This study was conducted in eight Rural Health Zones (RHZs) in the Beni and Lubero territories. These two territories are located in North Kivu Province in the Democratic Republic of the Congo. For approximately the past decade, insecurity linked to armed groups has affected both territories. This insecurity has led to large-scale population displacement toward major urban centers considered safer.

This was a multicenter cross-sectional analytical study examining the knowledge, attitudes, and practices (KAP) of healthcare professionals (nurses, midwives, physicians) regarding cesarean section. These healthcare professionals were assigned to the maternity wards of Healthcare Facilities (HCFs) that offered cesarean delivery services within their technical platform. The study was conducted from 1 July 1st to November 30th 2024, over a five-month period in 25 HCFs. These HCFs are distributed across eight RHZs, namely Kyondo, Musienene, Kalunguta, Lubero, Masereka, Vuhovi, Biena, and Manguredjipa.

Healthcare professionals assigned to the maternity unit of the targeted ESS were included in this study. The only obstetrician-gynecologist practicing in one of the targeted HCFs was excluded from the study. As a single individual, this participant did not allow for a meaningful statistical analysis or adequate representativeness of this professional category.

Sampling was comprehensive for physicians and midwives, whereas stratified sampling was applied for nurses, who accounted for 50% of the total health workforce. For this stratum, an exhaustive list of all nurses assigned to each facility was compiled, and each individual was assigned a unique number. Participants were then selected by simple random sampling from this list, in accordance with the number of nurses to be included in the study. All healthcare facility performing cesarean section were included exhaustively, i.e., a total of 25 facilities. Of 427 expected care professionals, 402 completed the questionnaire, yielding an overall response rate of 94%. Participation rates were 93% among physicians (109/117), 97% among midwives (132/136) and 93% among nurses (161/174). A structured 17-item questionnaire was developed by a team of three experts (one in public health and two in obstetrics and gynecology). In developing the instrument, the experts drew on theoretical frameworks relevant to each variable under study. The questionnaire was pre-tested on a sample of 25 health professionals. Following the pre-test, two items related to caesarean section practice were reworded by the expert team to improve clarity and comprehension. After validation, the questionnaire was programmed in KoboCollect. For the knowledge section, questions were primarily single-choice, and the correct answer had to be selected by checking the corresponding box. For the attitude and practice sections, items were measured using a Likert scale [14] with 5 points, except for one specific question. The latter used a 4-point scale to better reflect the available options. Nine interviewers were then trained over two days for data collection. During collection, each interviewer asked the questions and recorded responses in real time. The general characteristics of participants included age, sex, professional qualification (physician, nurse, midwife), years of practice, and EmONC training during professional practice (yes/no). To assess health professionals’ knowledge, the questionnaire covered several topics: the implications of caesarean section for future pregnancies [15] (long-term complications), the duration of physical recovery after caesarean section [16] (according to the WHO, the duration is six to eight weeks) and the option of analgesia during labor [17] (preferably nerve block). Health professionals’ attitudes toward caesarean section were explored across several themes. These included indications for caesarean section and informing patients about risks and benefits before decision-making. They also addressed the integration of educational programs aimed at promoting vaginal birth after caesarean section when necessary and the influence of social perceptions of caesarean section on the choice of delivery mode. They further concerned about the introduction of an in-depth discussion of delivery mode within antenatal care, as well as consideration of women’s preferences and wishes before scheduling a caesarean section. Regarding practice of caesarean section, questions focused on the monthly frequency of performing or assisting with caesarean sections. We predefined the required number corresponding to the Likert scale: Never (0 caesarean sections), rarely (at least two), sometimes (between 2 and 5), often (between 5 and 10), and very often (more than 10). The available human resources in health facilities that perform caesarean section (permanent presence of the anesthetist, the laboratory technician, and the pharmacy officer), as well as access to continuing education on techniques and practices related to caesarean section (availability of protocols and continuing-education schedules).

The study data were analyzed using SPSS software version 29.0. For the assessment of knowledge, attitudes, and practices, each correct answer received one point and each incorrect answer received zero points. Similarly, for each response option on the Likert scale, we assigned a numerical value ranging from 1 to 5 or from 1 to 4 depending on the item wording. Summing up the points for each item allowed us to obtain the score for the relevant items. For knowledge, attitudes, and practices, the overall score was obtained by averaging the scores of the respective items. A threshold of more than 75% has been used in several scientific studies as a performance cutoff [18][19]. Thus, the level of knowledge was considered sufficient when healthcare professionals achieved a score ≥ 75% of the maximum. Otherwise, it was classified as insufficient. The same threshold (≥75%) was applied to attitudes and practices. Attitudes and practices regarding caesarean section were considered appropriate when the overall score was ≥75% and inappropriate when the threshold was <75%. Relative and absolute frequencies were calculated for qualitative variables. The median and extremes were calculated for age. A bivariate analysis was performed to examine associations between the level of knowledge, attitudes, and practices and the independent variables one by one. Crude odds ratios with 95% confidence intervals and a p-value threshold of 0.05 were calculated. All variables showing a significant association in the bivariate analysis were entered into the binary multiple logistic regression model. Variables with p < 0.05 were considered determinants of providers’ level of knowledge, attitudes, and practices regarding caesarean section. For each retained independent variable, we calculated the adjusted odds ratio (aOR) with its 95% confidence interval and the p-value at the significance level (<0.05).

The protocol for the present study received a favorable opinion following review by the Ethics Committee of the University of Goma under N˚UNIGOM/CEM/006/2022, valid from 05 January 2022 to 05 January 2025. Confidentiality was ensured, and data were collected anonymously.

The median age was 32 years, with values ranging from 20 to 65 years.

Table 1.General characteristics of the respondents.

Table 1 shows that the majority of respondents were aged 26 - 35 years (72.64%) and female (54.48%). Among respondents, 32.84% worked as midwives, and 70.15% (n = 282) had never participated in EmONC training.

Table 2. Respondents’ knowledge of Caesarean section. For the overall recovery time after a cesarean section, intervals are defined with the upper limit excluded.

Table 2 shows that 14.93%, i.e., 60 respondents, had an adequate level of knowledge about overall post-caesarean recovery, the implications of caesarean section for future pregnancies, and analgesia during labour.

Table 3. Respondents’ attitudes toward Cesarean section.

Table 3 shows that 195 respondents (48.51%) agreed that caesarean section is reserved for medically necessary cases. Regarding the introduction of caesarean-section topics into the ANC program, more than 60% of respondents had an appropriate attitude for each topic.

Overall, the attitude was appropriate among 119 respondents, i.e., 29.6% (Table 3).

Table 4. Respondents’ practices regarding Cesarean section.

Table 4 shows that 111 (27.61%) had often practiced or assisted in a cesarean section. In practice, 223 (55.47%) found acceptable the availability of the resources required to perform cesarean sections. In contrast, 201 (50%) had limited access to continuing training on techniques and practices related to cesarean section.

Table 5. Bivariate analyses of factors associated with knowledge.

Appropriate attitudes and practices, as well as EmONC training, are significantly associated with adequate knowledge of cesarean section (Table 5).

Table 6. Bivariate analyses of factors associated with attitude.

Table 6 shows that the midwife qualification and having received EmONC training were associated with an appropriate attitude toward caesarean section.

Healthcare professionals aged 36 - 45 years were associated with appropriate caesarean section practices. In addition, those who had completed EmONC training were more than six times more likely to have appropriate caesarean section practices than those who had not received this training (Table 7).

Table 7. Bivariate analyses of factors associated with the practice.

Table 8. Multivariable logistic regression of factors associated with knowledge, attitudes, and practices regarding Caesarean section.

Age ≤ 25 years was used as the reference category.

Table 8 indicates that training in EmONC was associated with sufficient knowledge, as well as appropriate attitudes and practices regarding caesarean section. In addition, sufficient knowledge was also a facilitating factor for the adoption of appropriate attitudes and practices.

Table 1 shows that the most represented participants were women aged 26 - 35 years. In addition, 132 participants (32.84%) were midwives. Moreover, most had between 5 and 10 years of professional experience. These findings are consistent with those of a study conducted in Tanzania, in which the authors reported that the majority of maternity staff were relatively young, trained as midwives, and had at least seven years of professional experience [20].

The results of this survey show that respondents had an insufficient level of knowledge regarding the consequences of caesarean section for subsequent pregnancies. This finding is consistent with the results reported by Kamal et al. in a study conducted in Saudi Arabia [21]. The consequences of this deficit will repeatedly be evident during antenatal care (ANC) visits, when pregnant women with a scarred uterus are deprived of useful information on vaginal birth after caesarean (VBAC) [22]. Moreover, this lack of information may increase the risk of maternal-fetal complications, due to insufficient anticipation in the management of long-term caesarean-related complications [23]. In the present study, respondents’ knowledge of the usual duration of physical recovery after caesarean section was found to be inadequate. According to WHO recommendations, physical recovery after caesarean section generally lasts six to eight weeks, and this topic should be addressed during postnatal consultations [16]. Adequate knowledge of this timeframe enables health professionals to provide women with realistic information regarding the gradual resumption of daily, occupational, and sexual activities after childbirth [16]. In his study on postpartum recovery, Frijmersum found 15 weeks as the median duration of recovery after caesarean delivery. He therefore considered the six-to-eight-week recovery period recommended by the WHO to be insufficient for physical recovery after caesarean section [24].

The results of the present study highlighted that healthcare professionals had an insufficient level of knowledge regarding the different analgesic routes during labour. Bitew et al. reported that, in resource-limited settings, inadequate knowledge related to labour analgesia is associated with neglect, which is itself influenced by sociocultural perceptions of labour pain [25]. Indeed, as Mwakawanga noted, in some sub-Saharan African contexts, labour pain is often perceived as a natural phenomenon that does not require specific management [26]. This perception contradicts the WHO-promoted approach of humanized, person-centred care. The WHO recommends that all women should have access to analgesia throughout labour [27]. Moreover, in the DRC, in addition to these perceptions surrounding labour pain, the shortage of anaesthesia specialists also constitutes a major constraint on the implementation of obstetric analgesia [28]. Regarding participants’ attitudes, most participants agreed that caesarean section should be performed when medically necessary. They also believed that women should receive clear information about the benefits and risks of this intervention before making a decision. These results are consistent with WHO recommendations, which advocate using caesarean section only when medically justified [3]. Concerning informing pregnant women about the risks and benefits of caesarean section, the attitude adopted by most professionals proved appropriate. Indeed, according to WHO recommendations regarding postpartum follow-up, it is the responsibility of health professionals to provide women with systematic, clear, and understandable information on the benefits and risks associated with caesarean section [27]. This helps to strengthen patients’ autonomy and to limit the use of caesarean sections that are not medically justified. However, less appropriate attitudes alone are not sufficient to bring about positive change. Certain factors interfere with its implementation, including high workload, lack of specific training in communication, organizational constraints, and sociocultural barriers [29].

Most respondents stated that adherence to guidelines was important. In Rwanda, researchers found that most professionals did not comply with the WHO protocol for caesarean section practice [30]. Although our respondents considered adherence to the protocol important, in practice the observed situation is similar to that reported in Rwanda. We believe this may be due to limited monitoring of protocol implementation through formative supervision by managers of health facilities.

A very small proportion of respondents reported having access to continuing education on techniques and practices related to caesarean section. This gap has been observed in low-resource countries. Nevertheless, the authors unanimously agree that continuing education improves knowledge, and that new knowledge enhances competence [31].

The present study highlights a significant association between professional qualification (physician and midwife) and the level of knowledge regarding caesarean section. This finding supports the argument advanced by Frenk et al. [32], who believe that an imbalance exists in the local labour market. In their view, the problem is systemic. A mismatch is observed between the expected professional training and the degrees awarded. This situation generates a further mismatch between the skills acquired and the needs of patients and the population.

In this study, knowledge, attitude, and practice were not associated with age or experience. For Cho et al., age alone does not necessarily have a positive impact on cognitive aspects. To observe a beneficial effect, other factors must be involved, such as the environmental context, culture, or health status [33]. Moreover, Sobczak adds that, in the acquisition of knowledge, individual motivation plays a central role, particularly curiosity and the effort to remain regularly up to date [34]. Although experience is often considered a driver of knowledge and good practice, our results show that it is not associated with knowledge, practice, or attitude. This suggests that experience alone, in the absence of favorable conditions such as repetition, diversity of contexts, and support, is insufficient to develop appropriate skills or behaviors [35]. Moreover, training in Emergency Obstetric and Neonatal Care (EmONC) was associated with a higher level of knowledge. Indeed, capacity building among providers improves their skills in emergency obstetric and neonatal care and enables more appropriate practices, as demonstrated by studies conducted in Africa [36][37].