A STUDY ON THE PERCEPTION AND ATTITUDE OF PREGNANT WOMEN TOWARDS CAESAREAN SECTION
Objectives. To determine the perceptions and attitudes towards caesarean section [CS] among women attending maternity care at the University of Benin Teaching Hospital in Nigeria. Methods. Some 413 consecutive women, attending antenatal care in the hospital, were interviewed with a structured questionnaire that solicited information on their socio-demographic characteristics, their previous pregnancy and delivery history, and their knowledge and attitudes towards CS. Additional focus group discussions and in-depth interviews were held with women who recently underwent CS in the hospital, to gain further insights into attitudes and perception about CS in the women. Results. The women had good knowledge of CS; however, only 6.1% were willing to accept CS as a method of delivery, while 81% would accept CS if needed to save their lives and that of their babies. Up to 12.1% of women would not accept CS under any circumstances. Logistic regression showed that women’s low level of education, and past successful vaginal and instrumental deliveries, were most likely to be associated with women’s non-acceptance of indicated caesarean section. Further analysis showed that this was mainly due to inaccurate cultural perceptions of labour and caesarean section in the cohort of women. Conclusion. There is a need for programs to increase women’s and community understanding and perceptions of CS as a method of delivery in Nigeria.
Caesarean section [CS] is the most common obstetric operation performed worldwide (1). The origin of the procedure dates back to 100 BC, but authoritative evidence about the early use of the operation by obstetricians did not appear in the literature until the mid-17th century, when the classical work of Francois Mauriceau was published (1). At the onset, the operation was associated with high rates of morbidity and mortality, largely because of the low level of medical science available at the time. Consequently, its introduction into obstetric practice was greeted with misgivings and, in some instances, outright rejection. However, with advances in medical practice, there has been considerable improvement in maternal safety and neonatal outcome associated with caesarean delivery. Caesarean section is now the recommended method of delivery in several obstetric complications (2). While acknowledging the general concern about the rising rates of CS worldwide (3), CS still remains the most appropriate option for several obstetric situations (4). In developed countries, women often accept CS because of their improved understanding of its role and safety (5,6). By contrast, in many sub-Saharan African countries, several reports indicate that women are often reluctant to accept caesarean delivery (7,8). Indeed, a recent study (9) reported a gross underutilisation of CS throughout West Africa, compared to the large burden of obstetrics morbidity requiring resolution by CS. The inadequate use of early CS in African countries has been identified as a key factor in the continuing high rates of maternal and perinatal morbidity in the region (10). To date, there has been no systematic study exploring women’s knowledge and perceptions of Correspondence: Professor F.E. Okonofua, Department of Obstetrics and Gynaecology, U.B.T.H, P.M.B. 1111, Benin City, Edo State, Nigeria. E-mail: email@example.com Acta Obstetricia et Gynecologica. 2007; 86: 4247 (Received 8 December 2005; accepted 4 September 2006) ISSN 0001-6349 print/ISSN 1600-0412 online # 2007 Taylor & Francis DOI: 10.1080/00016340600994950 CS in Nigeria, and the reasons that women are averse to the procedure. Such data would be relevant for designing programs aimed at increasing women’s uptake of CS, an important intervention necessary to reduce maternal mortality in the country. The aim of this study was to determine women’s perceptions and attitudes towards CS in a tertiary center in Southern Nigeria. We believe the results of the study will contribute towards identifying strategies for improving the acceptability and uptake of CS, and reducing maternal morbidity and mortality in Nigeria.
2. Materials and methods
The study was conducted at the University of Benin Teaching Hospital (UBTH), a tertiary hospital in Benin City, Southern Nigeria. Benin City is a cosmopolitan city of /1 million inhabitants, and is the headquarters of Edo State, one of the 36 states in federal Nigeria. The UBTH provides tertiary obstetrics services to Edo State, as well as to several surrounding States. The study was conducted using quantitative and qualitative methods. In the quantitative study, a convenient sample of 413 women attending antenatal clinic at the UBTH were interviewed with a structured questionnaire. All women who attended the clinic during the period MarchAugust 2003 were approached for interview, and only those who agreed to participate in the study were interviewed. Written informed consent was obtained from each woman; they were assured of confidentiality of information obtained, and no actual names were identified in the questionnaire. The questionnaire obtained information on the women’s socio-demographic characteristics, their past and current obstetric history, and their knowledge and perceptions of different methods of delivery (including CS). The questionnaire also included questions that explored women’s willingness to accept CS in their current pregnancies if indicated, and the reasons for their chosen preferences. The questionnaires were essentially self-administered, after full explanation of the relevant sections by clinic staff. However, for non-literate women, the questions were explained by clinical staff in the local language, who also assisted them in completing the questionnaire. The questionnaires were pre-tested and validated among pregnant women in the hospital before use. Clinic staffs were also debriefed on the correct mode of administering the questionnaire before commencement of the study. Data from the survey were entered into a computer database using the EPI INFO Software. They were analysed with univariate and bivariate statistics, to provide an understanding of women’s knowledge and pattern of acceptance of various modes of delivery, including CS. Differences in rates of responses between sub-groups were compared using Chi-square test with Yates correction, as appropriate. Thereafter, the data were transformed into SPSS Pc/, and unconditional logistic regression was performed to identify the factors that predict the likelihood of women refusing CS when needed for safe delivery. The independent variables included in the model were women’s education, religion, past methods of delivery and sources of information. We also conducted focus group discussions with pregnant women and in-depth interviews with women undergoing CS in the hospital. Five focus group discussions [FGDs] were conducted, each consisting of 810 pregnant women. The FGDs explored women’s knowledge and perceptions of various methods of delivery, as well as their understanding of reasons that women prefer different methods of delivery. In particular, we elicited information on cultural beliefs in the community that may hinder or encourage the use of various forms of delivery, and how these influence women’s acceptance of caesarean delivery. In-depth interviews were held with 5 women who recently underwent CS in the hospital. The women were questioned in an open-ended manner, on their understanding of the reasons for the CS, why they accepted the operation, their experiences with the operation, their partners’ attitudes towards the operation, and whether or not they would accept the operation if asked in a future pregnancy. The interviews were necessary to document women’s current actual experiences, and their coping mechanisms following indicated CS. A well-trained team, versed in the local language and culture, conducted both the FGDs and the indepth interviews. All discussions were conducted in the local language or Pidgin English as appropriate, and audiotaped. They were then transcribed and analysed for both content and form. The results were triangulated with those obtained from the quantitative study to make inferences about the sociocultural perceptions and attitudes towards CS in the community.
3. Results of FGDs and in-depth interviews
During FGDs, women listed the methods of delivery known to them as normal vaginal delivery, ‘delivery Table I. Reasons for not accepting caesarean section as a mode of delivery in the cohort of women. Variables No. (%) Fear of death 123 (31.7) Fear of pain 113 (29.1) Cost 78 (19.8) Seen as a failure 28 (7.2) Off custom/culture 7 (1.8) Friends would laugh 6 (1.5) Husband disapprove 6 (1.5) Religion 86 (20.8) Thirty-four women gave more than one reason for not accepting CS. Table II. Logistic regression with odd ratios and confidence intervals for women’s likelihood to refuse caesarean section when offered as a method of delivery. Variables Odd ratio 95% Confidence interval Educational status Nil 3.6 1.1211.53 Primary 3.2 1.506.85 Secondary 1.7 1.082.57 Rc: Tertiary Religion None 0.54 0.093.00 Catholic 0.43 0.101.84 Protestant 0.58 0.132.58 Pentecostal 0.78 0.193.23 Rc: Islam Mode of last delivery SVD 3.59 1.448.92 Forceps/vacuum 20.66 1.95218.65 Rc: CS Outcome last pregnancy Baby went home with mother 0.47 0.141.58 ENND 1.25 0.1510.69 Rc: FSB Previous CS No 3.79 1.808.00 Rc: yes Sources of information Nurse at ANC 0.69 0.301.57 Nurse elsewhere 2.05 0.884.75 Friends 1.91 0.914.00 Rc: Doctor Rc, reference category. 44 M. Aziken et al. by operation’, forceps delivery, ‘delivery by hand’, use of pitocin injection and induction. However, when asked which women preferred, the unanimous answer was vaginal delivery. The most common reasons given for preference of vaginal delivery ranged from the pains associated with caesarean delivery, the scar left in the abdomen after the procedure, and the loss of lives often associated with CS. By contrast, normal vaginal delivery was perceived to be safer for women, to be less expensive and to be natural. The curtailment of the reproductive potential of women undergoing CS was also mentioned. According to a 25-year-old woman: ‘With normal delivery the woman can deliver as many children as possible but with CS the number of children a woman can have is limited’. The consensus was that women sometimes understood the reasons given by health providers for CS. Some of the reasons mentioned by women themselves included prolonged labour, ‘to save the life of the mother and the baby’, and ‘the baby being in the wrong position in the womb’. However, the women reported that illiterate women were less likely to understand these reasons compared to women with formal education. One woman commented as follows: ‘Most women do not understand the reason for CS, especially illiterate women and mother in-laws. The illiterate ones often feel that doctors are not patient enough to deliver the baby normally’. Overall, the feeling among the FGD participants was that women generally do not like CSs. It was felt that if women are allowed to push during delivery and with prayers, they will deliver successfully. Those who fail to deliver through the normal process are those who did not pray hard or who did not consult a native doctor before labour. The impression was that most pregnant women often consulted faith healers before embarking on labor, for rituals to be performed to ensure normal delivery and to prevent CS. It was felt that only women who did not consult faith healers before going into labour would experience difficulties in labour. Focus group participants reported a belief in the supernatural as the main determinant of the outcome of labour pervades the entire community. It was reported that women who failed to deliver normally are often accused of being witches or having been unfaithful to their husbands. Consequently, they are often asked to confess their sins before community elders. Participants were asked why women who had consulted oracles and performed necessary rituals before the onset of labour sometimes fail to deliver normally. In such instances, the perception was that doctors were not patient enough to ‘fix drips’ that would ensure normal delivery. They retorted that this was for monetary gains, as doctors often charge a lot of money for CSs compared to normal delivery. Interviews were conducted with 5 women who were recovering from recent CSs in the hospital. The women were interviewed on their experiences of CS at the time of their discharge from the hospital. The reasons for the CSs reported by the women were cephalopelvic disproportion, prolapse of the umbilical cord, prolonged premature rupture of membranes, fetal distress and maternal hypertension and placenta praevia. The reasons tallied with the reasons listed by the doctors in the case notes. As to why they accepted the operation, the women gave the following reasons: ‘to save my life and that of the baby’; ‘I agreed because I attempted delivery before with other hospitals, but with the same problem’; ‘I accepted because I felt they were right’; ‘I accepted because my scan revealed fetal distress and I wanted to save the life of my baby’; and ‘I accepted because I wanted to save my life first, and felt (the problem) was going to kill the baby’. Thus, the need to save the life of the women and their babies were the major reasons for accepting CS. They also appeared to have had confidence in the results of the clinical investigations conducted by the health providers. When asked their experiences of the current operation, they gave varied answers as follows: This is the second operation I am having and I have never had any complication from it. But my husband has not been happy with these repeated operations. I actually do not have complications but my vision is blurred. Also I feel psychologically bad since I am supposed to deliver normally like others. I had minor pains, psychologically demoralised, and my husband is not happy about it. No complication or psychological problem at all. Although I have no complication, I feel bad because I have never had CS before. This is my fifth child, with CS; I do not know why the baby decided to come out at the 7th month. Thus, there was evidence of some regret in some of the women for having undergone the operation; many were concerned about the reactions of their husbands. However, when specifically asked as to whether they regret having had the operation, the women responded that they did not, since mothers Women’s Attitudes towards caesarean section in Nigeria 45 and the babies were alive. They all reported that their husbands were not happy that they had to be delivered by CS. As to whether they will have the operation if requested for them in future pregnancies, all replied that they have no option but to accept. One woman replied in greater detail as follows: ‘I do not have any option, I will accept it because I understand that once you have done the operation once or twice, there is a high probability for you to have it again.’ The overall impressions of two women about CS based on their experience are as follows: Normal delivery is good because it was ordained by God but with CS, the pains from the stitches will be there and the constant fear of getting pregnant again, which will result in another CS, is there. Delivery by operation is not bad, although people do frown at it.
The results of this study indicate that 6.1% of pregnant women were willing to accept CS as a primary method of delivery. This finding is similar to a recent Swedish report that indicated that 8.2% of women will accept CS as a primary method of delivery (9). Pregnant women, mostly in developed (and some developing) countries, are increasingly requesting caesarean delivery for reasons ranging from the need to eliminate labor pains, the safety of their baby, and desire to avoid sub-standard intrapartum care (3,68). By contrast, the results indicate that 59% of the women are willing to accept CS if indicated, with up to 81% willing to accept it if they or their babies are at risk of death. This suggests that the need to preserve their safety and that of an infant is the major determinant of women’s acceptance of CS in Nigeria. It was of interest that as much as 19% of women would still reject CS, even at the risk of their lives or that of their babies. The latter situation contrasts with the Western world, where it is exceedingly rare that women do not choose a caesarean delivery when the obstetrician recommends it. This is because of their improved understanding of the role and safety of CS (5,6). The results of logistic regression revealed that low level of women’s education, previous successful vaginal or instrumental delivery and not having had a CS increased the likelihood that women would reject an indicated CS. This was further collaborated by the focus group discussions, where participants specifically mentioned the lack of maternal education as a factor likely to reduce the acceptance of CS. Some reasons given by women for not accepting CS included fear of death and pain, which is clearly a reflection of their ignorance of the present state of improved safety of anaesthesia and management of post operative pain. Cost as a reason for not accepting CS was given by 19.8% of the women. Other reasons, such as being laughed at by friends, husband’s disapproval, and the notion that delivery by CS is not culturally acceptable, testify to the low level of understanding of women about the need and justification for CS. The real reasons for refusal of CS were captured in the focus group discussions and in-depth interviews, where perceptions relating to reliance on faith and the supernatural to see women through labor were reported. There was very little understanding of the physiology and mechanisms of labor that could warrant CS. Rather, women believed that failed spontaneous vaginal delivery was due to lack of prayers for supernatural intervention or an offence committed by the woman earlier in life. Recourse to supernatural divination would then appear to be the solution, rather than delivery by CS. Overall, low maternal education reduces the risk perception of the real extent of these problems and accentuates the belief in supernatural methods to relieve the difficulties of labor. In Enugu, Southeastern Nigeria, Iloabachie (11), and Egwuatu and Ezeh (5), reported similar findings indicating low perception and acceptance of indicated CS by women with a low level of education. The results of this study suggest a need for specific health education of women and the community to reduce the level of beliefs about superstitions as causes of adverse pregnancy and labour outcomes, and increase women’s access to evidence-based methods of safe delivery, including CS. In particular, such education can be structured to increase women’s use of antenatal services, where more specific antenatal preparation of women has been found to enhance positive attitudes towards CS (12). The scale of this problem can be better imagined when it is recognised that this was a hospital-based study, and targeted women who were motivated to access formal health services for antenatal care and delivery. It is plausible that completely different results would be obtained if the study were to focus on women in the community, and those who use informal providers of maternity services. We believe that a community-based study will reduce the proportion of women willing to accept indicated CS, and expose more reasons for the low acceptance of CS in the community. This is because the fear of 46 M. Aziken et al. CS is one of the commonest reasons often proffered by women for not utilising formal maternity services (10), as a result of the various socio-cultural factors reported in this study. Thus, we believe that any interventions to address these problems must not only focus at the institutional level to provide specific antenatal education and counseling, but must also focus at the community level to provide broad-based community education and empowerment. In conclusion, this study reveals low acceptance of indicated CS by women at a tertiary hospital in Southern Nigeria due to women’s low understanding of the nature of the problem and adverse sociocultural and religious factors. Previous reproductive experience, such as previous stillbirth or neonatal death, and previous CS influence the level of acceptance of CS among Nigerian women. There is an urgent and critical need for programs to increase women’s and community understanding and perceptions of CS in Nigeria.
We are grateful to Becky Tita of the Women’s Health and Action Research Center, for assistance with data analysis.
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