., Sánchez, A. J., & Belizan, J. M. (2022). Women's preference for caesarean section: a systematic review and meta- analysis of observational studies. An International Journal of Obstetrics & Gynaecology, 123(3), 383-392. Mendoza-Sassi, R. A., & Cesar, J. A. (2018). Meta-analysis of the effectiveness of epidural anesthesia for cesarean delivery. Revista de Saúde Pública, 42(5), 946-956. Munro, S., Kornelsen, J., Corbett, K., Wilcox, E., Bansback, N., & Janssen, P. (2017). Do women have a choice? Care providers' and decision makers' perspectives on barriers to access of health services for the prevention and management of birth defects in high- income countries. BMC Pregnancy and Childbirth, 17(1), 1-12. Munro, S., Janssen, P., Corbyn, B., Wilcocks, K., Bansback, N., & Kornelsen, J. (2022). Modeling the costs of caesarean section and vaginal delivery for antenatal women in British Columbia, Canada using patient-specific Monte Carlo simulation model. Journal of Obstetrics and Gynaecology Canada, 39(3), 137-146. Mylonas, I., & Friese, K. (2015). Indications for and risks of elective caesarean section. Deutsches Ärzteblatt International, 112(29-30), 489–495. National Population Commission and ICF. (2019). Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF. Neuman, M., Alcock, G., Azad, K., Kuddus, A., Osrin, D., Shah, P. & Nair, N. (2014). Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ Open, 4(12), 1-17. Nielsen, H. S., Häger, R. M., & Henriksen, T. B. (2011). Tocophobia—a fear of childbirth: A national survey. Danish Medical Journal, 58(2), 43-54. Nyamtema, A. S., Pembe, A. B., Mmbaga, B. T., & Shayo, R. (2022). Preferences and factors associated with the intention of women to deliver by caesarean section in rural Tanzania: A cross-sectional study. BMC Pregnancy and Childbirth, 22(1), 1-9. Onankpa, B., & Ekele, B. (2019). Fetal outcome following caesarean section in a university teaching hospital. Journal of the West African College of Surgeons, 9(2), 1-11. Panda, S., Begley, C., & Daly, D. (2018). Influence of women's pre-labour preference for mode of delivery on mode of delivery and births following primary caesarean section: A systematic review and meta-analysis of observational studies. European Journal of Obstetrics & Gynecology and Reproductive Biology, 231, 9-19. Panda, S., Daly, D., Begum, H., Bharti, A., Nandy, S., & Bandyopadhyay, S. (2018). Factors influencing preference for Caesarean delivery in India. International Journal of Community Medicine and Public Health, 5(6), 2440-2446. Potter, J. E., Berquo, E., Perpétuo, I. H., Leal, O. F., Hopkins, K., Souza, M. R., & Formiga, M. C. (2021). Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ, 323(7322), 1155-1158. Ronsmans, C., Holtz, S., & Stanton, C. (2016). Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet, 368(9546), 1516-1523. Ryding, E. L., Wirfelt, E., Wangborg, I. B., & Sjogren, B. (1998). Edman Gynecological and obstetric aspects of life satisfaction in men and women 7 years after unsuccessful infertility treatment. Acta Obstetricia et Gynecologica Scandinavica, 77(7), 736-742. Sahoo, S. K., Bodenmann, P., & Jackson, Y. (2022). Socioeconomic determinants influencing maternal preference for caesarean delivery in India: A systematic review. BMC Pregnancy and Childbirth, 22(1), 1-14. Schytt, E., Lindmark, G., & Waldenstrom, U. (2017). Women's preferences for cesarean section and the actual mode of delivery in relation to postnatal bonding. Journal of Maternal- Fetal and Neonatal Medicine, 26(15), 1471-1477. Shamaki, P. U., & Buang, A. (2016). Factors influencing the high rate of caesarean section in Sokoto, North-Western Nigeria. African Journal of Primary Health Care & Family Medicine, 8(1), 1-6. Stoll, K., Fairbrother, N., Carty, E., Janssen, P., Abrahams, R., & Klein, M. C. (2017). Women's positions, preferences and experiences: Assisting with the decision-making process in cases of maternal request for caesarean delivery. Journal of Obstetrics and Gynaecology Canada, 39(7), 538-546. Stoll, K., Hall, W., Vicarious, J., & Berwick, D. M. (2015). What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study. BMJ Open, 5(3), e006400. Stoll, K., & Fairbrother, N. (2018). Obstetricians' attitudes and practices regarding caesarean delivery on maternal request. Obstetrics & Gynecology 131(5), 875-881. Storksen, H. T., Garthus-Niegel, S., Adams, S. S., Vangen, S., & Eberhard-Gran, M. (2015). Fear of childbirth and elective caesarean section: a population-based study. BMC Pregnancy and Childbirth, 15(1), 221. Thompson, S. M. A., Lim, C. L., Collins, C. T., & Cyna, A. M. (2020). Want for caesarean section in second stage of labour and previous childbirth experience. Journal of Psychosomatic Obstetrics & Gynaecology, 41(1), 63-71. Todman, D. (2007). A history of caesarean section: From ancient world to the modern era. Australian and New Zealand Journal of Obstetrics and Gynaecology, 47(5), 357-361. Vidya, T. P., Radha, K., & Priya, P. L. (2022). Preference of mode of delivery and factors influencing it among antenatal women attending a tertiary care hospital in South India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 11(4), 1064-1069. Vogel, J. P., Betran, A. P. & Vindevoghel, N. (2015). Use of the Robson classification to assess caesarean section trends in 21 countries: A secondary analysis of two WHO multicountry surveys. The Lancet Global Health, 3(5), 260-270. World Health Organization (2015). WHO statement on caesarean section rates. World Health Organization. World Health Organization (2020). Adolescent pregnancy. Retrieved from https://www.who.int/en/news-room/fact-sheets/detail/adolescent-pregnancy World Health Organization . (2018). WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections. https://apps.who.int/iris/bitstream/handle/10665/275377/9789241550338-eng.pdf Yakubu, J., Solanke, B. L., & Oyinlola, F. F. (2020). Factors associated with caesarean delivery among women of reproductive age in Nigeria. BMC Pregnancy and 0(1), 1-10. Zamani, P., Hosseini-Baharanchi, F., Latifnejad-Roudsari, R., Latifi, S., & Torkamanzehi, A.(2020). Women's choice of delivery model: A narrative review. Journal of Maternal- Fetal and Neonatal Medicine, 35(7), 1280-1287. Zhang, T., Sidorchuk, A., Sevilla-Cermeño, L., Vilaplana-Pérez, A., Chang, H., Fazel, S., & Larsson, H. (2015). Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring: a systematic review and meta-analysis. JAMA network open, 2(8), 15-23.