Awareness and Perceptions of and Attitudes towards Caesarean Delivery among Antenatal

Summary

Background

Caesarean section (CS) rates have been increasing steadily globally. The safety of the procedure has resulted in some women requesting it in the absence of any medical indication, particularly in the developed countries.

Objectives

To determine the awareness and perceptions of and attitudes towards caesarean delivery among antenatal clinic (ANC) attendants in a Ghanaian teaching hospital.

Design

Descriptive cross-sectional study.

Setting

The ANC of the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana.

Methods

A 13-point structured questionnaire containing items on demographic characteristics and assessment of knowledge of, perceptions and attitudes towards caesarean delivery was administered to women attending the hospital's antenatal clinic from 1^st December to 31^st December, 2006.

Results

Of 317 women interviewed 304 (96%) had heard of the operation; however only 43 (13.5%) could mention specific indications for it. Vaginal delivery was preferred by 296 (93.3%) while 11 (3.5%) preferred planned caesarean delivery; the remaining 10 (3.2%) were undecided. Although 164 (51.7%) perceived it as being dangerous to the mother and baby, 287 (90.5%) were willing to undergo the operation when indicated; 19 (6%) would refuse the operation even when indicated. Almost all the women, 311 (98.1%), wanted caesarean section to be part of client education at the antenatal clinic and 314 (99.1%) wanted to be informed about the specific indication before surgery.

Conclusion

There is a high level of awareness of caesarean delivery among ANC attendants at the Komfo Anokye Teaching Hospital. Client education is necessary to address some concerns on safety of and indications for the operation.

Introduction

During the last 10 years, CS rates worldwide have increased despite recommendations of the World Health Organisation to keep rates below 10–15%.¹ At the Korle-Bu Teaching Hospital in Accra, Ghana, the CS rate has increased from 10.9% 20 years ago to the current figure of about 21%.² The rate at the Komfo Anokye Teaching Hospital in Kumasi, Ghana, has similarly increased from 14.8% in the year 2001 to 21.8% in 2005 (unpublished data). The proportion of CS among total deliveries in Ghana increased steadily from 4.3% in 1999 to 5.8% in 2003.³ In a study of caesarean delivery at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, the rate increased from 10.3% in 1989–1991 to 23.1% in 2000–2003.⁴ There is however a widely held belief that women in the West African subregion have an aversion for surgical delivery.⁵ The purpose of this study was to determine among Ghanaian women awareness of, and perceptions and attitudes towards caesarean section in the light of its increasing use in modern obstetric practice in the country. It was carried out among pregnant women attending the antenatal clinic at KATH in Kumasi. KATH has a very large antenatal, labour and delivery service with annual deliveries of over 12,000.

Subjects and Methods

Only pregnant women who had never had any previous surgical operations and who consented to participate were recruited into the study. The study was carried out from 1^st to 31^st December 2006.

A 13-item pre-tested structured questionnaire was administered to 317 women by personnel of the biostatistics department of the hospital. Each morning, consenting women who met the study criteria were assigned numbers serially as they reported at the antenatal clinic. A client was then picked at random from the first three eligible attendants. Every third eligible attendant from the one picked was then interviewed.

Any woman who was interviewed had her antenatal card marked ‘CS’ to avoid repeat recruitment during any subsequent clinic attendance. The women answered both closed and open-ended questions. Data collected included information on age, parity, marital status and educational background; the women were then asked whether they had ever heard of Caesarean section as a mode of delivery and whether or not they considered it dangerous to the mother and/or the baby. They were also asked whether, if they had the choice, they would prefer planned Caesarean or vaginal delivery and whether if it was indicated they would be willing to undergo Caesarean section. Their opinions were sought concerning the need for client education on Caesarean section at the antenatal clinic as well as the need for preoperative information on indication for the operation in each particular case.

A woman was considered to be aware of caesarean section if she had ever heard about it as an alternative to vaginal delivery. The perceptions were assessed by the concerns for the safety of CS as a means of delivery. Their attitudes were assessed by the preference for CS as a means of delivery, willingness to undergo the operation when indicated and their desire for client education on CS at the ANC and for preoperative information on indication for the operation. The study was approved by the local ethical committee of the Komfo Anokye Teaching Hospital.

Results

There were 317 respondents during the one month period. Basic demographic data are given in Table 1.

Table 1.

Basic demographic data of respondents (n = 317)

Mean Age (years)	29.4 (SD 5.3)
Mean Parity	1.6 (SD 1.5)
Marital status	Number (% of total)
Married/Cohabiting	298 (94.0)
Single	19 (6.0)
Educational level	Number (% of total)
No formal education	32 (10.1)
Primary	22 (6.9)
Secondary	213 (67.2)
Tertiary	50 (15.8)

Three hundred and four (96%) had ever heard about caesarean section whilst the remaining 13 (4%) had not. Only 43 (13.5%) clients could mention any specific indications for the operation.

The indications given were: the cervix unable to open, big baby, baby not lying well and mother too ill. Of the 304 ‘ever heard of CS’, 70 (23%) heard about it from a single source while 234 (77%) heard about it from multiple sources. The commonest sources of information were from health workers 34.4%, relatives 26.5% and the media 20.8%.

Of the 317 women interviewed, 164 (51.7%) perceived caesarean section as being dangerous to the mother and baby; 94 (30.6%) felt CS was not dangerous, whilst 56 (17.7%) could not tell whether or not the operation was dangerous to the mother or baby. The reasons cited for caesarean section being considered dangerous and the number of women giving such responses was: death of the mother (10), harm to the baby (30), post operative complications such as pain (120), loss of ‘vitality’ and strength (100).

Two hundred and ninety six women (93.3%) preferred vaginal delivery against planned caesarean section. Eleven women (3.5%) preferred planned caesarean delivery. Ten women had no preference.

The reasons given for preferring vaginal delivery to caesarean section were: natural way to deliver, 205 (64.7%); safer way to deliver, 61 (19.2%); less expensive, 15 (4.7%); reduced post delivery morbidity, 36 (11.4%) and early discharge from hospital. Of those who preferred caesarean delivery, the avoidance of labour pains was the main reason given.

Majority of the women, 287 (90.5%) said they would agree to the operation if it was indicated. Nineteen (6.0%) said they would not agree to undergo the procedure even when indicated. The rest of the women, 11 (3.5%) were undecided. Two hundred and forty seven (78%) of the women felt that one caesarean delivery did not preclude vaginal delivery in a subsequent pregnancy, whilst 40 women (12.6%) felt that once a caesarean section was done vaginal delivery was not possible again. Three hundred and eleven (98.1%) of the women wanted caesarean section to be part of antenatal clinic educational topics. Almost all the women, 314 (99.1%) wanted to be told the indication for caesarean section if they had to undergo the operation. Table II shows the summary of responses for awareness, perceptions and attitudes.

Table 2.

Summary of responses to questions on awareness and perceptions of and attitudes towards Caesarean Section (n = 317)

CHARACTERISTIC	NUMBER (% of total)
AWARENESS
Ever heard of CS	304 (96)
Never heard of CS	13 (4)
PERCEPTIONS
Considered CS dangerous	164 (51.7)
Did not consider CS dangerous	94 (30.6)
No opinion	56 (17.7)
ATTITUDES
Preference for vaginal delivery	296 (93.3)
Preference for planned CS	11 (3.5)
No preference for particular route of delivery	10 (3.2)
Willing to undergo CS if indicated	287 (90.5)
Unwilling to undergo CS even if indicated	19 (6)
Undecided about undergoing CS if indicated	11 (3.5)
Desirous of client education on CS at ANC	311 (98.1)
Desirous of preoperative information on indication for CS	314 (99.1)

Discussion

The study has found out that majority of pregnant women attending the antenatal clinic were aware of caesarean section as the alternative to vaginal delivery. This finding was consistent with that of a similar study done in an urban setting in Nigeria.⁶ A little over half of the women in our study considered caesarean section as being dangerous. The reasons given for this perception were death of mother, harm to the baby and pain. Although studies have reported a 3–4 fold increased risk of maternal death from caesarean section as compared with vaginal delivery^7,8 and that post operative complications such as febrile morbidity, sepsis, haemorrhage and wound infection, are higher with caesarean delivery,⁹ the operation remains one of the most commonly performed surgical operations in obstetric practice the world over.⁵ It has become relatively very safe due to improved surgical technique, better anaesthesia, safe blood transfusion and the availability of highly effective antibiotics.⁶

The overwhelming majority of the women interviewed (93.3%) preferred vaginal delivery to caesarean section. In a similar study involving 180 pregnant women in Chile where the caesarean section rate is reported to be as high as 60% in private clinics, 77.8% of the women preferred vaginal delivery, 9.4% preferred caesarean section and 12.8% had no preference.¹⁰ Another study in Australia involving 290 pregnant women also showed a high preference for vaginal delivery (93.5%), with only 6.4% of them preferring caesarean section.¹¹

The results of these studies, and what we also found, suggest that even though some few women may prefer primary caesarean section as their mode of delivery, the majority of women still prefer to deliver their babies vaginally. The main reason given by the women who preferred caesarean delivery in this study was similar to that cited in other studies: avoidance of labour pains. In the Australian study however, some of the women thought caesarean section was safer for their babies.¹¹

Given the high preference for vaginal delivery among women against the high caesarean section rates in most obstetric units globally, the question then arises as to whether women would readily agree to undergo the procedure when it is indicated. This study showed that majority of the women (90.5%) would readily undergo the operation when indicated. A similar result was reported in a study in Nigeria where the acceptability of the operation was found to be 85% even though majority of the women in that study said they would seek further approval from relatives, especially their husbands before consenting.⁵ In one study however, up to 12.1% of the women said they will not accept caesarean section under any circumstances.¹²

Most of the women in our study wanted caesarean section to be included in antenatal health education topics. However, studies may be required to determine the content of the CS educational messages since untested information about the risks of caesarean delivery may scare women from the operation when it is actually indicated. Nevertheless, the messages must address the issues of safety and client refusal since more than 50% of our respondents considered CS to be dangerous to the mother and baby and 6% would refuse it even when indicated.

The respondents wanted to be told the specific indication for the operation when indicated. This is a very important finding and practitioners should endeavour to inform patients about the indication for a caesarean section to improve the acceptability of the operation. The reported aversion of women to caesarean section in Sub-Saharan Africa may not be a fear of the operation per se, but a reflection of the desire of the women to have vaginal birth which they deem natural. Indeed, this desire for vaginal birth has been expressed by women in developing and developed countries.^{6, 10–13}

In conclusion, majority of the women in this study prefer vaginal delivery even though they had high awareness of caesarean section as an alternative to vaginal delivery. The attitudes towards caesarean section were positive if the operation is indicated. In view of the current high caesarean section rates appropriate content education about the operation should be considered routine at the antenatal clinic. Clinicians should endeavour to tell patients clearly the indications for the procedure and be ready and willing to answer any questions they may have before surgery to improve the acceptability of the operation.