Pre-eclampsia is a major cause of maternal and perinatal mortality worldwide [1]. While the symptoms and complications of Pre-eclampsia are well known and far-reaching, the exact etiology remains unknown [2]. Pre-eclampsia has remained a significant public health threat in both developed and developing countries contributing to maternal and perinatal morbidity and mortality globally [3]. Severe hypertension is described in the 2021 ISSHP guidelines as a situation where the Systolic blood pressure remains ≥ 160 mmHg and/or diastolic blood pressure remains ≥ 110 mmHg [1]. Pre-eclampsia is a pregnancy-related hypertensive disorder occurring usually after 20 weeks of gestation. If left untreated, it progresses to eclampsia. Thus, the aim of this study is to highlight the decision challenges of choosing caesarean section or natural birth by pregnant women with Pre-eclampsia in Ado- Ekiti, Ekiti- State, Nigeria.

The number of maternal deaths in Nigeria is still very high as about 59,000 women die annually in Nigeria. This accounts for 10.0% of the world total maternal mortality rate. Globally, over 500,000 women die annually from complications arising from pregnancy, delivery and puerperium [4], [5], [6]. Maternal mortality is one of the indices used to evaluate a country’s health care delivery and country’s economic developmental stage. For women of childbearing age in Nigeria, complications arising from pregnancy remain a major threat [7], [8]. Pregnancy induced hypertension (PIH) is a condition specific to pregnancy which is a syndrome of hypertension with or without proteinuria, with the clinical manifestation usually occurring during the 20th week of gestation or late in pregnancy and regressing after delivery. It is a condition that combines high blood pressure with excess protein in urine and leading to swelling of mother’s hand and face and damage to other organs of the body if not properly managed [9].PIH is a leading cause of maternal and perinatal mortality and can also lead to long term health problem like kidney failure, chronic hypertension, or nervous system disorders [10], [11]. It is a major pregnancy complication that can cause premature delivery, fetal growth retardation, abruption of placenta and fetal death, maternal mortality, morbidity and disability [9]. In Nigeria, the prevalence of Pre-eclampsia ranges between 2% to 16.7% [3].

Delivery of the infant and placenta is the only effective treatment of PIH. Theoretically, the benefits of faster interruption of pregnancy through a cesarean section would be greater [12]. Delivery at an earlier gestational age, however, is associated with an increased risk of adverse neonatal outcome [13]. Women with Pre-eclampsia have an increased rate of cesarean section consequent upon the high incidence of intrauterine growth restriction, fetal distress and prematurity [2]. A cesarean section is the delivery of a fetus through an abdominal incision (laparotomy) followed by a uterine incision (Uterotomy), regardless of whether the fetus is alive or dead [14]. On one hand, cesarean section can be a life-saving operation for a fetus in jeopardy; on the other hand, it increases the risk of cardiopulmonary morbidity associated with Pre-eclampsia. This is due to the altered hemodynamics in women with Pre-eclampsia [2], [15]. However, taking a decision to choose cesarean section over natural birth can be demanding especially in a situation where the condition is yet to graduate into eclampsia.

Decision-making may perhaps be deliberated as a conceptual/mental (cognitive) process which finally results in hands-on opting for or picking among different alternatives [16]. A final choice is the end result of every process of making decision which is either an idea or an action [17]. Decision-making is an analytical process which ends when a substantial clarification is reached [18] hence, decision-making may perhaps be deliberated as a challenging and sensitive process which could be (ir)rationally established on inherent/explicit assumptions. Values, culture, views, personality, belief systems, understanding of the decider(s), attitude and approach are pedestals which the process of decision-making is done [19], [20]. The process of decision-making when it comes to personal issues, encompasses less rationality. Individual behavior and actions are therefore the bedrocks for most of the decisions taken [21].

The foremost processes involved in decision-making is made up of identification of the situation, alternative generation, evaluation/consideration and choice, follow-up and implementation. It is noteworthy that in the task of decision-making, the better decision is taken when the authority deciding is closer to the basis of the problem [22]. Decision-making process as regards the kind of delivery in pregnant women with Pre-eclampsia can be a challenge for both the patient and the physician with the benefit from the Shared decision making (SDM) model in mind. Universal guidelines advocate that at eight months of pregnancy, the mode of delivery and every vital information is shared with patient paying special attention to the predisposing factors and emphasizing the satisfaction and danger of both natural birth and elective cesarean delivery [23]. Doctors have a duty at that moment to re-examine the patient and authenticate the understanding of the provided information to review the patient’s decision making in the subsequent meetings and make every effort to honor her ultimate decision [24].

Shared decision making (SDM) is a decision making model practice whereby patients have the support of their physicians or doctors when it comes to choice of birth while taking into consideration their underlying health condition, preference and value they place on their birth choice [25]. Even though the best method is considered when it comes to clinical happenstance, the execution of SDM is very perplexing, predominantly in populaces where literacy level is quite low, in settings where overprotective model is still desired, or in situations where there is limited access to aids. This is also an issue when it comes to pre-existing or underlying health challenge like Pre-eclampsia during pregnancy which most women have no idea of in developing countries especially in Nigeria.