The burden of caesarean section refusal in a developing country setting CO Chigbu, GC Iloabachie Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Correspondence: Dr CO Chigbu, Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu 400001, Nigeria. Email chchigbu@yahoo.com Accepted 22 May 2007. Objective To investigate the prevalence, aetiology and outcomes of caesarean section refusal in pregnant women. Design A prospective controlled study. Setting University of Nigeria Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria. Population A total of 62 Nigerian women who declined elective caesarean section. Method Interviewer-administered questionnaires at the time of caesarean section refusal and postdelivery. The delivery outcomes of the subjects were compared with that of a matched control group of women who accepted caesarean section. Main outcome measures Prevalence, maternal reasons for caesarean section refusal and the resultant maternal and perinatal mortality. Results The prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal delivery and inadequate counselling. Outcomes were significantly worse among women who refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%, P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001). Conclusion There is a high prevalence of caesarean section refusal in south-eastern Nigeria. Women declining caesareans have very poor maternal and perinatal outcomes and need extra support. Keywords Burden, caesarean, country, developing, refusal. Please cite this paper as: Chigbu C, Iloabachie G. The burden of caesarean section refusal in a developing country setting. BJOG 2007;114:1261–1265. Introduction Maternal aversion to caesarean section is well known in devel- oping countries. 1,2 While developed countries are dealing with the ethical and legal issues associated with caesarean section on maternal request, 3,4 developing countries are still struggling with issues of refusal of caesarean section even in the face of obvious defined risks of maternal and perinatal mortality and morbidity. The actual population of women who rejected caesarean section in real-life clinical practice has not been previously studied in an African setting. While the contribution of caesarean section to maternal mortality has been reported, 2 no report exists on the consequences of refusing caesarean section in a setting with limited health facilities. Knowledge of the reasons for refusing caesarean section and the resultant delivery outcome are important to show the consequences of such decisions and to provide a basis for developing appropriate strategies to improve the acceptance of caesarean section. This study examined the prevalence, causes and outcomes of pregnancies of women who refused caesarean section for a defined risk. Methods Setting The University of Nigeria Teaching Hospital is a tertiary hos- pital that serves as a referral centre for the south-eastern Nigerian states of Enugu, Abia, Imo, Ebonyi, Anambara and Benue states. Aghaeze Hospital is a specialist hospital for women located at Enugu metropolis. In these units, the con- sultants and senior registrars usually make the decision to recommend an elective caesarean section to a woman, and they usually do the counselling. However, due to heavy work pressure, it is not infrequent for more junior doctors in the unit to counsel the women instead. Although there is no fixed time point for informing the women, in most instances, the women are informed as soon as the decision is made. Most ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology 1261 DOI: 10.1111/j.1471-0528.2007.01440.x www.blackwellpublishing.com/bjog Intrapartum care