CHAPTER ONE
INTRODUCTION
1.1
Background
to the Study
The
joy that comes with the birth of a healthy baby is unparalleled by any other
achievement in life, especially when the mother avoids the tragedy of labor
complications or postpartum illness. Conversely, there is no loss more
agonizing than that of a mother during a complicated pregnancy or difficult
labor, particularly when it occurs due to the refusal of a cesarean section.
Delivery marks a pivotal moment in every woman's life, where certain medical
conditions associated with pregnancy and labor may necessitate a cesarean
section to safeguard both maternal and infant lives (Lawani et al., 2019;
Zamani-Alavijeh et al., 2018).
A
cesarean delivery, commonly referred to as C-section, involves the birth of a
fetus through an incision in the abdominal wall and uterus after 28 weeks of
gestation (Narayanaswamy et al., 2016). It is one of the most frequently
performed major abdominal surgeries worldwide, with rates varying significantly
between countries and healthcare settings. Most cesarean sections are performed
when vaginal birth poses a risk of serious harm to either the mother or child.
However, approximately 2.5% of cesarean sections are estimated to occur at the
mother's request without medical indication, a rate that has risen over the
past decade (Smith, 2018).
Globally,
the rate of cesarean sections has doubled over the past 15 years and was
reported to be 26.2% (Zakerihamidi et al., 2021; Freeman, 2022). In the United
States, nearly 1.3 million women undergo cesarean sections annually, accounting
for almost a third of all births (Jones, 2018). Rates in European countries
range from 13% to 25%, while in the Caribbean and Latin America, cesarean
sections constitute 44% of births, reaching up to 90% in private clinics in
Brazil and 70% in northern Iran (Zakerihamidi et al., 2019).
Factors
contributing to the high cesarean section rates in Brazil include cultural
preferences for scheduled births, perceptions of modern and cleaner delivery
methods, and physician pressure, among others (Purzucki, 2018). In contrast,
many African countries report cesarean section rates as low as 2–4%, which may
contribute to higher maternal and neonatal mortality rates compared to regions
with rates between 10% and 19% that are associated with improved outcomes (Ye
et al., 2016; Boerma et al., 2018).
In
Nigeria, cesarean section rates have increased from 9.4% to 34.6% since the
1970s, with a significant proportion arising from emergency cases among
unbooked patients (Ezeome et al., 2018). A study conducted at the University of
Benin Teaching Hospital found that while only 6.1% of women were initially
willing to consider cesarean section, 81% would accept it if necessary to save
their lives or those of their babies, while 12.1% would refuse it under any circumstances
(Aziken et al., 2017).
The
World Health Organization recommends that cesarean sections be performed in
only 10-15% of births worldwide, based on medical necessity, due to the
procedure's potential benefits outweighing its risks in certain complications
or risk factors (Freeman, 2022; Zakerihamidi et al., 2015). However, in some
developing countries, there remains a perception that cesarean sections are
primarily due to women's supposed inadequacies or inability to achieve vaginal
delivery (Roux, 2020). Recently, cesarean sections have also been viewed as a
means to avoid labor pain and as a safer, healthier alternative to vaginal
delivery (Zakerihamidi et al., 2022).
Given
the prevailing beliefs and perceptions, particularly in the West African
sub-region, where there may be an aversion to surgical delivery (Okonkwo et
al., 2023; Ezeome et al., 2021), this study seeks to explore the perceptions of
pregnant mothers regarding cesarean section as a birthing option at Niger Delta
University Teaching Hospital, Okolobiri.
1.2
Statement
of Problem
Caesarean section, as a
life-saving birthing procedure, has significantly reduced maternal and infant
mortality rates worldwide. However, its alarming increase, particularly in
developed countries, as such. In the United States, for instance, approximately
one in ten childbirths involves a cesarean section, with rates estimated at
26.1% in 2022 (Zakerihamidi et al., 2023). Similarly, Nigeria, as a developing
country in West Africa, has seen its cesarean section rates rise from 9.4% to 34.6%
between the 1970s and the present, largely due to emergency cases among
unbooked patients (Ezeome et al., 2018).
Conversely, in many
developing countries, there remains a reluctance to accept cesarean sections,
even when they are medically necessary to save the lives of pregnant mothers
and babies, such as in cases of obstructed labor. This reluctance is often due
to cultural beliefs or concerns about the complications that may arise from
surgical interventions, including conditions like vesico-vaginal fistula (VVF),
recto-vaginal fistula (RVF), and stress incontinence, which can significantly impact
quality of life (Roux, 2020; Okonkwo et al., 2012; Ugwu & Kok, 2018). These
factors contribute to increased maternal and neonatal mortality and morbidity rates
in such settings (Dare, 2019).
In the researcher's
clinical experience at the Antenatal Clinic and Labour ward of Niger Delta
University Teaching Hospital (NDUTH), it was observed that many pregnant
mothers whose health conditions contraindicate vaginal delivery do not readily
opt for cesarean section unless faced with emergency situations. Similarly,
women in prolonged labor often resist cesarean delivery, believing in the
timing appointed by God for their baby's birth. In light of these observations,
the researcher is motivated to investigate 'Pregnant mothers' Perception of
Cesarean Section as a Birthing Option at Niger Delta University Teaching
Hospital (NDUTH), Okolobiri.'
1.3 Objectives
of the Study
The
objectives of this study were specifically:
1)
To assess the perception of pregnant
mothers on cesarean section as a method of birth option in Niger Delta
University Teaching Hospital, Okolobiri;
2)
To identify the factors influencing
mother’s perception on cesarean section as a method of birth option in Niger
Delta University Teaching Hospital, Okolobiri; and
3)
To determine the possible strategies for correcting the negative
perception of pregnant mothers on cesarean section as a method of birth option
in Niger Delta University Teaching Hospital, Okolobiri.
1.4 Research
Questions
The
research questions this study seeks to answer are as follows:
1)
What are the perception of pregnant
mothers on Caesarean section as a method of birth option in Niger Delta
University Teaching Hospital, Okolobiri?
2)
What are the factors influencing
mother’s perception on Caesarean section as a method of birth option in Niger
Delta University Teaching Hospital, Okolobiri?
3)
What are the possible strategies for
correcting the negative perception of pregnant mothers on Caesarean section as
a method of birth option in Niger Delta University Teaching Hospital,
Okolobiri?
1.5 Significance of the Study
This study is paramount in so many ways such that
its findings will promote positive perception or correct negative perception
toward caesarean
section as a method of birth option among pregnant mothers and women of
reproductive age. The strategies identified from this study will direct the
attention of nursing practitioners and other health personnel on areas to build
on and develop during health education, seminars, symposium etc. Also, it will
be useful for further research work and increase the body of already existing
knowledge in nursing practice.
1.6 Scope of the Study
The
scope of this study will focus on perception of pregnant mothers, women of
reproductive age (15-45years) on Caesarean section attending Antenatal and
Postnatal Clinics in Niger Delta University Teaching Hospital, Okolobiri.
1.7 Operational Definition of Terms
1. Caesarean Section:
This is an intervention
carried out in other to ensure both mother and child is safe from harm, it
involves delivery of the baby by means of abdominal operation.
2. Pregnant mothers:
A pregnant mother is a woman who is in the state of pregnancy, which is the
period during which a fertilized egg develops into a fetus inside her uterus.
This stage begins with conception and lasts until childbirth. Pregnancy
typically spans around 40 weeks and is divided into three trimesters:
3. Perception of Pregnant mothers:
Personal, cultural and
religious views or opinion of pregnant mothers on a particular subject matter.
CHAPTER
TWO
LITERATURE
REVIEW
This
chapter deals with a review of literature for the study. The literature review
INCLUD: a review of concept of Caesarean section, theoretical framework,
empirical review, application of theory to the study.
2.1 Concept of Caesarean Section
The concept of Cesarean Section (CS) has deep historical roots, reflecting
both its evolution and the changing perceptions of its practice.
The origins of cesarean section can be traced back to ancient
civilizations, where it was performed under rudimentary conditions. Historical
texts from ancient Egypt, India, Greece, and Rome mention the procedure. For
instance, Hippocratic writings and Pliny the Elder's works reference cesarean
sections, though these were often last-resort measures with high mortality
rates for both mothers and infants (Smith, 2004). The term "cesarean"
is derived from the Latin word "caesus," meaning "cut," and
while there is a popular belief linking the procedure to Julius Caesar,
historical evidence supporting this claim is lacking (Harris, 1995).
During the Middle Ages, cesarean sections were performed
infrequently and were generally associated with poor outcomes. This was
primarily because the procedure was typically only done when the mother was
already deceased or dying (Jones, 1997). The high risk of infection and lack of
antiseptic techniques contributed to the procedure's dangerous reputation.
Significant progress began in the 17th century with the development
of more refined surgical techniques. However, it was not until the 19th century
that cesarean sections became considerably safer. The introduction of
antiseptics by Sir Joseph Lister in the 1860s greatly reduced infection rates,
and advancements in anesthesia further improved safety and comfort during the
procedure (Lister, 1864). Surgeons such as Ferdinand de Orellana and William
Smellie played key roles in improving surgical methods and maternal care during
this period (Smith & Jones, 2000).
The 20th century marked a transformative period for cesarean sections. With the advent of advanced surgical techniques, better anesthesia, and antibiotics, the procedure became more common and safer for both mothers and babies (Williams & Williams, 2001). The introduction of elective cesarean sections allowed for more planned deliveries, driven by various factors including maternal preferences and medical indications (Brown, 2008).
In the 21st century, cesarean sections are a routine part of obstetric care, with a focus on minimizing risks and improving outcomes. Advances in medical technology, including modern imaging techniques and enhanced surgical methods, have further increased the safety of the procedure (Adams & Nelson, 2019). Contemporary research continues to explore the long-term effects of cesarean deliveries on maternal and infant health, aiming to balance the benefits of the procedure with the promotion of vaginal births when feasible (Johnson, 2022).
Caesarean
section as defined by Marshall, Raynor, Nolte
and Myles (2021) is ‘an operative procedure that is carried out under
anesthesia whereby the fetus, placenta and membranes are delivered through an
incision in the abdominal wall and the uterus. This is usually carried out
after viability has been reached (i.e., 24weeks of gestation onwards). Also, Saju (2021), defined it as the delivery
of a fetus through surgical incisions made through the abdominal wall
(laparatomy) and the uterine wall (hysterectomy) or rarely to remove a ‘dead
fetus’.
The
first modern caesarean section was performed by a German Gynecologist,
Ferdinand Adolf in 1881. The procedure was usually performed when a vaginal
delivery would put the baby’s or mother’s life at risk, although in recent
times, it has been performed upon request for child birth that could otherwise
have been natural.
Types of Caesarean
Section
1) Classical Caesarean Section:
A mid-line,
vertical incision on the abdomen and the uterus is made to deliver the baby
owing to a large number of complications associated with the technique, it is
hardly practiced any longer.
2) Lower Segment Caesarean Section
(LSC/S): It is the most commonly preferred method wherein a
horizontal or transverse pfanensteil/bikini line incision is made on the lower
part of the abdomen to deliver the baby. It involves less blood loss, and is
easier to repair than other incisions employed for the purpose. It also heals
faster (Marshall et al, 2022). The LSC/S
can further be graded depending on when it is performed as follows:
(a)
Emergency
Caesarean Section (Unplanned C/S): When there is
suspected danger to the mother’s or
baby’s condition during pregnancy or labour, an emergency section is resorted
to. This can further be sub-classed into two (2):
i.
Real Emergency C/S: Where immediate
action must be taken to deliver the baby for it to survive such as in cord
prolapse with fetal compromise.
ii.
Urgent Emergency C/S: More time can be
taken to prepare for the operation and proposed actions can be discussed with
the parents in a more relaxed manner. Reasons for urgent emergency C/S are:
antepartum hemorrhage, cord prolapse, uterine rupture (dramatic/scar
dehiscence), CPD diagnosed in labour, fulminating pre-eclampsia, eclampsia,
failure to progress in the first or second stage of labour and fetal compromise
if delivery is not imminent.
(b)
Elective
Caesarean Section (Planned Caesarean Section):
This is a planned caesarean section and done on a specific date chosen by the
patient and the gynecologist after assessing the maturity of the baby and
conditions warranting the C/S. The decision for the surgery to be elective must
be taken prior to labour commencement i.e., during pregnancy. Elective C/S are
further grouped into two sub-categories for clarity sake such as:
i.
Booked Elective C/S: These are truly
elective C/S that are booked around term at a time convenient for mother and
surgeon while
ii.
Scheduled C/S: In this case, early delivery is required, but there is no
immediate compromise to mother or foetus (Marshall et al, 2022).
According to
Marshall et al (2021), definite indications for elective C/S are:
cephalo-pelvic disproportion (CPD), major degree of placenta praevia, high
order multiple pregnancy while possible indications are: breech presentation,
moderate to severe pre-eclampsia, a medical condition that warrants the
exclusion of maternal effort, diabetes mellitus, intrauterine growth
restriction (IUGR), antepartum hemorrhage and certain fetal abnormalities such
as hydrocephalus.
3) Caesarean Hysterectomy:
It is a life-saving procedure in which the uterus is removed after delivering the
baby through a caesarean section. It is performed when bleeding cannot be
controlled or when the placenta adheres to the uterine wall and it is not
possible to separate it.
Indications for
Caesarean Section
A
Caesarean delivery is performed for maternal indication or fetal indications or
both. The leading indications for caesarean delivery are breech presentation,
an elective or indicated repeat caesarean section, fetal distress, previous
caesarean section and placenta abnormalities. These indications are responsible
for 85% of all caesarean deliveries (Saju, 2021).
Maternal Indications:
These include –
i.
Obstructive lesions in the lower genital
tract, including malignancies, obstructive vagina septa, large vulvo vagina
condylomas.
ii.
Relative maternal indications include
conditions in which the increase intrathoracic pressure generated by valsalva
maneuver could lead to maternal complications, which include – dilated aortic
valve root, and recent retinal detachment.
iii.
Pelvic abnormalities that preclude engagement
or interfere with descent of the fetal presentation in labour.
Fetal Indications
i.
Twin gestation: The first twin in a
non-vertex presentation is an indication for caesarean delivery, as are higher
order multiples (triplets or more).
ii.
Congenital anomalies: Caesarean delivery
is an indication for several congenital anomalies such as fetal neural tube
defects (to avoid sac rupture) and hydrocephalus with an enlarged bi-parental diameter.
iii.
Maternal infections: Among patients with
first episode genital herpes infection, the risk of maternal fetal transmission
is 33 times higher than with recurrent outbreaks.
iv.
Fetal Distress: This is the most common
fetal indication for caesarean section. It is recommended to prevent a mixed or
metabolic acidaemia that could potentially cause significant morbidity and
mortality.
According
to Smith (2018), a Caesarean might also occur by maternal choice. A person
might choose Caesarean delivery on maternal request (CDMR) for a complex range
of reasons, according to a 2017 study, such as: a fear of pain during childbirth or anxiety about vaginal delivery; previous experience;
interactions with healthcare professionals; a range of social influences,
including the media, friends, and family; and a feeling of control over the
birthing process.
Risks for Caesarean
Section as a method of birth option
Risk for Mother: The
mortality rate for both caesarean section and vaginal birth in the Western
world continues to drop steadily in 2000. The mortality rates of caesarean
section in the United State were 20 per 1,000,000, that is 20 deaths in every
1,000,000 caesarean sections (Pia, 2020).
Women
with severe medical conditions or higher-risk pregnancies often require a
caesarean section which can distort the mortality figures. As with all
abdominal surgery, a caesarean section is associated with risk of
post-operative adhesions, wound infection and incisional hernia, blood loss,
blood clot, injury to associated organs such as bladder, bowel; adverse
reactions to medications and anesthetic agents, potential complications during
future pregnancies, endometritis (Pia, 2020; Smith, 2018).
Risk for Fetus: These
risk include -
i.
Fetal
Injury: Injury may occur during uterine incision and
extraction.
ii.
Premature
Birth: If gestational age was not calculated correctly, a
baby delivered by caesarean section could be delivered too early and have low
birth weight.
iii.
Breathing
problems: When delivered by caesarean section, a baby is more
likely to have breathing and respiratory problems such as transient tachypnea
or respiratory distress syndrome. Some studies show the existence of greater
need for assistance with breathing and immediate care after a caesarean
delivery than with a vaginal delivery.
iv.
Low
Apgar Score: Babies may have an adverse reaction to
the anesthesia given to the mother causing a period of inactivity or
sluggishness after delivery (Christensen, 2020; Smith, 2018).
Perception of Women
about Caesarean Section as a method of birth option
The trend of acceptability and the rate of C/S have been on
the increase in the developed countries and less remarkable in developing
countries. This variation has a relationship with the diverse perceptions
(positive and negative) of women about Caesarean Section as a method of birth
option irrespective of the justifiable
medical and non-medical indications (Zamani-Alavijeh
et al, 2018).In some developing countries ,C/S
is still being perceived as an abnormal means of delivery by some women. It is
also perceived as a curse for an unfaithful and weak woman i.e., incompetent in
childbirth, hence shy away from talking about it when they have one. The
C/S scar is also perceived as a badge of dishonor (Zamani-Alavijeh
et al, 2018; Smith, 2018). It was also reported in a study conducted among
Yoruba women in Southwestern part of Nigeria that C/S was perceived with
suspicion, aversion, misconception, fear, guilt,
misery and anger. In respect to the above negative perceptions,
elective C/S of non-medical indications
is not an issue to mention or rarely undertaken by few while it is unwillingly
accepted when it is indicated by a medical reason. In Zamani-Alavijeh
et al (2018) study, its acceptance was as a result of being worried about baby’s health and change in genital tract. This was also found in a reviewed study by
Okonkwo et al (2022), that following a successful live birth, the majority
(85.2%) said they would like to experience vaginal delivery in their next
pregnancy in order to feel like “a real woman”, further confirming the already
known preference for vaginal delivery by African women. This study showed that
the belief that Caesarean section is the way to ensure a live birth was a
critical factor in making the choice for Caesarean section owing to prolonged
infertility, repeated pregnancy losses, and advanced maternal age at first
pregnancy were common reasons.
Factors that Influence
Women Perceptions about Caesarean Section as a method of birth option
As
noted by Zakerihamidi,
(2018), it is difficult to pinpoint an
exact cause for the rising rates of Caesarean sections. Medical, Institutional,
legal, psychological, religious, cultural and sociodemographic factors play a
contributing role in women perceptions about Caesarean section reflecting in
its increase or low incidence.
Medical Factors/ Maternal
Request: Elective Caesarean sections are increasingly being performed
for a variety of reasons including concern for pelvic floor injury associated
with vaginal birth, medically indicated preterm birth and patient request (Narayanaswamy et al, 2016). As noted in the
findings from the study of Partnership for Women and Families
(2019), despite much media and professional attention to
“maternal request” Caesareans, only 1% of respondents who had a planned
initial, or “primary,” Caesarean did so with the understanding that there was
no medical reason as against a study review of Dusabe et al (2018), where 77%
of the respondents had a medical indication. About one mother in five (22%)
reported asking their providers to schedule a Caesarean before labor, and 87%
of those did so believing that it would offer a health benefit to them or their
babies, leaving about 2% overall who asked the provider to schedule a Caesarean
with no medical reason contradicting International
Federation of Obstetrics and gynecologists who stressed that conducting
C-section without a medical reason is not moral (Zamani-Alavijeh et al,
2018).
Institutional Factor
Increased supply of C/S delivery by healthcare institutions without restrictions from maternal demand with non-medical indication(s) is an implicated factor owing to the fact that it is an important source of revenue for hospitals and health-care providers (WHO, 2021) resulting to a high C/S rate recorded in private clinic C/S (Jones, 2018). As reported in a survey by National Partnership for Women and Families (2019), many women report experiencing pressure from a care provider to have a Caesarean. Overall, 13% of pregnant mothers reported experiencing pressure from a care provider to have a Caesarean. However, this rose to 22% among women who had a repeat Caesarean section, and 28% among both pregnant mothers who had a primary Caesarean and those who had a vaginal birth after Caesarean.
More so, it was noted by
National Partnership for Women and Families (2019) that discussion
about giving birth after one or two prior Caesarean steers many women toward repeat Caesarean, even
though research and professional guidelines support offering vaginal birth to
nearly all such women (Fraser et al, 2018).
Unfortunately, in most developing countries, limited access to the service and health systems inadequacies are responsible for its low C/S rate. More so, according to National Partnership for Women and Families (2019), a significant proportion of Caesarean section may be related to lack of access to vaginal birth after Caesarean (VBAC). It was reported that in a study that out of women with a previous Caesarean, almost half (48%) were interested in the option of a VBAC, but 46% were denied that option, out of which 24% denied was due to unwillingness of the provider while 15% was that the hospital did not allow VBAC/S.
Women who have had one birth by caesarean section usually
give birth the same way to reduce the risk of uterine rupture; however, a
number of studies, show that vaginal births to women with previous C/S is possible (Dusabe et al, 2018).
Interventions in labor are closely linked with
having unplanned Caesarean as it was observed
that among first-time pregnant mothers with term births who experienced labour,
those who had both labour induction and epidural analgesia were six times as
likely to have a Caesarean section (31%) as those who had neither intervention
(5%) (National Partnership for Women and Families, 2019).
Legal: One of the main goals of every medical team, dealing with
childbirth, is performing a safe delivery. Fear of litigation regarding
whatever loss resulting from denied maternal C/S request is a perpetuating
factor (WHO, 2021).
Psychological Factor
Fear of vaginal
delivery consequences increase demand by women requesting a caesarean section
especially, when having one child is the norm, rich and well educated women
because they think it is safer and free from pain and anxiety (WHO, 2021). According to Zakarihamidi et al (2016), the
attitude towards labor pain can be determinant of women’s decisions about mode
of delivery and culture has a significant impact on people’s perceptions and
attitudes towards labor pain, definition of labor pain, coping mechanisms
against pain, and related behaviors.
Sociodemographic Factors
Social
factors such as wealth status, education and
women on health insurance are implicated in increase maternal request for C/S
with educational factor most implicated However, the above first three factors
explanation as a cause of the increase in C/S rate cannot be made (WHO, 2021).
Unfortunately, according to Ugwu &
Kok (2019), there is great inequity in
access to C/S based on economic capacity; in Nigeria rates drop below 1% for
the poorest 80% of the population.
Parity
and Geographical Factor: In a study embarked on by World Health Organization
(WHO) (2021), it was reported that C/S rate between
2002 and 2023, among primiparous women
living in cities in China rose from 18% to 39% while rural China it is
estimated to be above 25% with its slow pace of increase More so, about two-third of urban women now give birth by
caesarean section.
Okonkwo et al (2021) noted that in developed countries, while fear of birth, increasing maternal age at marriage and first pregnancy, fear of pelvic floor damage, and genital prolapse in later years are implicated reasons, in developing countries, the view that Caesarean section is the surest way to a live birth is believed to be a critical factor underlying their choice. Also, Dusabe et al (2018) reported that maternal age (older women) has also been associated with increased co-morbidities and increased perceived need for Caesarean section delivery.
Strategies
for correcting the negative perception of women on Caesarean section as a method of birth option
The availability and provision of
Emergency Obstetric Care (EmOC) either basic or comprehensive in nature is one
of the most paramount requirements of maternal mortality reduction programs and
at the long run the attainment of one of the components of the Sustainable Development goals. C/S is a comprehensive EmOC which has
been reported to be universally accessible and available (Ugwu
& Kok, 2018).
Availability
of social support system is paramount to the woman in labour as noted in Zamani-Alavijeh
et al (2018), research where it was shown that
private social support was about 87.2% among women and the women stated that
presence of doctors, midwife, could lead to the reduction of fear of NVD.
et al
Fear of being unable to bear the pain, of dying, of being dilacerated, as well
as the feeling of not being able to give birth predispose women in labour to
medical conditions. Therefore, provision of physical, psychological, and
educational support to women in labour are encouragement factors to them.
Emotional support such as having the participation of fathers and/or companions
during the process of parturition enhances a natural childbirth, free of
interventions. Another strategy to give support to women and their families at
this time is to have the assistance of an obstetric nurse in the process, with
the aim of understanding the emotions of those involved, conveying confidence,
encouraging women, and showing them that they are able to endure painful
sensations during labor, therefore ensuring lower rates of Caesarean
sections. In addition to the aspects related to emotional support, nurses
can use non-pharmacological methods of pain relief, such as the use of the
Swiss ball, a therapeutic bath, and massage, among others. This intervention
helps to increase their knowledge about this moment, thereby reducing external
influences that could lead to a birth with intervention.
According to Ugwu & Kok (2019), there is need to find means
of facilitating necessary C/S by addressing the prevailing socio-cultural norms
and expectations that hinder its acceptance. Engaging and guiding alternative
providers (traditional birth attendants and faith healers) who wield much power
in their communities, will be important to minimize delays and improve cultural
acceptability of C/S.
2.2 Theoretical Review
This
research study adopted a Health Belief Model (Motivational theory) proposed by Rosenstock in the 1950s. The model (HBM) was modified in 1974
to include these components: individual perceptions, modifying factors and
variables likely to affect initiating action.
Rosenstock
(1979) assumed that good health is an objective common to all people. Becker
added “positive health motivation” as consideration. HBM is among the various
behavioural models designed to explain the process of behavior change and the
interaction among these factors. The use of such models is useful to ensure
completeness of messages and the possible outcomes. The model included these
constructs:
·
Perceived
threat (whether the danger imposed by not undertaking a
certain health action recommended is great).
·
Perceived
susceptibility (an individual’s assessment of their
risk of getting the condition).
·
Perceived
severity (an individual’s assessment of the seriousness of
the condition, and its potential consequences).
·
Perceived
barriers (an individual’s assessment of the influences that
facilitate or discourage adoption of the promoted behavior).
· Perceived benefits (an
individual’s assessment of the positive consequences of adopting the behavior).
· Demographic variables
(Such as age, gender, ethnicity, occupation).
· Perceived efficacy (an
individual’s self-assessment of ability to successfully adopt the desired
behaviour).
· Cues to action
(external influences promoting the desired behavior, may include information
provided or sought, reminders by powerful others, persuasive communications,
and personal experiences).
The prediction of the model is the likelihood of the
individual concerned to undertake recommended health action such as preventive
and curative health action.
Application of the
Model to the study
The
model involves the knowledge and perception regarding caesarean section and its
importance. Demographic variables are those that influence women decision
making, which include maternal age, parity, religion, education level,
knowledge and perception.
Perceived
benefits; when a woman perceived that benefits of caesarean section outweighs
side effect; she will consent to it. Perceived susceptibility; a woman during
antenatal when told of caesarean section and she is knowledgeable about her
condition, she will assess herself and take action. Perceived threat; when a
woman perceives her condition as serious and there is danger if she does not
take action, she will take action to prevent such. Perceived seriousness; a
woman in labour when informed of caesarean section may not accept the procedure
depending on her condition and this may lead to complication or death. On the
other hand, perceived seriousness of the condition will prompt immediate and
timely consent to C/S to avoid complications.
Perceived barriers; if a woman assesses the influence that may hinder
her from taking action, and the benefits of the action outweigh the influence,
she will take action. Cues to action may include: knowledge from the hospital,
media, personal experience and others. Perceived efficacy; this enables her to
consent to C/S procedure base on her knowledge about good prognosis.
2.3 Empirical Review
In a cross-sectional
study carried out by Lawani et al (2019), on ‘Perception and Socio-cultural
Barriers to the Acceptance of Caesarean Delivery in A Tertiary Hospital in
Abakaliki (FETHA), South East Nigeria,’ 344 patient at FETHA were utilized as the
sample from October 1 to November 30, 2016 and data were using a
self-administered questionnaire, analyzed using SPSS version 20.0. The findings
revealed that respondents’ awareness on C/S as an operative abdominal procedure
for delivery was 100%; of these, 14.0% had experienced the procedure
previously; 82.3% that had a previous C/S were well informed about the indications.
About 20.3% did not accept C/S for any reasons. The major barriers to
acceptance were being considered way peers as a reproductive failure (29.2%),
high cost (20.8%) and religious beliefs (12.5%).
In a case-control study by Dusabe
et al (2018), ‘factors associated with
caesarean sections at health facilities in Kabarole District, Western Uganda’
were examined among 134 women that had a
caesarean section and 134 controls that had a “normal” vaginal delivery
during March to May 2016, using a
two-stage sampling technique, three public health facilities and two randomly
selected private facilities. The factors associated with caesarean section delivery
were: having a previous caesarean section delivery, attendance of four or more
ANC visits. Inadequate human resource, medicines and supplies affected access
to the service. Misconceptions such as negative branding of women that have
caesarean section deliveries as “lazy” reduced its acceptance thus low
utilization of the service.
In a mixed method study by Ugwu and Kok (2019) on ‘Socio-cultural factors,
gender roles and religious ideologies contributing to Caesarian-section refusal
in Nigeria’, a Semi-structured interviews, focus group discussions (FGD) and informal
observations were their sources of data on the qualitative end. It was reported
that, 2 % of maternity clients refused C/S and more than 90% of the C/S in
the focal hospital were emergencies which may indicate late arrival at the
hospital after seeking assistance elsewhere. The qualitative analysis reveals
that socio-cultural meanings informed by gender and religious ideologies, the
relational consequences of having a C-section, and the role of alternative
providers are some key factors which influence when, where and whether women
will accept C-section or not.
In a descriptive review conducted by Sunday-Adeoye and Kalu (2021)
on ‘Pregnant Nigerian women's view of
Caesarean section’ at Ebonyi State University Teaching Hospital
Abakaliki (EBSUTH), available hospital records of 2005 and 2006 were reviewed
and it was found that C/S rate for the 2 years was 16.6%. A structured, 4-point Likert Scale
questionnaire was administered to 300 consenting pregnant clients attending the
antenatal clinic between September and November, 2021. The analyzed data using
EPI INFO 3.3.2 software findings include: 9.4% have had a previous history of
C/S, 78.3% had delivered at least once by the vaginal route and 12.3% were
nulliparous. 76.9% of the respondents who had C/S were favorably received at
home following the C/S as against 23.1%. Regarding their current pregnancy,
81.2% of the women viewed C/S as good if their life or that of their baby was
in great danger; 1.4% as very good and elected to undergo C/S to avoid the
pains and complications of labor and delivery; 12.3% said it is bad and would
only reluctantly undergo the procedure if the doctors thought it was necessary
to save their lives or their baby. Only 1.1% viewed C/S as being very bad and will
not accept the procedure in any circumstance. Majority of the study population,
82.7% would recommend the procedure for their daughters or daughters-in-law if
their lives and or that of the baby were in great danger. 66.1% and 34% of the
study population indicated that the cultural perception of their people about
C/S is that it is a normal obstetric decision and was negative respectively
being perceived as a procedure done by unfaithful and cursed women as well as
women who were weaklings. Also, majority of the respondents 43% were
afraid of death as a complication of C/S, 29.2% did not have any fear about
C/S, while 19.9% were afraid of the postoperative pain associated with C/S.
A
cross-sectional survey carried out by Okonkwo et al (2022) on ‘Maternal demand
for Caesarean section: perception and willingness to request by Nigerian
antenatal clients’ among 843 antenatal clients at Agbongbon/Orayan primary
health care centers (PHC/S), Adeoyo Maternity Hospital (SHC), and UCH Ibadan
(THC), representing the three different levels of health care in Nigeria, women
awareness on MDC/S was 39.6%. Predictors of awareness were education and type
of health facility. Women from THC and those with tertiary education and above
were more likely to be aware of MDC/S than others. Doctors were major sources
of information on MDC/S (30.8%) as well as friends (24.3%). Common reasons
reported for MDC/S were fear of labor pains (68.9%), and fear of poor labor
outcome (60.1%), and fear of fecal (20.2%) and urinary incontinence (16.8%).
More women from the THC than other facilities believed that requests for MDC/S
should be granted. However, willingness to request MDC/S was low (6.6%). More
than 50% of those willing to request MDC/S would likely be criticized, mainly
by their husbands.
2.4 Summary of Literature Reviewed
The reviewed literature in this study was done on the concepts of
caesarean section as a method of birth option. theoretical framework and its
applications including empirical studies. The adopted theoretical framework was
Health Belief Model by Rosenstock (1979). It was discovered in the literature
reviewed that a lot of study have been carried out on Caesarean sections
assessing attitude, its influencing factors, comparative study of C/S with
vaginal delivery, perceptions in different places including Nigeria. However,
published articles or journals in South-South are few or lacking. Also, general
perceptions on C/S had been researched on but perceptions on the measures to
reduce its trending rate or adjustment means to bring the rate to standard in
developing countries is lacking. Hence, necessitating this study.
CHAPTER
THREE
METHODOLOGY
The
methodology employed in gathering necessary information in regard to the
problem under study is as follows:
3.1 Research
Design
A
descriptive research design will
be
adopted in this study. This is because it does not enable the researcher to
willfully manipulate the variables, but rather a systematic collection and
presentation of data obtained from respondents.
Therefore, it helps to elicit information on perception of pregnant
mothers on Caesarean section as a method of birth option in Niger Delta
University Teaching Hospital (NDUTH), Okolobiri.
3.2 Research
Setting
The study is carried out in Niger Delta University
Teaching Hospital (NDUTH) Okolobiri. NDUTH Okolobiri is located in the region of Bayelsa.
Bayelsa's capital Yenagoa (Yenagoa)
is approximately 14.9 km / 9.3 mi
away from Okolobiri. The Hospital
was established in 1982 as general hospital. It was upgraded to became a Teaching hospital in September 2007. Niger Delta University
Teaching Hospital (NDUTH) Okolobiri was established by the Bayelsa State
Government under the Bayelsa State Law. The hospital was officially established
through the Bayelsa State Law No. 2 of 2013, which was enacted to provide
healthcare services, training, and research in the medical field within the
region. Niger Delta University Teaching Hospital (NDUTH) Okolobiri is
surrounded by several neighboring communities. To the southeast of Okolobiri
lies Obunagha, while Nedogo is situated to the southwest. Tombia Town is
located to the west of Okolobiri, offering a neighboring settlement with its
own distinct characteristics. Ogboloma can be found to the northwest, while
Igbogene is positioned to the north of Okolobiri. Each of these communities
contributes to the regional network around NDUTH Okolobiri, reflecting a
diverse and interconnected local landscape. NDUTH is made up of 20 blocks which are representations of the twelve
units/departments including nurses, doctors, pharmacists, medical laboratory
scientist, paramedical workers and other non-medical workers. It is one
of the biggest teaching hospital in the south-south regions of Nigeria with about
200-bed spaces. The staff strength is about 500. The departments and units
studied were those ones that handle biohazards, namely; intensive care unit,
theater, wards, laboratories, casualty, outpatient departments, and blood bank.
It consist of nine (9) wards. It is
accessible by road either through Igbogene or Nigeria liquefied Natural Gas
(NLNG) Obunagha road. The NDUTH Okolobiri is been chosen by the researcher as
the area of study due to the fact that it is a major tertiary hospital and is
visited by most people within and outside the state for their health care.
3.3 Target
Population
The
target population is the
group of individuals that the intervention intends to conduct research in and
draw conclusion from. It is a portion of the whole universe of people selected
as the subject audience. The population for study will be a total of 224 females
conveniently selected, which comprises of all expectant pregnant
mothers (15-45years) attending Antenatal Clinic from the month of January to June, 2024.
3.4 Sample
Size
From
the above population of study (224), using Taro Yamene’s formula the sample
size calculation is shown below:
Taro Yamane’s
Formula:
Where: n = Sample size
N = Finite population
r =Taro’s constant (0.05)
e
= Sampling error
Substituting the
values,
= 143.58≈ 144.
10% attrition of 144 = 14.
n = 144 +14 = 158.
Therefore,
the sample size was158Expectant Pregnant mothers attending Antenatal Clinic of
NDUTH, Okolobiri.
3.5 Sampling
Technique
Purposive Convenience sampling techniquee will be used for this study, to select subjects that
are readily available and accessible for the research based on the expectation
that participant will provide information of value for the study.
3.6 Inclusion Criteria
The
inclusion criteria of the respondents comprised of:
§ All
expectant pregnant mothers attending Antenatal Clinic in NDUTH, Okolobiri
irrespective of other sociodemographic variables such as educational
qualification, occupation, marital status etc.
§ All
expectant pregnant mothers who are available and willing to participate in the
study.
3.7 Instrument
for Data Collection
A
‘self-structured questionnaire’ developed
by
the researcher on ‘perception of pregnant mothers on Caesarean Section’ will be utilized for data collection. The questionnaire
consists of four sections. Section ‘A’ entails sociodemographic data of the
respondents while section ‘B, C and D’ elicited data that answer the research
questions accordingly and are presented in 5-point Likert Scale form with
‘Strongly Agree (SA), Agree (A), Undecided (U), Strong Disagree (SD) and
Disagree (D)’ options.
3.8 Validity
of the Instrument
The
face and content validity of the instrument will be ascertained by sending copies of questionnaire to the
researcher’s supervisor and two other lecturers in the field of study of
Faculty of Nursing Sciences. Corrections made will be considered andeffected by the
researcher where necessary to prevent ambiguity of the instrument prior to its
administration.
3.9 Reliability
of the Instrument
A test-retest study will be carried out using 10% of the
sample size (i.e, 16 respondents) to evaluate the clarity, and applicability of
the tools. The reliability test was conducted in General Hospital, Amassoma.
The interval between the two tests was a month. The reliability coefficient was
ascertained using Pearson Product-Moment Correlation and considered reliable as
it takes a positive value of +0.80.
3.10 Procedure for Data Collection
The
instrument will be
administered by the researcher to the respondents during Antenatal Clinic days
and they will be
retrieved immediately after their completion. The same instrument will be interpreted by the researcher in
either Pidgin or ‘Izon’ verbally to the non-educated respondents. The data
collection will be
carried out during Clinic hours while the respondents’ area waiting to be seen
by their Physicians after health talks. The administration will be done in all clinic days (i.e.
Monday to Friday with the exception of Wednesday) within 2weeks that is eight
(8) clinic days.
3.11 Method of Data Analysis
The
data will be
analyzed manually using frequencies and percentages in frequency distribution
tables, pie chart and bar chart. The 5-point Likert scale questions will be analyzed with a scoring system of
5 to 1 for strongly agree, disagree, undecided, strongly disagree and disagree
respectively. A mean score ≥3.0 represents acceptance while a score < 3
represents rejection of the phenomenon in view. The data analysis and
presentation will be
in accordance with the research questions.
3.12 Ethical Considerations
An introductory letter will
be obtained from the Dean of
Faculty of Nursing Sciences, Niger Delta University, Amassoma and
would be presented to the research and
ethical committee, NDUTH Okolobiri to
obtain permit for the conduct. More so, pre-information necessary
for participation of the respondents will be made known to them and that the study methodology will be safe with no
harm to gain their consent.
Also, they will be
made to understand that participation is voluntary and freedom for withdrawal from
participation at any time was assured. All information
provided were treated with dignity, privacy and confidentiality.
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QUESTIONNAIRE ON
‘PERCEPTION OF PREGNANT MOTHERS’ ON CAESAREAN
SECTION AS A METHOD OF BIRTH OPTION IN NIGER DELTA UNIVERSITY TEACHING HOSPITAL
(NDUTH), OKOLOBIRI, BAYELSA STATE
SECTION A
(Instruction: Please tick [P] the correct answer in the options
provided)
1. Age
(years) (a) 18-22 [ ] (b) 23-27 [ ]
(c) 28-32 [ ] (d) 33 -37 (e) 38 and above [ ]
2. Marital
status (a) Married [ ]
(b) Single [ ] (c) Separated [ ] (d)Divorced [
] (e) Widow [ ]
3. Religion
(a) Christianity [ ] (b) Islamic [
] (c) Others
4. Educational
background (a) Informal [ ] (b) Primary [ ] (c) Secondary [ ] (d) Tertiary [ ]
5. Parity: (a)
Nil [ ] (b) One [
] (c) Two [ ] (d) three (e)
four and above [ ]
6. Trimester: (a) First (1-3months) [ ] (b) Second (4 – 6months) [ ] (c) Third
(7 – 9months) [ ]
7. Have
you experienced Caesarean Section (C/S)? (a) Yes [
] (b) No [
]
SECTION B
KEY: SA – Strongly Agree SD
– Strongly disagree D – Disagree
SD – Strongly Disagree U – Undecided
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