Date of Award


Document Type


Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Dr. Khairunnisa Dhamani

Second Supervisor/Advisor

Dr. Abraham Mukaindo

Third Supervisor/Advisor

Dr. Evans Sequeira


Obstetrics and Gynaecology (East Africa)


Background: The rates of caesarean sections have continued to rise despite public and professional concern. This has continually increased the proportion of the obstetric population with a history of previous caesarean delivery. These women may be offered either elective repeat caesarean section (ERCS) or planned vaginal birth after caesarean delivery (VBAC). This study aimed to identify the timing, level of knowledge and factors that influence the decision-making.

Objectives: The primary objective was to elicit the factors that contribute to women to choose VBAC or ERCS. The secondary objectives were to determine the timing of this decision, measure the level of knowledge informing this decision and ascertain the level of conflict expectant women with one prior c-section delivery experience with the decision of ERCS versus VBAC.

Design and methodology: Patients attending the Maternal and Child Health Clinic at the Aga Khan University Hospital, Nairobi (AKUH-N) with one previous caesarean section and pregnant in their third trimester were recruited into the study. Data was collected using two approaches: a validated, quantitative 5- 10 minute Decision Conflict Scale (DCS) questionnaire followed with a 10 minute semi-structured interview. Interviews were transcribed verbatim and sorted into codes, categories and themes manually. DCS scores were analysed using descriptive statistics.

Results: Using consecutive sampling, twenty-three women were assessed for eligibility. Twenty-one women consented to the study, however only twenty women completed the data collection. Saturation was achieved after 14 interviews but six more interviews were conducted to confirm no other information could be obtained. From the interviews, fifty-one codes emerged which were grouped into eleven categories and then three themes. Several factors influenced the participants’ decision on mode of delivery. The leading factor that influenced the participants to choose ERCS was the fear of labour pains while desire to experience ‘normal’ birth was the leading factor that led the participants to choose VBAC. Approximately half of the participants made the decision on the mode of delivery during the interval between the two pregnancies. Nineteen participants scored less than 25 in the DCS and so all but one of the participants were more likely to implement their decision. In the informed subscale score, all the participants scored low scores implying that they were aware of the risks and benefits of each option. However, during the interviews less than half of the participants were able to mention any risk or benefit of either option.

Conclusion: Several factors e.g. fear of labour pains, desire to experience ‘normal’ birth influence women’s decision on mode of delivery after one previous c-section. This decision is not always based on actual facts that consider the risks and benefits of each option but rather on assumptions and misconceptions e.g. that either option is without any risks. For a majority of women, previous delivery experiences and information that they gained from family and relatives helped them make this decision. This results in women being decisive on the mode of delivery during subsequent pregnancies and the decision is usually made during the interval between the two pregnancies.

Recommendations: As part of pre-conception care, women with one previous c-section should have a detailed discussion of their options for delivery during a subsequent pregnancy. This discussion should be individualized taking into account the woman’s preferences, her attitudes towards the risk of rare but serious adverse consequences, future pregnancies plans and her chances of a successful VBAC. Fear of labour pains could be addressed by advocating pain relief strategies in labour e.g. epidural analgesia.