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Prevalence of Caesarean sections in Enugu, southeast Nigeria: Analysis of data from the Healthy Beginning Initiative

  • Jayleen K. L. Gunn ,

    Affiliation Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America

  • John E. Ehiri,

    Affiliation Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America

  • Elizabeth T. Jacobs,

    Affiliations Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America, University of Arizona Cancer Center, Tucson, Arizona, United States of America

  • Kacey C. Ernst,

    Affiliation Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America

  • Sydney Pettygrove,

    Affiliation Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America

  • Katherine E. Center,

    Affiliation BrightOutcome, Inc., Buffalo Grove, Illinois, United States of America

  • Alice Osuji,

    Affiliation Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria

  • Amaka G. Ogidi,

    Affiliation Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria

  • Nnabundo Musei,

    Affiliation Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria

  • Michael C. Obiefune,

    Affiliations Healthy Sunrise Foundation, Castle Ridge Avenue, Las Vegas, Nevada, United States of America, Institute of Human Virology, University of Maryland, Baltimore, Maryland, United States of America

  • Chinenye O. Ezeanolue,

    Affiliation Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria

  • Echezona E. Ezeanolue

    Affiliations Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria, Healthy Sunrise Foundation, Castle Ridge Avenue, Las Vegas, Nevada, United States of America, Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, Nevada, United States of America



In order to meet the Sustainable Development Goal to decrease maternal mortality, increased access to obstetric interventions such as Caesarean sections (CS) is of critical importance. As a result of women’s limited access to routine and emergency obstetric services in Nigeria, the country is a major contributor to the global burden of maternal mortality. In this analysis, we aim to establish rates of CS and determine socioeconomic or medical risk factors associated with having a CS in Enugu, southeast Nigeria.


Data for this study originated from the Healthy Beginning Initiative study. Participant characteristics were obtained from 2300 women at baseline via a semi-structured questionnaire. Only women between the ages of 17–45 who had singleton deliveries were retained for this analysis. Post-delivery questionnaires were used to ascertain mode-of-delivery. Crude and adjusted logistic regressions with Caesarean as the main outcome are presented.


In this sample, 7.22% women had a CS. Compared to women who lived in an urban setting, those who lived in a rural setting had a significant reduction in the odds of having a CS (aOR: 0.58; 0.38–0.89). Significantly higher odds of having a CS were seen among those with high peripheral malaria parasitemia compared to those with low parasitemia (aOR: 1.54; 1.04–2.28).


This study revealed that contrary to the increasing trend in use of CS in low-income countries, women in this region of Nigeria had limited access to this intervention. Increasing age and socioeconomic proxies for income and access to care (e.g., having a tertiary-level education, full-time employment, and urban residence) were shown to be key determinants of access to CS. Further research is needed to ascertain the obstetric conditions under which women in this region receive CS, and to further elucidate the role of socioeconomic factors in accessing CS.


Globally, the number of Caesarean sections (CS) has been on the rise over the last decade [1, 2, 3, 4]. While CS are potentially life-saving, the adverse maternal and perinatal outcomes when a CS is not medically necessary have become a major public health concern as the associated expenses decrease resources available for other maternal and child health interventions [5, 6]. According to the World Health Organization (WHO), as a population’s CS rates approach 10%, maternal and newborn deaths decrease [7]. A medically necessary CS can prevent maternal and infant mortality; however, there is no evidence that CS benefits women who do not require the procedure [7]. The WHO has estimated—based on rates of fistula—that in 15.5% of pregnancies in Nigeria, a CS is medically necessary [1, 8, 9]. Underutilization of CS is of particular concern in most of Africa where 7.4% of all births occurred by CS in 2014 [3].

Although most African countries have regional hospitals with surgical services available to perform CS, multiple individual and health system characteristics impede access and contribute to the delay in women seeking services during pregnancy and delivery. Thaddeus and Maine (1994) developed the “three-delay” model that has been widely accepted as a framework to explain the obstacles in obtaining adequate healthcare during pregnancy and delivery [10]. This three-tiered framework includes: delay in decisions to seek care, delays in reaching a healthcare facility, and delays in receiving adequate treatment for obstetric complications.

In sub-Saharan Africa (SSA), delayed access to healthcare services during pregnancy and delivery can be influenced by multiple factors. Lack of knowledge of the importance of perinatal care and an inability to pay for healthcare services are common reasons for delaying healthcare utilization [10]. Women also delay seeking treatment during pregnancy and delivery because of poverty, gender inequalities in household decision making, cultural barriers, and geographical and transport barriers [10]. Increased age, education and wealth are all positively associated with deciding to have a doctor present at delivery in SSA [11, 12]. When life-threatening complications occur during labor, delays in seeking adequate care can increase maternal mortality even when lifesaving CS is performed.

In 2013, Nigeria had the second highest number of maternal deaths and had the 11th highest crude birth rate, making it an important country in which to study the barriers to obtaining adequate obstetric care [13, 14]. In 2014, 2% of births in Nigeria utilized CS [3]. More than 75% of all CS in Nigeria are linked to obstetric emergencies that could have been prevented by earlier medical care [15]. Even with birth plans in place, many Nigerian women opt to deliver with an unskilled birth attendant in a setting other than a hospital because of barriers in seeking treatment, including cost and geographical/transportation difficulties [10, 15, 16]. Cultural factors such as gender inequalities and the acceptance of home deliveries, compared to hospital deliveries, also influence a woman’s decision to deliver at a healthcare facility [17]. Delays in seeking treatment results in women attempting to access care at healthcare facilities only after life-threatening complications develop. Increasing access to obstetric care, such as CS, decreases maternal and infant morbidity and mortality [18, 19]. However, fears associated with having a CS may further delay a woman’s decision to seek treatment. Common fears associated with having a CS in Nigeria include: cultural beliefs that vaginal birth is a confirmation of womanhood, stigma of being mocked by other women, death, violation of religious beliefs, post-operative pain, future infertility, expense, and medical incompetence [2022]. A woman’s socioeconomic status also influences access to CS, with the richest women, as measured by wealth index, having better access to CS compared to the poorest women [9]. Education and age are also strong predictors of a woman’s willingness to have a CS in Nigeria [17, 18]. Women who are either younger or less educated are more likely to refuse a CS even when it is medically necessary, and this usually stems from concerns about the expense [12, 23, 24].

Even women who do attempt to access healthcare facilities during delivery, often encounter poorly trained personnel and a lack of proper equipment and supplies [12]. Most studies evaluating pregnancy outcomes in Nigeria equate having a doctor present at delivery to having access to quality healthcare. However, this metric may not be an accurate predictor of the facility’s ability to perform a CS. Many healthcare facilities within Nigeria cannot offer a CS, and ambulance services are virtually non-existent [25]. In fact, one study demonstrated that only 1 in 21 health facilities in Nigeria is equipped to perform CS [26]. This complicates the ability of pregnant women to obtain adequate healthcare during pregnancy and delivery.

In order to meet the Sustainable Development Goal target of reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [27], increased in access to lifesaving obstetric measures such as CS is needed [18, 19, 28]. Examining factors associated with having a CS will help provide insight into ways to increase access to healthcare during pregnancy and delivery. In addition, socioeconomic and comorbid conditions are often not examined together when exploring factors associated with CS in Nigeria. Therefore, the aims of this paper were two-fold: 1) to establish the rates of CS in Enugu, southeast Nigeria; and 2) to determine socioeconomic or medical risk factors associated with having a CS.


Geographical area

Enugu State is in the southeastern part of Nigeria. With a population between 3–6 million, according the state government, Enugu has predominately rural agrarian households with some urban centers [29].


Data for this study were derived from the Healthy Beginning Initiative study (HBI), which has been described in detail elsewhere [30]. Briefly, the parent study was a two-arm randomized cluster trial aimed to assess rates of HIV testing. HBI used congregation-based sampling to recruit pregnant women and their partners in 40 churches from four dioceses (the Anglican Diocese of Enugu, the Catholic Diocese of Enugu, the Anglican Diocese of Oji-River, and the Catholic Diocese of Agwu). Women who were self-identified as pregnant were included in the study. Recruitment occurred at the level of the churches and participants (in that order), while randomization occurred only at the church level—that is, churches were randomly assigned to either the intervention or control groups. The intervention group participated in educational games about healthy pregnancy habits in addition to HIV acquisition modes, and effective prevention of mother-to-child transmission. They were also offered free prenatal care in the form of blood samples taken on-site to test for HIV, hemoglobin, malaria, hepatitis B, sickle cell gene, and syphilis. Women who tested positive for HIV were linked to local HIV care. Women in the control group were encouraged to attend prenatal care through nearby health facilities and were also referred to the health facility for testing. The research team maintained direct contact with health facilities to confirm HIV testing and prevention of mother-to-child transmission completion. Women in both the control and intervention groups completed a post-delivery questionnaire, which was available every 2 to 3 months at church. Maternal mortality was not ascertained in the parent study.

In Nigeria, approximately 35% of pregnant women deliver at a healthcare facility; therefore, a community-based sampling technique was employed to obtain a more representative sample of pregnant women [31]. Also, because pregnant women were recruited from churches in Enugu State, Nigeria, a more representative sample of pregnant women was expected as the population is more than 95% Christian and church attendance approaches 90% [30]. Pregnant women interested in the study were asked to read and sign a consent form in either English or the local language, Ibo. If the participant was illiterate, the consent form was read aloud to her in the local language; then the participant affixed her thumb print as an indication of her consent to participate in the study [30]. Demographic characteristics of participants were obtained at baseline via a semi-structured questionnaire [30]. Trained research staff and church-based health advisors administered this questionnaire written at a 6th grade reading level. Participants had the option of reading the survey themselves or having study personnel read to them. Because of inherent risks associated with having multiples (i.e. twins, triplets etc.), only women between the ages of 17–45 at baseline, who had singleton deliveries, were retained for this analysis. The length of pregnancy at baseline was not ascertained. Participants remained in the study until post-delivery. Post-delivery questionnaires were used to ascertain the mode of delivery, i.e., CS or vaginal birth, and singleton or multiple deliveries. Gravidity was dichotomized as primigravida and multigravida. Overall 76.6% (n = 2300) of participants who gave informed consent answered questions regarding their mode of delivery (Control n = 1042; Intervention n = 1258). Only women who answered the question regarding mode of delivery on the post-delivery questionnaire were retained for the analysis described in Table 1. However, not all women had complete data on socioeconomic and comorbid conditions; therefore, only 1,680 women were retained for the analysis described in Table 2. The study took place from January 2013 to August 2014.

Table 1. Comparison of participant baseline characteristics and infant gender with mode of delivery.

Table 2. Crude and logistic regression models of the odds of C-Section vs vaginal birth.

Laboratory measures

Variables assessed by laboratory tests were hemoglobin, malaria parasitemia, human immunodeficiency virus (HIV), and sickle cell disease/trait (SCD). Participants were tested either at baseline—following recruitment into the study—or during their prenatal visits, whereupon records were obtained from the participant’s corresponding hospital.

Hemoglobin was assessed using the standard cyanmethemoglobin method [32]. WHO guidelines for anemia were employed [33], and pregnant woman were classified as anemic if they had a hemoglobin level below 11g/dl.

Peripheral parasitemia levels were assessed using the malaria plus system [34]. Because results indicated that 99% of this sample showed malaria parasitemia, malaria parasitemia was reclassified as low and high based on the malaria plus system with those in the 0 and + group classified as low parasitemia and those in the ++ and +++ groups classified as high parasitemia.

HIV testing was performed using the Rapid Testing Serial Algorithm II [35]. If both tests were positive for HIV, the individual was considered HIV positive; if both tests were negative, the individual was considered HIV negative. When the tests showed conflicting results, they were both repeated and the results were read by another technician, who did not know the results of the first series of tests.

EDTA-treated venous blood samples were used to screen for SCD. To decrease the chances of a false positive or negative of SCD, each sample was tested twice. If incongruent results occurred, the test was rerun.

Statistical methods

Univariate analyses were based on Pearson's Chi-square test for comparison of proportions for all variables. Fisher's exact tests for contingency tables were used to test for significance in proportions when the expected cell counts were less than 5. Chi-square analyses with p<0.10 were further analyzed using crude and adjusted logistic regression with CS as the main outcome. Having a CS in previous pregnancies is known to predict current CS; therefore, gravida was included in logistic regression models. Because no information was collected specifically regarding previous CS, a sensitivity analysis was performed among those experiencing their first pregnancy. Statistical significance was set at p<0.05. An adjusted trend in the Odds Ratio (OR) was conducted to determine whether there was an increasing trend in the odds of having a CS as a participant’s age and education level increased by using the “tabodds” function in Stata [Stata Corporation, College Station, TX]. Participant’s age was recorded during pregnancy on the baseline survey and was categorized as 17–24, 25–34, and 35–45. Only one women who had a CS had no formal education; therefore, education was categorized as none/primary, secondary and tertiary and above. Age and education were retained as categorical variables for inclusion in multivariable models. Birthweight was collected as part of the parent study; however, because it was self-reported and most newborns were not weighed at birth, birthweight was not deemed reliable. Therefore, birthweight was not included in this analysis. A power analysis was conducted in the parent study [30]; because mode of delivery was not the main outcome of the trial, no additional power analyses were completed before data collection. No difference was observed in mode of delivery between the control and intervention groups (CS intervention group 7.20%, control group 8.54%; mode of delivery chi-square: p = 0.27). Therefore, data was not restricted to only the control group and all analyses treated the sample as a cohort. Data analyses were conducted using Stata version 12.0. The parent study was approved by the Institutional Review Board of the University of Nevada, Reno, and the Nigerian National Health Research Ethics Committee. This secondary data-analysis was appraised by Research Office of the Mel and Enid Zuckerman College of Public Health, and was considered exempt. This research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute of Mental Health (NIMH) and the President’s Emergency Plan for AIDS Relief (PEPFAR) under award number R01HD075050 to Echezona Ezeanolue, MD.


Results from univariate analyses are shown in Table 1; 166 (7.22%) women had CS and 2134 (92.78%) had vaginal deliveries. A woman’s age was statistically associated with having a CS (p<0.01), with a greater percentage of women aged 35–45 having had a CS (11.22%) than women aged 25–34 (7.05%) or 17–24 (3.27%). Education was statistically associated with having a CS (p<0.01), with a greater percentage of women with tertiary education having had a CS (15.06%) than those with a secondary education (5.95%) or a primary education or less (5.03%). Employment status was also statistically associated with having a CS (p = 0.03); women with full-time employment had higher percentages of CS than women who worked part time or who did not indicate they were currently employed (8.72%, 5.01%, and 6.89%, respectively). Area of residence (i.e., rural vs urban), was significantly related to having a CS (p<0.01) with more women in urban settings having a CS (12.00%) compared to women in rural settings (5.55%). A mother’s baseline malaria parasitemia was significantly associated with having a CS (p = 0.03); more women with high malaria parasitemia at baseline had a CS than women who displayed low levels of malaria parasitemia (8.80% vs 6.08%, respectively). No significant relationship was observed between CS and number of people in the household, gravidity, distance to nearest healthcare facility, marital status, HIV, sickle cell disease, or anemia. When analyses were restricted to women who did not have a prior pregnancy (n = 333), 7.81% (n = 26) had CS and 92.19% (n = 307) had vaginal deliveries (Table 1). Among these primigravida women, living in an urban environment was significantly related to having a CS (p<0.01) with 14.29% of urban women having a CS compared to only 5.11% of rural women. No other participant characteristics were significant predictors of having a CS among primigravida women.

Table 2 presents the crude and adjusted odds ratios (95% CIs) for having had a CS or a vaginal birth by participant characteristics. The adjusted models showed that, compared to women aged 17–24, the odds of having a CS were higher when the mother was aged 25–34 years (adjusted OR (aOR): 2.00; 95% CI: 1.03–3.87) and when the mother was aged 35–45 years (aOR: 2.69; 95% CI: 1.24–5.82; p-trend <0.01). Compared to those with a primary school education or less, the odds of having a CS were higher if the mother had at least a tertiary education (aOR: 2.85; CI: 1.50–5.40), but not if she had a secondary education (aOR: 1.26; CI: 0.71–2.23; p-trend <0.01). The odds of having a CS were significantly lower if participants were employed part-time compared to full-time (aOR: 0.55; CI: 0.32–0.96). Compared to women who lived in an urban setting, those who lived in a rural setting had a significant reduction in the odds of having a CS (aOR: 0.58; CI: 0.38–0.89). Significantly higher odds of having a CS were seen among those with high peripheral malaria parasitemia compared to those with low parasitemia (aOR: 1.54; CI: 1.04–2.28). After adjustment for confounders, no relationship was found between CS and number of people in the household, gravidity, marital status and not being employed. Among primigravida women, adjusted logistic regression models showed a significant relationship between woman living in an urban vs rural environment and having a CS (aOR: 0.27; CI: 0.09–0.81). No other significant relationships were found among primigravida women between having a CS and a woman’s baseline characteristics.


Women in SSA continually struggle to obtain adequate obstetric care. Increased access to emergency obstetric care, such as CS, decreases maternal and infant morbidity and mortality [18, 19]. Nigeria has one of the fastest growing populations in the world, making it a key location to study access to healthcare in pregnancy and delivery. Overall results indicate that 7.22% of women in Enugu, southeast Nigeria had a CS while 92.78% had a vaginal delivery. Percentages of CS increased as maternal age and/or education increased. Compared to women who had full-time employment, women who worked part-time had 45% lower odds of having a CS after adjusting for potential confounders. Likewise, significantly lower odds of having a CS were observed among women who live in a rural setting compared to those who reside in an urban setting in both the full sample and among primigravida women. After adjustment for confounding, this study demonstrated 54% higher odds of having a CS if participants had high peripheral malaria parasitemia compared to those with lower peripheral malaria parasitemia.

The present work demonstrated higher percentages of CS in older women and those with more education. In SSA, education has been shown to be a strong predictor of using professionally-assisted delivery services [11, 36]. Older and more educated women in SSA are thought to be more confident and influential in their household decision-making, including the use of healthcare services [11, 37]. Likewise, women with more education and/or women who are employed often have greater control over family resources and play a larger part in reproductive decision-making [17, 37, 38]. These variables may be a proxy of a woman’s ability to access healthcare, thereby increasing her chances of having had a CS.

Although the results did not demonstrate an association between having had a CS and distance to nearest health facility, there was a statistically significant relationship between having had a CS and living in rural vs urban environments. Distance has consistently been an important barrier to seeking healthcare in rural settings [10, 12, 39]. It is possible that in this self-report study, area of residence (i.e., rural vs urban) was an indirect assessment of the ease of reaching a healthcare facility for childbirth. Women living in rural parts of Enugu State, Nigeria—like women in other rural areas—may have had increased difficulty accessing healthcare facilities that can perform a CS because of limited transportation options, poor road conditions, and poverty [10, 12, 17]. Women in rural areas also refrain from using healthcare facilities during pregnancy because of financial constants, cultural norms that discourage delivery in a hospital setting, or gender inequalities in household decision-making [10, 12, 17]. Therefore, it remains unclear if distance to the nearest healthcare facility was a measure of difficulty accessing a healthcare facility or willingness to use a healthcare facility and it does not indicate if the nearest facility had CS access.

To the authors’ knowledge, this study is the first epidemiological investigation to report that high malaria parasitemia is associated with higher odds of CS. The literature and current guidelines are based on case studies [4042]. It is unknown if a biological pathway exists underlying this relationship, or if women with higher malaria parasitemia lack adequate health care overall, which inherently makes their pregnancies higher risk. The relationship between malaria parasitemia and CS warrants further attention.

In SSA, some evidence has suggested that women with SCD are more likely to have a CS [43, 44]. However, it is difficult to determine whether those with SCD receive any benefits from having a CS, because both SCD and CS are related to high risk of adverse maternal and neonatal outcomes in SSA [4446]. It has been established that malaria and SCD are associated with anemia during pregnancy [4750]. There has been much debate in the literature on whether anemia is related to an increase in maternal morbidity and mortality in the context of developing countries [51]. Having a CS would complicate this relationship and also warrants further attention.

Our study is consistent with a meta-analysis that found HIV-infected women were no more likely to have a CS than those uninfected [52]. Evidence from resource unconstrained areas suggests that having a CS is beneficial if a woman’s HIV-RNA level is above 1000 copies/ml near delivery [53]. Because women in resource-constrained areas are often unaware of their viral load before delivery, having a CS could be beneficial for HIV-infected women [54]. However, in resource-constrained areas, CS are often unavailable and unsafe; therefore, the WHO guidelines do not currently recommend that HIV positive women in resource constrained regions have an elective CS [55]. Instead, the WHO recommends that HIV positive women take 3 or more antiretroviral medications in order to decrease mother to child transmission of HIV [56]. The WHO also recommends that infants receive antiretrovirals during the post-natal period if their mother is HIV positive [56].

Implications for practice and policy

When medically necessary, CS are frequently lifesaving procedures. However, risks associated with CS are often highest within African countries as medical personnel may lack the training to perform a safe CS and lack proper equipment and supplies [6, 12]. In general, maternal and newborn deaths decrease as a population’s CS rates approach 10% [7]. Although the CS rate of 7.22% in our sample fell below this level, the WHO has estimated—based on rates of fistula—that in 15.5% of pregnancies in Nigeria, a CS is medically necessary [1]. This is double the rate found in our sample. Additionally, because of contact with study personnel it is possible the true population estimate may be lower. This indicates that unlike in other parts of the world where discussion centers on overutilization of CS [1], it is likely that in this area of Nigeria, there is an overall underutilization of CS, particularly in rural settings where only 5.55% of all births were delivered via CS.

Although many countries in SSA have healthcare facilities that can perform CS, the quality of care within these clinics is neither consistent nor reliable [57]. It is estimated that less than 1% of individuals in Western SSA have access to surgical care that is safe, affordable and can be performed in a timely manner [58]. Countries in SSA suffer from an overall shortage of facilities equipped to perform such specialized treatment; additionally, many countries in SSA suffer from a lack of skilled workers capable of performing specialized medicine [10]. Because previous research in Nigeria showed that only 1 in 21 health facilities were equipped to perform CS [26], it is likely that even if access to health clinics were increased, most clinics would not be equipped to perform CS safely. Increased access to trained healthcare personnel who can identify and perform life-saving obstetric procedures is needed, especially in rural areas of Nigeria.

Strengths, weaknesses and future research

This study is unique to the literature on CS in SSA given that it explored the relationship between CS and socio/demographic variables as well as different disease statuses. This allowed us to capture a holistic understanding of risk factors associated with CS in Nigeria. However, the study was not without limitations. In the overall sample, the reasons a woman had a CS were not established, nor was prior use of CS. Because our findings are derived from analysis of secondary of data, indications for having a CS could not be ascertained. The hypothesis that most CS in the study setting were for emergency complications deserves further investigation. It is possible that irrespective of obstetric indication, women with higher education and those in full time jobs could have opted for an elective CS. It is also important to think about factors such as pain management during vaginal delivery and how this affects use of CS particularly among those that have access to this service. Also, the role of cultural preference for vaginal delivery even when a CS is medically indicated, deserves elucidation. An attempt was made to control for prior CS by using the number of people in the household as well as gravidity status as proxies for prior CS; however, it is unknown if this control method was adequate. A sensitivity analysis was also performed using only primigravida women; but the number of women (N = 26) that had a CS for their first pregnancy was small. Therefore, significant relationships between CS and other variables may not have been present in this study because of lack of power. In the parent study, only the intervention group was provided onsite laboratory disease testing. Therefore, participants in the control group were more likely to have missing disease data. It is unknown if this changed the relationship between disease status and mode of delivery. Also, no follow-up occurred when women did not attend post-natal interviews. Thus, it was not possible to determine the rate of maternal mortality. Because all women in this study were self-identified as pregnant and no gestational age estimates were collected, the time between baseline survey and follow-up exit interviews when mode of delivery was ascertained varied and it is unknown how this effected the results. Finally, it is unknown whether women in rural settings truly had difficulty accessing a healthcare facility; perhaps more women in urban settings elected to have a CS. However, given the WHO estimates that 15.5% of pregnancies in Nigeria need a CS, it is likely that women in both rural and urban areas need better access to hospitals with supplies and trained doctors to perform a CS. Answering these questions is essential to understanding the barriers that women face when seeking adequate perinatal care in Nigeria.

In conclusion, rates of CS remain substantially lower in Nigeria than suggested by the WHO Working Group on Caesarean Section [7]. Findings from this study reveal that contrary to the increasing trend in use of CS in low- and middle-income countries and globally, the rate of CS among women in the study setting was low. Further research is needed to ascertain the obstetric conditions under which women in this region receive CS.


We are grateful to the Catholic Bishop of Agwu Diocese, Anglican Bishop of Enugu; Catholic Bishop of Enugu; and Anglican Bishop of Oji-River. Their support was instrumental to the successful implementation of HBI. HBI implementation would not have been possible without the support and tireless effort of the priests in the participating churches. Church-based Volunteer Health Advisors took ownership of the program and made the process of recruitment and implementation smooth for our study team and participants. This study would have been impossible to conduct without the support of PeTR-GS (our PEPFAR-supported partner) staff and volunteers.

Author Contributions

  1. Conceptualization: JG JE EJ KE SP KC AO AGO NM MO CE EE.
  2. Data curation: JG EE.
  3. Formal analysis: JG.
  4. Funding acquisition: AO AGO NM MO CE EE.
  5. Investigation: AO AGO NM MO CE EE.
  6. Methodology: JG JE EJ KE SP EE.
  7. Project administration: EE.
  8. Resources: EE.
  9. Supervision: EE.
  10. Visualization: JG JE EJ KE SP EE.
  11. Writing – original draft: JG JE EJ KE SP EE.
  12. Writing – review & editing: JG JE EJ KE SP KC AO AGO NM MO CE EE.


  1. 1. Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. 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. 2010;30:1–31.
  2. 2. Roberts CL, Nippita TA. International caesarean section rates: the rising tide. The Lancet Global Health. 2015;3(5):e241–e2. pmid:25866356
  3. 3. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014. PLoS ONE 11(2): e0148343. pmid:26849801
  4. 4. Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. 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. 2015 May 31;3(5):e260–70. pmid:25866355
  5. 5. Althabe F, Belizán JM. Caesarean section: the paradox. The Lancet. 2006;368(9546):1472–3.
  6. 6. Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC medicine. 2010;8(1):71.
  7. 7. Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM for the WHO Working Group on Caesarean Section. WHO Statement on caesarean section rates. BJOG. 2016;123:667–670. pmid:26681211
  8. 8. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and perinatal epidemiology. 2007;21(2):98–113. pmid:17302638
  9. 9. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet. 2006;368(9546):1516–23.
  10. 10. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social science & medicine. 1994;38(8):1091–110.
  11. 11. Burgard S. Race and pregnancy-related care in Brazil and South Africa. Social science & medicine. 2004;59(6):1127–46.
  12. 12. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC pregnancy and childbirth. 2009;9(1):34.
  13. 13. World Health Organization, UNICEF. Trends in maternal mortality: 1990 to 2013: estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division: executive summary.
  14. 14. Bank TW. Birth rate, crude (per 1,000 people) 2015 [2016 November 17]
  15. 15. Onoh RC, Eze JN, Ezeonu PO, Lawani LO, Iyoke CA, Nkwo PO. A 10-year appraisal of cesarean delivery and the associated fetal and maternal outcomes at a teaching hospital in southeast Nigeria. International Journal of Women's Health. 2015;7:531. pmid:25999769
  16. 16. Onah H, Ugona M. Preferences for cesarean section or symphysiotomy for obstructed labor among Nigerian women. International Journal of Gynecology & Obstetrics. 2004;84(1):79–81.
  17. 17. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria-looking beyond individual and household factors. BMC Pregnancy and Childbirth. 2009;9(1):43.
  18. 18. Cross S, Bell JS, Graham WJ. What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries. Bulletin of the World health Organization. 2010;88(2):147–53. pmid:20428372
  19. 19. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. The Lancet. 2010;375(9730):2032–44.
  20. 20. Sunday-Adeoye I, Kalu C. Pregnant Nigerian women’s view of cesarean section. Nigerian journal of clinical practice. 2011;14(3):276–9. pmid:22037067
  21. 21. Olofinbiyi B, Olofinbiyi R, Aduloju O, Atiba B, Olaogun O, Ogundare O. Maternal views and experiences regarding repeat Caesarean section. Nigerian journal of clinical practice. 2015;18(4):489. pmid:25966720
  22. 22. Jeremiah I, Nonye-Enyidah E, Fiebai P. Attitudes of antenatal patients at a tertiary hospital in Southern Nigeria towards caesarean section. Journal of Public Health and Epidemiology. 2011;3(13):617–21.
  23. 23. Aziken M, Omo-Aghoja L, Okonofua F. Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta obstetricia et gynecologica Scandinavica. 2007;86(1):42–7. pmid:17230288
  24. 24. Olusanya B, Alakija O, Inem V. Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: an observational study. Journal of biosocial science. 2010;42(03):341–58.
  25. 25. Akinola OI, Fabamwo AO, Tayo AO, Rabiu KA, Abisowo OY, Alokha ME. Caesarean section-an appraisal of some predictive factors in Lagos Nigeria. BMC pregnancy and childbirth. 2014;14(1):217.
  26. 26. Shah A, Fawole B, M'Imunya JM, Amokrane F, Nafiou I, Wolomby J-J, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. International Journal of Gynecology & Obstetrics. 2009;107(3):191–7.
  27. 27. United Nations. Sustainable Development Goals: 17 Goals to Transform Our World 2016 [July 28, 2016].
  28. 28. Wylie BJ, Mirza FG. Cesarean delivery in the developing world. Clinics in perinatology. 2008;35(3):571–82. pmid:18952023
  29. 29. Enugu State Government. Welcome to Enugu State: geographical location / demography 2017 [January 30, 2017].
  30. 30. Ezeanolue EE O M, Yang W, Obaro SK, Ezeanolue CO, Ogedegbe GG. Comparative effectiveness of congregation-versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial. Implementation Science 2013;8(1):62.
  31. 31. Department of Maternal, Newborn, Child and Adolescent Health (MCA/WHO) 2016 [January 20, 2017].
  32. 32. Drabkin DL, Austin JH. Spectrophotometric studies II. Preparations from washed blood cells; nitric oxide hemoglobin and sulfhemoglobin. Journal of Biological Chemistry. 1935;112(1):51–65.
  33. 33. World Health Organization. Development of indicators for monitoring progress towards health for all by the year 2000. 1981.
  34. 34. World Health Organization. Basic laboratory methods in medical parasitology 1991 [2016 November 17]
  35. 35. World Health Organization. Guidelines for appropriate evaluations of HIV testing technologies in Africa: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2006.
  36. 36. Mekonnen Y, Mekonnen A. Factors influencing the use of maternal healthcare services in Ethiopia. Journal of health, population and nutrition. 2003:374–82.
  37. 37. Jejeebhoy SJ. Women's education, autonomy, and reproductive behaviour: Experience from developing countries. OUP Catalogue. 1995.
  38. 38. Nwakoby BN. Use of obstetric services in rural Nigeria. The Journal of the Royal Society for the Promotion of Health. 1994;114(3):132–6.
  39. 39. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bulletin of the World Health Organization. 2007;85(10):812–9. pmid:18038064
  40. 40. Royal College of Obstetricians & Gynaecologists. The diagnosis and treatment of malaria in pregnancy. Green–top Guideline No. 54b. April 2010 [2016 November 17]
  41. 41. Wong RD, Murthy ARK, Mathisen GE, Glover N, Thornton PJ. Treatment of severe falciparum malaria during pregnancy with quinidine and exchange transfusion. The American journal of medicine. 1992;92(5):561–2. pmid:1580303
  42. 42. Samanta S, Samanta S, Haldar R. Emergency caesarean delivery in a patient with cerebral malaria-leptospira co infection: Anaesthetic and critical care considerations. Indian journal of anaesthesia. 2014;58(1):55. pmid:24700901
  43. 43. Wilson NO, Ceesay FK, Hibbert JM, Driss A, Obed SA, Adjei AA, et al. Pregnancy outcomes among patients with sickle cell disease at Korle-Bu Teaching Hospital, Accra, Ghana: retrospective cohort study. The American journal of tropical medicine and hygiene. 2012;86(6):936–42. pmid:22665597
  44. 44. Odum C, Anorlu R, Dim S, Oyekan T. Pregnancy outcome in HbSS-sickle cell disease in Lagos, Nigeria. West African journal of medicine. 2001;21(1):19–23.
  45. 45. Muganyizi P. Determinants of adverse pregnancy outcomes among Sickle Cell Disease deliveries at a tertiary hospital in Tanzania from 1999 to 2011. 2013.
  46. 46. Oteng-Ntim E, Meeks D, Seed PT, Webster L, Howard J, Doyle P, et al. Adverse maternal and perinatal outcomes in pregnant women with sickle cell disease: systematic review and meta-analysis. Blood. 2015:blood-2014-11-607317.
  47. 47. Huch R, Huch A. Erythropoietin in obstetrics. Hematology/oncology clinics of North America. 1994;8(5):1021–40. pmid:7852210
  48. 48. Huddle J, Gibson R, Cullinan T. The impact of malarial infection and diet on the anaemia status of rural pregnant Malawian women. European journal of clinical nutrition. 1999;53(10):792–801. pmid:10556986
  49. 49. World Health Organization. Sickle cell disease prevention and control [2016 November 18]
  50. 50. Gilles H, Lawson J, Sibelas M, Voller A, Allan N. Malaria anaemia and pregnancy. Annals of tropical medicine and parasitology. 1969;63(2):245–63. pmid:4190223
  51. 51. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(Supplement 2):519–617.
  52. 52. Calvert C, Ronsmans C. HIV and the risk of direct obstetric complications: a systematic review and meta-analysis. PloS one. 2013;8(10):e74848. pmid:24124458
  53. 53. Prevention CfDCa. HIV Among Pregnant Women, Infants, and Children 2014 [2015 April 4]
  54. 54. Buchanan AM, Cunningham CK. Advances and failures in preventing perinatal human immunodeficiency virus infection. Clinical microbiology reviews. 2009;22(3):493–507. pmid:19597011
  55. 55. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2013. 2013.
  56. 56. World Health Organization. HIV/AIDS 2015 [2016 November 17]
  57. 57. Kwast BE. Quality of care in reproductive health programmes: Concepts, assessments, barriers and improvements—an overview. Midwifery. 1998;14(2):66–73. pmid:10382474
  58. 58. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. The Lancet Global Health. 2015.