KNOWLEDGE, ATTITUDE AND ACCEPTABILITY OF CESAREAN SECTION AMONG PREGNANT WOMEN IN THE CAPE COAST METROPOLIS
CHAPTER ONE INTRODUCTION
Pregnant women at term give birth either through cesarean section (CS) or vaginal delivery; depending on the circumstances surrounding the pregnancy (Boz, Teskereci & Akman, 2016; Cunningham et al., 2014). Vaginal birth is referred to as normal birth, where the baby is born with the head first through the vagina (birth canal) (Joint Policy Statement, 2008). According to the World Health Organization (WHO), normal birth is spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. Thus, the infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy (WHO, 1996).
Vaginal delivery may involve a number of medical interventions which include induction, artificial rapture of membranes, oxytocin for augmentation, and analgesics for the relief of pain (Joint Policy Statement, 2008; Walker, 2009). Vaginal delivery can be assisted or unassisted. The earlier requires the use of forceps (instrument) or vacuum cup to deliver the baby in prolonged labour, maternal exhaustion, abnormal position of the baby’s head, and other maternal medical conditions such as hypertension, diabetes, and maternal herpes (Fraser & Cooper, 2003). However, in situations where vaginal delivery poses a risk to both the mother and the baby, CS is indicated (WHO, 2015).
Cesarean section is the surgical delivery of the fetus through an abdominal and uterine incision, that is, laparotomy and hysterotomy (Pajntar, 2015). Cesarean section is one of the most common and major obstetric surgeries in the world with a global rate of 18.6%. It has contributed to improved
obstetric care in the world (Betran et al., 2016; Harrison & Goldernberg, 2016). It is categorized into emergency and elective or planned CS. Elective or planned CS is done when the obstetrician decides with the pregnant woman on a cesarean delivery (CD) prior to labour for reasons such as previous CS, multiple pregnancies. Other reasons include transverse lie, breech presentation, cephalopodal disproportion, pelvic cyst or fibroid, hypertension, diabetes and maternal infections (for example, genital herpes, HIV). Emergency CS is also indicated in cord prolapse and compression, abruptio placenta, placenta previa, and failure of labour to progress (Fraser & Cooper, 2003; Pajntar, 2015).
Although CS is done to protect maternal and fetal health, the risk of maternal and neonatal morbidity and mortality when not medically justified is high compared to spontaneous vaginal delivery (Rahmati-Najarkolaei, Eshraghi, Dopeykar & Mehdizadeh, 2014; WHO, 2015). These risks are higher in women with limited access to comprehensive obstetric care (WHO). Cesarean section may be associated with blood transfusion, and longer hospital stay. Moreover, mothers are less likely to initiate breastfeeding immediately after delivery due to the post operative pain. Cesarean section can result in low post-birth weight and also affect bonding between the mother and the baby. There may also be delay in the flow of breast milk compared with normal vaginal delivery. Mothers also find it difficult carrying babies due to the pain, and will have to be assisted in self care activities until the pain wears off. Nothing is giving by mouth on the day of surgery, and 24 hours after surgery until the woman can tolerate fluid orally (in general anaesthesia). There is usually activity intolerance due to incisional pain and weakness from the effects of anesthesia for the first 24-48 hours. Women undergoing CS may have to wait
for six to eight weeks recovery before resuming work, driving and engaging in any other activity (Rahamati-Najarkolaei et al., 2014).
There are many other underlying complications such as infection, bleeding, pulmonary embolism and headache from anesthesia, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications (Rahmati-Najarkolaei et al., 2014; WHO, 2015). The risk involved in CS has been debated. Some authors claim that CS decreases perinatal morbidity and mortality in breech presentation and increases the risk of the mother and the baby in cephalic presentation (Villar et al., 2007; Villar et al., 2006). There is also another view that CS increases maternal and neonatal risk in maternal request (Belizan, Althabe & Cafferata, 2007; Souza et al., 2010). For instance, studies in the United States of America and Ireland found a relationship between CS and perinatal mortality (CS decreases perinatal mortality and morbidity) while other studies found the opposite (Pajntar, 2015; Villar et al., 2007).
The rate of CS has recently increased drastically in developed and some developing countries with that on maternal request (without medical indication) contributing greatly to the increase (Pajntar, 2015; WHO, 2015; Yilmaz, Bal, Beji & Uludag, 2013). The reasons for the rise in maternal request are perceived medical benefit, social, cultural, physiological and psychological factors (Boz et al., 2016; Pajntar, 2015). A study revealed that women’s knowledge of CS complications and vaginal delivery, fear of vaginal delivery, number of pregnancies, physician’s persuasion and socio-economic status affect the choice of CS (Yousefi, Mirzaee, Khosravi & Khazaee, 2013). Though the legal and ethical issues concerning CS on maternal request are complex, it is required that
obstetricians establish a reason for the request and provide clear unbiased information based on the best available evidence (Pajntar, 2015; WHO, 2010). An approximated 18.5 million CSs occur annually in the world (WHO,
2010). WHO’s 2011 report revealed that between 2000-2011, Cyprus and Chad had the highest (50.9%) and the lowest (0.4%) CS rates, respectively (WHO, 2011). The incidence of CS has increased from 4-5% to 15-25% in Great Britain, Canada, with other countries such as South Korea and Italy reporting much higher rates in the year 2000 (45% and 52%), respectively. It is also believed that CS rates are high in countries where delivery is supervised by doctors and low in countries with midwives supervision, hence the high rates in USA (Pajntar, 2015). In Canada, the rate was 18% in 1994 and 1995, 22% in
2000 and 2001, 27-29% in 2010 and 2013 (Kelly et al., 2013). The rate in Great
Britain was 12.5% in 1990 and increased to 18.3% in 1999 (Yilmaz et al., 2013). WHO’s report in Iran also revealed that, 41.9% of deliveries were by CS in 2008 (WHO, 2010).
In spite of the rising rate, a study by WHO on the trends in CS by country and wealth quintile found the rates to be low in sub Saharan African countries. The rate is less than 2% in 10 countries, with Ghana, Kenya, Lesotho, Rwanda, and Uganda recording national rates above 5% (Cavallaro et al., 2013). This is because women in sub Saharan Africa do not accept CS. They view it as a curse and believe it results from unfaithfulness on the part of the women (Awoyinka, Ayinde & Omigbodun, 2007; Sunday-Adeoyo & Kalu, 2011). A study conducted in 72 countries under World Health Organisation by Boatin et al. (2018) also revealed low rates of CS.
Statement of the Problem
Cesarean section rates have increased in developed and some developing countries, with increasing safety when medically indicated (WHO, 2015). The rate of CS in Ghana was 6.9% from 2000-2008, and increased to 13% in 2014, 14.6% in 2015 and 16% in 2016 in all hospital deliveries (GSS, GHS, & ICF International, 2015; Ghana Health Service, 2016; Gulati, & Hjeldi, 2012). This implies that the CS rate is gradually increasing and likely to double as the years go by. In the Central Region of Ghana, the CS rates from 2011 to 2016 ranged between 11%-15%, with varying rates in the various districts. Some districts have rates exceeding WHO’s recommended rate. For instance, between 22% and 26% of all deliveries in Cape Coast from 2011 to 2016 were CS (Central Regional Health Directorate, Statistics Unit, 2017). However, the statistics did not give a breakdown on the CSs being medically indicated or not.
In spite of the rising rate, some studies have revealed that women in sub Saharan Africa have strong aversion for CS, even when medically indicated (Awoyinka et al., 2007; Sunday-Adoeoyo & Kalu, 2011). The aversion for the procedure could be influenced by the information they have, as well as their attitude towards it. Cesarean section is perceived as an abnormal means of delivery, reproductive failure, a curse and unfaithfulness on the part of African women.
With the increasing number of CSs, pregnant women with medically indicated reasons will have no choice but to undergo CS. Those who request for it will also claim the right to be granted their request even without knowledge of the associated implications. It is believed that the knowledge an individual has on a commodity is very vital as it gives understanding and guides one in
decision making regarding such commodity. Also, limited exposure to information on CS can result in high level of ignorance, impacting on decision making, thus posing danger to both the mother and baby (Mboho, 2013; Mungrue et al., 2010). A study at Korle Bu Teaching Hospital and Tema General Hospital found that non acceptability of contraceptive use by women resulted from lack of knowledge on contraception (Biney, 2011). Another study also found high knowledge to influence the acceptance of modern family planning methods. Therefore, it is imperative for pregnant women to understand issues relating to CS, have adequate knowledge on the indications, risks and associated benefits. This is likely to help pregnant women take appropriate decisions on the mode of birth they believe its right for them, and exhibit positive attitudes and behaviours that will make it possible to have safe CS to improve maternal and neonatal health. Several studies have been conducted in Nigeria, Ghana, and other countries on knowledge, attitude, preferences, and perceptions regarding CS (Adageba, Danso, Adusu-Donkor & Ankobea- Kokroe, 2008; Owonikoko, Bello-Ajao, Atanda & Adeniji, 2014; Robinson- Bassey & Uchegbu, 2016; Soaji, Nayse, Kasturwar & Relwani, 2011; Sunday- Adeoyo & Kalu, 2011; Varghese, Singh, Kour, & Dhar, 2016). Few studies in Nigeria have also looked at knowledge, attitude and acceptability of CS (Awoyinka et al., 2007; Nathani et al., 2011). A study at University Hospital, Cape Coast also looked at knowledge, attitude and perceptions of pregnant women towards CS (Prah, Kudom, Lasim & Abu, 2013). However, I did not come across any study in Cape Coast assessing knowledge, attitude and acceptability of CS in my search. Hence, the study seeks to assess the
knowledge, attitude and acceptability of CS among pregnant women in the Cape Coast Metropolis.
Purpose of the Study
The purpose of the study was to assess the knowledge, attitude and acceptability of CS among pregnant women in the Cape Coast Metropolis.
Research Questions
The following research questions guided the study.
1. What is the knowledge level of pregnant women in the Cape Coast Metropolis about CS?
2. What is the attitude of pregnant women in the Cape Coast Metropolis towards CS?
3. What is the level of acceptability of CS among pregnant women in the Cape Coast Metropolis?
4. To what extent is knowledge on CS associated with acceptability by the pregnant women in the Cape Coast Metropolis?
5. To what extent is attitude towards CS associated with acceptability by the pregnant women in the Cape Coast Metropolis?
6. What socio-cultural factors influence the acceptability of CS by pregnant women in the Cape Coast Metropolis?
7. What demographic factors influence the acceptability of CS by pregnant women in the Cape Coast Metropolis?
Significance of the Study
The results of the study will help to plan strategies to educate pregnant women on the benefits, and risks associated with CS at the antenatal clinics and in reproductive health programs by the maternal and child health division at the
Regional Health Directorate in the Cape Coast Metropolis. It will also help inform strategies to address misconceptions about CS. Finally, it will serve as a source of information to support further studies related to the CS. Delimitations of the Study
The study involved only pregnant women selected from the facilities under the five sub health metros (Ewim, Adisadel, Efutu, University of Cape Coast and Reproductive and Child Health Division; Cape Coast Metropolitan area) that render antenatal services within the Cape Coast Metropolis.
Limitations of the Study
Accidental and quota sampling techniques were used to collect data from the pregnant women. These are non-probability sampling methods. Thus, the findings cannot be generalized. Also, facility based study was done. With this, access to services provided within facilities may be unequal resulting in biases. Again, members of the population who do not seek and obtain services from the facility will not be captured. This is likely to result in under sampling and biases. Also, there will be differences in those who seek and who do not seek the services of the facility.
Definition of Terms
Abruption placenta: premature separation of a normally situated placenta after the 22nd week of pregnancy (Fraser & Cooper, 2003).
Acceptance: the agreement with or belief in cesarean section (Cobuild, 2006).
Analgesic: a drug that relieves pain (Weller, 2005).
Apnoea: cessation of breathing (Weller, 2005).
Attitude: is ones thought and feeling about something, which reflects ones behavior (Cobuild, 2006). It also reflects ones negative or positive belief about performing a health related behavior.
Breech presentation: longitudinal lie of fetus with buttock presenting in the lower pole of the uterus (Tiran, 1997).
Cephalic presentation: presentation of the head (Weller, 2005). Cephalopodal disproportion: disparity between the size of the mother’s pelvis and the fetus (Fraser & Cooper, 2003).
Cesarean section: it is the surgical delivery of the baby through the abdominal and uterine wall (Fraser & Cooper, 2003).
Conception: fertilization and implantation in the lining of the uterus (Fraser & Cooper, 2003).
Cord prolapse: baby’s cord felt below the presenting part on vaginal
examination (Fraser & Cooper, 2003).
Cues to action: exposure to factors that prompt the action or help to make health related decisions (Glanz & Rimer, 2005).
Diabetes: a disease characterized by excessive excretion of urine (Weller, 2005).
Drape: a cloth used to cover something or a part of the body (Cobuild, 2006).
Dystocia: difficult or slow labour (Weller, 2005).
Eclampsia: a severe condition ocuring in pregnancy in which convulsions may occur as a result of an acute toxaemia in pregnancy (Weller, 2005).
Ectopic pregnancy: pregnancy in which the fertilized ovum becomes inplanted outside the uterus instead of wall of the uterus (Weller, 2005).
Herpes: an inflammatory skin eruption showing small vesicles caused by the herpes virus (Weller, 2005).
Hypertension: persistently high blood pressure in which the systolic pressure is equal to or greater than 140 mmHg and the diastolic pressure is equal to or greater than 90 mmHg (Weller, 2005).
Hypoxia: a diminished amount of oxygen in the tissue (Weller, 2005).
Hysterectomy: removal of the uterus (Weller, 2005).
Hysterotomy: an incision into the uterus to evacuate the content (Tiran, 1997). Knowledge: the awareness, understanding or information, acquired through experience, education or learning (Cobuild, 2006).
Laparotomy: exploratory opening into the abdominal cavity (Tiran, 1997).
Liquor: a watery fluid in which the fetus floats (Weller, 2005).
Membranes: elastic tissue covering the surface of certain organs and lining the cavities of the body (Weller, 2005).
Modifying factors or variables: individual characteristics that influence personal perception, such as age, ethnicity, education level, social class, past experience, culture, among others (Glanz & Rimer, 2005).
Obstetrician: a person skilled to deal with pregnancy, labour and pueperium (Tiran, 1997).
Oxytocin: a hormone which stimulates uterine contraction and the ejection of milk (Weller, 2005).
Perceived barriers: The belief of benefits outweighing cost in performing a health behavior (Glanz & Rimer, 2005).
Perceived benefits: one’s belief on the advantages or reduction in the severity
or susceptibility to the condition when action is taken (Glanz & Rimer, 2005).
Perceived severity: one’s believe on the potential consequences of the condition (Glanz & Rimer, 2005).
Perceived susceptibility: one’s belief about his vulnerability or risk to a
condition/disease (Glanz & Rimer, 2005).
Perceived self-efficacy: one’s ability to successfully carryout a health behavior
or take action (Glanz & Rimer, 2005).
Placenta previa: an abnormally situated placenta in the lower uterine segment, completely or partially covering the internal os (Tiran, 1997).
Post partum: after labour (Weller, 2005).
Pre-eclampsia: a condition ocuring in late pregnancy and characterized by proteinuria, hypertension and oedema (Weller, 2005).
Prevalence: it is the proportion of the population with a particular condition divided by the total number of persons at risk for the condition during that period (Epidemiology and Surveillance, 2006; Schoenbach & Rosamond, 2000).
Thromboembolism: clot of blood in the bloodstream blocking a blood vessel (Weller, 2005).
Transverse lie: the longitudinal axis of baby lies across the mother’s uterus
(Tiran, 1997).
Organisation of the Study
This study was organized into five chapters; one, two, three, four and five. Chapter one focused on the background to the study, statement of the problem, purpose of the study, research questions, significance of the study, delimitations, limitations and definition of terms. The review of related literature is covered under chapter two. Chapter three is the methods. It addressed the design, population, study area, sample and sampling technique,
data collection instrument and procedure, and data analysis. Chapter four and five presents results and discussion, summary, main findings, conclusions and recommendations, respectively.
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