Knowledge, Perception, and Attitude Towards Caesarean Delivery among Women and Service Providers: Insights from High-Prevalence Regions in India

Background: Cesarean section (C-section) rates in India have risen markedly, especially in private facilities and specific regions, often surpassing WHO recommendations. This trend raises concerns about overuse, informed consent, and maternal autonomy. The study explores knowledge, perceptions, and attitudes toward C-sections among pregnant and recently delivered women. Methods: A cross-sectional mixed-methods study conducted in 11 districts across five Indian states included interviews with 2,362 women (955 pregnant, 1,407 recently delivered) at public and private facilities. Composite indices assessed knowledge (21 items), perception (27), and attitude (19) toward C-sections. Qualitative insights were drawn from 37 interviews with obstetricians and gynecologists in four states. Results: While most women were aware of vaginal (99%) and cesarean (86%) deliveries, awareness of assisted deliveries was notably low (9%). Information sources were primarily family and relatives (56.1%), with limited engagement from healthcare providers (16%). Knowledge, perception, and attitude scores varied significantly by religion, caste, income, education, and reproductive history, with higher scores associated with older age, delayed marriage, prior cesarean experience, and chronic health conditions. These patterns were reinforced by qualitative insights, which highlighted the influence of personal experience and social context on women's understanding and attitudes toward delivery modes. Conclusion: Despite widespread awareness of C-sections, knowledge and attitudes vary, especially among disadvantaged groups. Limited involvement of health professionals in the delivery of education underscores the need for stronger antenatal and postnatal counselling. Equity-focused interventions are vital to support informed choices and reduce unnecessary C-sections. Keywords: C-section, maternal health, knowledge, perception, attitude, quantitative, qualitative, India.