Background to the Study
The trend of acceptability and the rate of cesarean delivery have been on the increase in the developed countries in the last three decades due to the current safety of the procedure (Sunday-Adeoye and Kalu 2011), conversely, in the developing countries, the change in cesarean delivery rate has been less dramatic during the same period. While developed countries are dealing with the ethical and legal issues associated with caesarean delivery on maternal request, developing countries are still struggling with issues of refusal of caesarean delivery even in the face of obviously defined risks of maternal and perinatal morbidity and mortality. Kwawukume (2001) stated that in developed countries women often accept caesarean delivery because of their improved understanding of its role and safety, and the increasing importance of the right to self decision making regarding mode of delivery. By contrast, in developing countries women are reluctant to accept cesarean delivery, which may be as a result of many factors such as their traditional beliefs and socio-cultural norms as well as financial problems. Cesarean delivery is still being perceived as an abnormal means of delivery by some women in the developing countries. Sunday-Adedoye and Kalu (2011) affirmed that among women in the developing countries, cesarean delivery is still being perceived as a curse on an unfaithful women and the lot of weak women. They further noted that cesarean delivery was viewed with suspicion, aversion, misconception, fear, guilt, misery and anger.
In developed countries court-ordered caesarean deliveries are performed on mentally competent women on their refusal to the procedure. It was carried out when a woman refused the operation in circumstances where it was considered to be essential for the safety of herself, her baby or both, and following a court application made by doctors or hospital administrators (Chigbu & Iloabuchi, 2007). Unfortunately, no such order exists in most developing countries particularly in Nigeria where there is prevalence of this refusal of cesarean delivery.
Studies have established that maternal aversion to caesarean delivery is prevalent in developing countries especially in Sub-Saharan Africa. According to Behaque (2000) in Nigeria, as in most Sub-Saharan African countries, it has been suggested that women accept cesarean delivery reluctantly even in the face of obvious clinical indications. Thus, Awoyinka, Ayinde and Omigbodun (2006) noted that despite the well-documented record of safety of cesarean delivery, there are strong aversion of women in sub-Saharan Africa to the procedure (cesarean delivery), even in the presence of life-threatening indications. Okonta, Okali, Otoide and Twomey (2002) affirmed that refusal of life cesarean delivery is not uncommon among women in urban settings in Sub- Saharan Africa particularly in a country like Nigeria which is a leading contributor to both local and regional burden of maternal mortality.
Though the actual population of women who rejected caesarean delivery in real-life clinical practice has not been established in the previous studies in an African setting, many studies have reported that there is a mass rejection of cesarean delivery in Africa and other developing countries. For example a study conducted by Saoje, Nayse, Kasturwar and Relwani (2011) reaveled among other findings that 91.5 percent of the women in their study show preference to vaginal delivery against cesarean delivery when asked for their preferred mode of delivery. Orji, Ogunniyi and Onwudiegwu; (2003) affirmed that there is a general aversion to cesarean delivery in developing countries such as Nigeria, giving rise to difficulties in persuading patients to undergo surgery even in the context of obstetric emergencies. They further stated that reasons for these are grounded in social misconception, religious views, fear of surgical complications and cost.
While the contribution of caesarean delivery to maternal mortality has been reported in literature, the safety of elective cesarean delivery has not been well reported. Most of the literature on the maternal and neonatal outcomes following cesarean delivery addresses the emergency cesarean delivery, and this may not be comparable to elective cesarean delivery. Cesarean delivery is classified as elective if the decision to perform the operation was made before onset of labour, even when labour started before the operation. All others were considered as emergency. Finger (2003) posited that in those women who are having a scheduled procedure, the decision has already been made that the alternate of medical therapy, that is, a vaginal delivery, is least optimal. For other patients admitted to labour and delivery, the anticipation is for a vaginal delivery. Every patient admitted in this circumstance is admitted with the thought of a successful vaginal delivery. However, if the patient’s situation should change, a cesarean delivery is performed because it is believed that outcome may be better for the fetus, the mother, or both. The relative safety of elective cesarean delivery has seen a rise in the number of women being delivered in this way in developed countries. Gonen, Tamir and Degani, (2002) noted that most maternity units in the UK deliver between 10 and 20 per cent of babies by caesarean delivery.
Women in the developed countries like America, United Kingdom, Brazil, Northern Ireland and Canada, show favourable attitude towards cesarean delivery and some consider it the best option for themselves, while women in Sub Saharan Africa distaste it. WHO (2006) reported that in most African countries women may refuse surgery because of fear of suffering and other cultural perceptions of womanhood. Olusanya and Solanke (2009) affirmed that non-vaginal delivery is generally viewed in Nigeria as a sign of maternal laziness, reproductive failure or a curse from perceived enemies or deity in this population. It was therefore not uncommon even where cesarean delivery was indicated by past pregnancy history for women to attempt vaginal delivery until there was a glaring failure with obvious threat to the life of the mother or unborn child. Aziken, Omo-Aghoja, and Okonofua (2007) noted that qualitative studies have established that some women will not even accept cesarean delivery under any circumstances for reasons such as the fear of pain or death, financial cost, embarrassment by friends, religious beliefs and husband’s disapproval. The delays associated with these and other factors may have contributed to the high proportion of emergency cesarean delivery, maternal and fetal disability as well as maternal and fetal mortality.
A cesarean delivery (C-delivery) is a surgical procedure in which one or more incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies (Roberts, Algert & Douglas, 2002). Pieter and Dongen (2007) also defined C-delivery as the surgical removal of the fetus through an incision made in the wall of the abdomen and in the uterus, usually used as an alternative when natural delivery through the vagina is considered risky. A C-delivery is usually performed when a vaginal delivery would put the baby’s or mother’s life or health in jeopardy; although in recent times it has been also performed upon request for childbirths that could otherwise have been natural. According to Olsen, Ndeki and Norheim (2005) the procedure has been included in the package of comprehensive emergency obstetric care by World Health Organization (WHO). C-delivery is performed for maternal indications, fetal indications, or both. According to Chong and Mongelli (2003), in some situations a C-delivery may be the only safe option for mother and baby. For the purpose of this study, C-delivery is defined as the surgical removal of a baby through a cut (incision) in the mother’s belly and uterus used when natural delivery (vaginal delivery) is unsafe for the mother, baby or both. C-delivery is usually referred to as cesarean section (C/S).
While C-delivery is often performed for legitimate medical reasons, the procedure is still a major surgery and is not without risk. Thus Hellums, Lin and Ramsey (2007) stated that even with a “successful C-delivery,” the woman is not out of danger. They maintained that the surgery poses mortality risks to the mother and the fetus, which is often twice higher than the vaginal birth. Doctors consider all of these factors in their decision about whether a woman needs a C-delivery. However while doctors share the goal of birth of a perfect baby to a healthy mother, there may be other concerns that affect the decision. Studies have established that women have become more educated about the procedure due to increased focus on the issue, but with all the information and knowledge, they may still express a negative attitude towards C-delivery by their profound refusal of the procedure. Ezechi, Fasubaa, Kalu, Nwokoro and Obiesie (2004) revealed that the 6224 patients (100 % of the study population) interviewed know what C-delivery is, however only 33.3 per cent knows reasons for performing C-delivery. While only 28.9 per cent will accept C-delivery on doctor’s advice, 71.1 percent will not accept C-delivery for any reason, 26.8 per cent of the patients that have had previous C-delivery prefer to die while attempting vaginal delivery than to have a repeat C-delivery. Thus, a pregnancy power struggle could result in which the doctor wants to perform a procedure that the woman does not want. Unlike a normal doctor-patient relationship, this attitude of women towards C-delivery affects an unborn third party.
Attitude as defined by Allport, (1985) are the tendencies to evaluate an entity with some degree of favour or disfavour ordinarily expressed in cognitive, affective, and behavioral responses and formed on the bases of cognitive, affective and behavioral processes. Attitude is a predisposition to act in a certain way towards some aspect of one’s environment including other people, object and events. It can be positive or negative and can affect the behaviour of an individual. Breckler and Wiggins (1992) posited that attitude has a profound influence on behaviour by influencing the perception of objects and peoples exposure to and comprehension of information and choice of friends. Attitude therefore can be described as a dynamic element in human behavior, the motive for activity. Park (2009) noted that success or failure in life depends upon attitudes.
When attitude relates to cesarean delivery, it is called attitude to cesarean delivery (ACD). Attitude to cesarean delivery in the context of this study refers to the tendencies of the pregnant mothers to evaluate cesarean delivery with some degree of favour or disfavour ordinarily expressed in cognitive, affective and behavioural responses. It is the feelings which predispose pregnant mothers to respond either positively or negatively towards C-delivery. This study sought to find out the attitude of the pregnant mothers towards accepting C-delivery, towards those who undergo C-delivery and towards the medical staff who execute C-delivery. A positive attitude to cesarean delivery will lead to acceptance of the procedure while negative attitude will lead to non acceptance and a consequent emergency C-delivery or maternal and fetal disability and mortality. Aziken, Omo-Aghoja and Okonofua (2007) revealed that women exhibits an unfavourable attitude to C-delivery. However, Awoyinka, Ayinde and Omigbodun (2006) concluded that with proper health education, especially during antenatal care, many more women would find C-delivery acceptable.
Antenatal care (ANC), also known as prenatal care is one of the “four pillars” of safe motherhood, as formulated by the Maternal Health and Safe Motherhood Programme Division of Family Health, of the World Health Organization (WHO 2006). Antenatal care was defined by Bassavanthappa (2008) as the advice, supervision and attention a pregnant woman receives to ensure good health throughout the period up to having a live healthy baby at the end of the pregnancy. The aim of good antenatal care is to detect any potential problems early, to prevent them if possible and to direct the woman to appropriate specialists or hospitals, if necessary. So much of what is discussed in the general antenatal classes is actually highly relevant to women faced with the possibility of having their babies by C-delivery, they are just needed to be helped to make the connections. During the class, the teachers focus for some time on the reasons why a C-delivery may be required (situations when it is the most likely outcome). The emphasis is on identifying problems, finding ways to cope and enabling parents to be positively involved in their care. The aim of these teachings is to create a positive cesarean experience in the pregnant mothers thereby making them to adopt a favourable attitude towards the procedure.
A mother as defined by Brocklehurst and Volmink (2003) is a female person who is pregnant with or gives birth to a child. A pregnant mother is a woman carrying one or more fetuses, in the womb. For the purpose of this study, a mother is a female person who is pregnant, or has had previous pregnancies. Pregnancy being one of the most important periods in the life of a woman, a family and a society, necessitates that an extra attention be given to the pregnant woman. This attention is best provided in an organized health institution such as general hospitals.
General hospital is described by Risse (1990) as the best-known type of hospital which is set up to deal with many kinds of health problems. General hospitals normally have emergency departments to deal with immediate and urgent threats to health and as such provides emergency obstetric care of which C-delivery is part of. Within the context of this work, general hospitals are the government owned tertiary health institutions set up to deal with various health problems including obstetrics services.
Ideally C-delivery should not replace the normal birth method- vaginal delivery; it is just a child of necessity. If one is pregnant, chances are good that they will be able to deliver through the birth canal (vaginal birth). But there are cases when a C-delivery is needed for the safety of the mother or baby. When possibility of normal delivery is remote and threatens the life of the mother, child or both, an alternative means must be employed. For woman at the point of death to refuse the only option she has to live with her baby is deplorable. So even if the plan is on a vaginal birth, it’s a good idea to have a positive attitude towards C-delivery, in case the unexpected happens. Moreover there is no doubt that a positive C-delivery is infinitely preferable to a traumatic vaginal delivery.
C-deliveries are performed as a result of obstetric complications which may develop anytime during the pregnancy. These complications as noted by Finger (2003) are breech presentation, dystocia, fetal distress, cord prolapsed, placenta previa, placental abruption , failure to progress in labour, uterine rupture, multiple births, cephalopelvic disproportion, active genital herpes, diabetes preeclampsia, birth defects and repeat cesarean delivery. Rooks, Winikoff, and Bruce (1990) noted that women not identified as “high-risk” can and do develop obstetric complications. They further stated that most obstetric complications occur among women with no risk factors. The majority of C-deliveries are performed because of some difficulty arising during the labor and delivery process. One may be pushing with all her might, but baby still refuses to make his or her way down the birth canal. In cases like these, a C- delivery is often recommended.
However, Onah (2002) submitted that Nigerians appear to view childbirth as a natural, at times, lengthy phenomenon; as such, it is not unusual to avoid analgesia and medical intervention, such as C-delivery. This perception may be a contributing factor to maternal and fetal mortality in Nigeria and other African countries. Okonufua (2011) affirmed that the negative view and perception of C-delivery by women in the developing countries has led to gross underutilization of the procedure compared to the large burden of obstetric morbidity requiring resolution by C-delivery. Thus Dumont, De Bernis, Bouvier-Colle, Bréart, and Moma, (2001) stated that paradoxically, in Africa, where more C-deliveries are needed to improve maternal and perinatal survival, its availability and utilization are very low. Ronsmans and Graham (2006) affirmed that maternal mortality in sub- Saharan Africa is predominantly attributable to obstetric complications during pregnancy and childbirth and can be averted or substantially curtailed through availability and access/proximity to modern obstetric services by skilled attendants. United Nations (2010) noted that every minute of every day, somewhere in the world and most often in a developing country, a woman dies from complications related to pregnancy or childbirth. That means 515,000 women, at a minimum, dying every year. According to United Nations (2010) nearly all maternal deaths (99 %) occur in the developing world, making maternal mortality the health problem with the largest statistical disparity between developed and developing countries.
When a mother dies, children lose their primary caregiver, communities are denied her paid and unpaid labour, and countries forego her contributions to economic and social development. A woman’s death is more than a personal tragedy. It represents an enormous cost to her nation, her community, and her family. Any social and economic investment that has been made in her life is lost. Her family loses her love, her nurturing, and her productivity inside and outside the home. Thus it is very necessary that women possess a positive attitude towards this life saving procedure (C-delivery), which will go a long way in reducing the number of lives that is lost as a result of pregnancy. That is why this study is focused on finding out the attitude of mothers towards C-delivery in Anambra State general hospitals.
Women have been chosen to be a target for the study because nature has made it that they are the only group that gets pregnant and such have obstetric complications that can lead to C-delivery. Magadi, Diamond, Madise and Smith (2004) posited that throughout history pregnancy has carried a lot of risk of death secondary to obstetric complications. The women to be used for the study are mothers attending antenatal clinics at the general hospitals in Anambra State.
Anambra is a State in South-Eastern Nigeria created on 27th August 1991 with its capital and the Seat of Government at Awka. Its boundaries are formed by Delta State to the West, Imo and Rivers State to the South, Enugu State to the East and Kogi State to the North. There are 21 Local Government Areas in the State. The indigenous ethnic group in Anambra State is the Igbo (98% of population) and a small population of Igala (2% of the population) who live in the North Western part of the State (Igboegbunam, 2009). The people of Anambra State were traditionally farmers, but a significant number of them have become traders as well as academicians.
Anambra State is a pronatalist society like other Igbo societies in the South-East zone of Nigeria, where childbearing is accorded high priority within marriages. Unfortunately, not much seem to be done traditionally to enhance maternal health. Poor maternal health status in Nigeria, in general and indeed Anambra State is largely attributable to poor antenatal and obstetric care practices, lack of access to and use of skilled attendants at birth and a weak healthcare delivery system (Uzochukwu, Onwujekwu. and Akpala 2004). Policies and programmes in maternal health are seemingly ineffective in the State. However, reasons for this situation remain unclear. Despite the effort made by Governor Peter Obi’s government to improve all round health in the State, maternal mortality ratio still remains high. The maternal mortality in the State could be attributable to a number of medical and socio-cultural factors. While the medical factors include preventable pregnancy complications and obstetric deaths, the socio-cultural factors include poor utilization of ANC and obstetric care services which may be as a result of a number of factors.
There are some demographic factors that affect the attitude of mothers towards C- delivery. This study is concerned with such factors as age, parity, previous mode of delivery and educational attainment. Educational attainment is a factor that exerts a great influence on the attitude of women to C-delivery. Jeremiah Enyidah and Fieba (2011) concluded that the high acceptance rate of cesarean in their study is directly linked with the educational status of the women. Parity is also another factor as nulliparity (first pregnancy) has been identified as a factor that influences acceptance of C-delivery while multiparity (more than one pregnancy) influences non acceptance of C-delivery (Luthy, Malmgren, Zingheim and Leininger, 2003).
Age is yet another factor that has been identified by researchers to influence the attitude of mothers to cesarean delivery. According to Obikeze and Okeibunor (2002), the reproductive/child bearing age ranges between 15- 49 years. However National Population Commission (NPC) Nigeria Demographic and Health Survey (2003) noted that women in Anambra State tend to delay pregnancy until a later age of 19 years and above. Rise in maternal age and specific risk factors associated with it such as gestational diabetes and hypertension influences the decision making concerning modes of delivery (Bayrampur and Heaman 2010). They further noted that there is increased likelihood of cesarean birth acceptance among women of advanced maternal age. However Kolwek & Franzisk (2012) noted that despite the risks that were found in various studies for mothers of 35 years or older, they still prefere vaginal delivery. For the purpose of this study, the age bracket that will be used will be grouped into three which are 15-25 years, 26-35 years and 36 years and above.
Previous mode of delivery also influences the attitude of mothers to cesarean delivery. Aziken, Omo-Aghoja and Okonofua (2007) found out that past successful vaginal and instrumental deliveries, were most likely to be associated with women’s non-acceptance of indicated caesarean section. Also Buyukbayrak and Lufti (2010) noted that the most common reasons for choosing cesarean delivery by women in their study were fear of vaginal delivery, tubal ligation demand, and previous cesarean section.
This study was anchored on two theories. These are theory of cognitive dissonance and theory of reasoned action. The theory of cognitive dissonance is based on an assumption that conflicting ideas result to dissonance and dissonance being unpleasant motivates a person to change his cognition, attitude, or behaviour. The theory of reasoned action is based on the assumption that individual behavioural intentions are directly related to their attitudes. These two theories guided this study that was carried out among mothers attending antenatal clinics at the general hospitals in Anambra State.
Statement of the Problem
If a cesarean is anticipated to be needed for a woman, it is preferable to perform this electively during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anesthetic complications that can follow from emergency surgery. Pregnant mothers ought to possess a positive attitude towards C-delivery knowing very well that all pregnant mothers are at risk of obstetric complications which cannot all be predicted by prenatal screening.
Regrettably, literature has established that in secondary and tertiary maternity hospitals in Nigeria many mothers arrive in a moribund state or with complications that may either lead to death or severe morbidity and disability in the mother after emergency surgical intervention. Nigeria as reported Ximena, Andión and Ibañez (2008) makes up 2 per cent of the world’s population, while it accounts for 10 per cent of its maternal deaths, and for every maternal death, 20 other women suffer serious and often permanent pregnancy-related complications and health problems. While the Nigerian government has passed laws and policies to address maternal morbidity and mortality, these actions have not led to significant improvements in maternal health.
Literature has identified undue delays in initiating life-saving surgical intervention for women at risk of severe complications as some of the causes of high maternal mortality following cesarean delivery. Such outcomes may be due to delay in seeking life-saving surgical intervention such as cesarean delivery. Such delay may be as a result of the attitude of women towards cesarean delivery. This may be the case with women in Anambra State where this study was conducted which poses the question: what is the attitude of women in Anambra state towards C-delivery? The answer to this question is the main interest of this research “to find out the attitude of mothers attending antenatal clinics at the general hospitals in Anambra State towards C-delivery”. Moreover, to the best knowledge of this researcher, no research work has been conducted on this previously in this area.
Purpose of the Study
The purpose of the study was to find out the attitude of mothers attending antenatal clinics at the general hospitals in Anambra State towards C- delivery. Specifically, the study aimed to find out the attitude of the women:
- towards accepting C- delivery;
- towards those who undergo C- delivery;
- towards the medical staff who execute C- delivery;
- to C- delivery according to age;
- to C- delivery according to parity;
- to C- delivery based on educational attainment; and
- to C- delivery on the basis of previous mode of delivery.
- What is the attitude of the women towards accepting C- delivery?
- What is the attitude of the women towards those who undergo C- delivery?
- What is the attitude of the women towards the medical staff who execute C- delivery?
- What is the attitude of the women to C- delivery according to age?
- What is the attitude of the women to C- delivery according to parity?
- What is the attitude of the women to cesarean delivery on the bases of educational attainment?
- What is the attitude of the women to C- delivery based on previous mode of delivery?
The following null hypotheses were formulated to guide the study and were tested at .05 level of significance at the appropriate degrees of freedom.
- There is no statistically significant difference in the attitude of mothers towards C- delivery according to age.
- There is no statistically significant difference in the attitude of the women towards C- delivery according to parity.
- There is no statistically significant difference in the attitude of the women towards C- delivery according to educational attainment.
- There is no statistically significant difference in the attitude of women towards C-delivery according to previous mode of delivery.
Significance of the Study
The findings of this study showed that mothers attending antenatal care at the general hospitals in Anambra State demonstrated negative attitude towards C- delivery. Specifically the data that were generated on attitude of mothers towards accepting C- delivery may be beneficial to the government and health planners in the State and those elsewhere. The findings revealed the rate of acceptance of C-delivery. This will provide a basis for developing appropriate strategies to improve the acceptance.
Data generated on the attitude of the women towards those who undergo C-delivery exposed the way the mothers regarded their fellow women who undergo C-delivery. This will help the health workers to find a way of correcting any misconception the women have, concerning C-delivery and those who undergo it thereby making the pregnant mothers to accept it as a normal mode of delivery whenever it is recommended.
Data generated on the attitude to those who execute C-delivery exposed the idea of the women about the doctor’s reasons for recommending C-delivery. This will help the health workers to know the importance of involving the women in decision making as well as giving them appropriate counseling on the reasons for recommending C-delivery.
Furthermore, data generated on the demographic factors that were associated with the attitude of the women towards C-delivery will be beneficial to the Government and the health workers. Data to be generated on the attitude of the women to C-delivery according to age revealed the age bracket that their attitude to C-delivery is more favourable. This will help the health workers to know the age group they will pay more attention to especially during client education.
The findings on the attitude of the women to C-delivery according to parity revealed the influence the number of pregnancies one has had exerted on her attitude towards C-delivery. This will be useful to health workers to know the group that needs more counseling on C-delivery.
The findings on the attitude of the women to cesarean delivery on the bases of educational attainment revealed the relationship between educational attainments and attitude of the women to C-delivery. This will help the government and health workers to know if there is a need for programmes to improve on the women’s and community’s ugnderstanding and perceptions of C-delivery.
Data generated on the attitude of the women to C-delivery based on previous mode of delivery revealed the relationship between the previous mode of delivery and attitude towards C-delivery. This will be beneficial to the health workers in that it will open their eyes to the necessity of client education addressing some concerns on safety of and indications for the operation.
Finally, this study was anchored on theory of Cognitive Dissonance and theory of reasoned action, the result of the study is intended to help verify the relevance of these theories to the attitude to C-delivery among mothers in Anambra State general hospitals.
Scope of the Study
The study was carried out in Anambra State. The study was delimited to ten hospitals that were selected from the 20 general hospitals in the State. The general hospitals in Anambra State are located at ; Onitsha, Awka, Ekwulobia, Enugu-ukwu, Nimo, Agulu, Ogidi, Ukpor, Oraifite, Nnokwa, Nnobi, Mbaukwu, Umuleri, Orumba, Ossomala, Okija, Ichi, Ifitedunu, Agulu-Uzoigbo and Umuchu (Government of Anambra State Hospital Management Board, 2010) The study is concerned with finding out the attitude of the mothers in Anambra State towards; accepting C-delivery, towards mothers who undergo C-delivery and towards the health workers who execute C-delivery. The socio-demographic factors of age, parity, educational attainment and previous mode of delivery, and their association with the attitude of mothers towards C-delivery