CLINICAL ARTICLE Obstetricians' opinions and attitudes toward maternal refusal of recommended cesarean delivery in Nigeria Chibuike O. Chigbu ⁎, Cyril C. Ezenyeaku, Eziamaka Ezenkwele Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria abstract article info Article history: Received 15 December 2008 Received in revised form 31 December 2008 Accepted 16 January 2009 Keywords: Cesarean delivery Nigeria Patients' refusal Obstetricians' attitude Objective: To assess the opinions and attitudes of Nigerian obstetricians toward women's refusal of cesarean delivery. Method: We used a questionnaire with 5 clinical scenarios drawn from published cases in which Nigerian women refused to undergo a recommended cesarean delivery. Results: Most obstetricians (84.8%) advocated continuous counseling of these women but, from their response to the scenarios, few (13.7%–16.1%) would actually do so. Insufficient facilities and poor logistics for emergency obstetric care were their stated major reason for not respecting maternal choices in situations where vaginal delivery could have been given a chance. Conclusion: The possibility of providing emergency obstetric care would remove many indications for cesarean delivery from the list of absolute indications in Nigeria; and management guidelines would protect obstetricians in the event of litigation, and improve their acceptance and respect of maternal choice. © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Cesarean delivery is one of the most common and controversial surgical interventions in obstetrics. Traditionally, it has been indicated when vaginal delivery is considered dangerous for the fetus, the mother, or both. In recent times, the indications have expanded to include convenience and maternal preference. The concept of cesarean birth on maternal demand, without a medical indication, has taken center stage in the discourse on cesarean delivery in high- income countries. On the other hand, maternal refusal of indicated cesarean delivery, even in the case of absolute necessity, has been a continuing concern in many low-income countries [1]. Only a few published reports have given evidence-based insight into the complexity of maternal refusal of recommended cesarean delivery in low-income countries, however [1–3]. One from Nigeria states that 24% of all recommended women decline the procedure in that country [2]. This represents a huge maternal and fetal risk, given that cesarean delivery is recommended as a last resort in low-income countries, where resources are scant. This Nigerian report also states that physicians can deny further medical care to women who decline their recommendations, which causes the women to seek alternative care, with significant adverse outcome [2]. Another report from Nigeria states that 25% of women dying in labor before reaching a hospital have postponed seeking formal medical care because of their fear of undergoing a cesarean delivery, according to the women's relatives [4]. In Bangladesh, maternal refusal of a cesarean delivery has been identified as a major contributor to the low national cesarean delivery rate of 2.4% [5]. Whereas the reasons for maternal refusal are well documented in the first Nigerian report cited, the reasons for the obstetricians' denial of further care are not known. The publication of that report raised concern about supposed paternalistic attitudes on the part of obstetricians from low-income countries—resulting in their own refusal of maternal autonomy, thereby contributing to maternal and neonatal mortality and morbidity [6,7]. The attitudes of obstetricians toward women who refuse a cesarean delivery have only been studied in high-income countries [8]. The present study was conducted in Nigeria to explore the opinions and attitudes of obstetricians regarding women's refusal of surgical delivery in scenarios where the intervention would be considered absolutely necessary. Knowing the attitudes and opinions of obstetricians in a low- income country will help placing this matter in its proper context. Furthermore, considering the serious implications of the matter [2], insights could emerge on how to address it. 2. Methods A self-administered structured questionnaire was distributed to obstetricians attending the 41st Annual Conference of the Society of Obstetricians and Gynecologists of Nigeria in Benin City, Nigeria, which was held from November 14 to November 17, 2007. The questionnaire was also sent by e-mail to obstetricians who did not attend the conference. It had been tested in a pilot study with a random sample of obstetricians from Eastern Nigeria. International Journal of Gynecology and Obstetrics 105 (2009) 248–251 ⁎ Corresponding author. E-mail address: chchigbu@yahoo.com (C.O. Chigbu). 0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2009.01.012 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo