Abstract
Background: Although Caesarean section (CS) is the commonest major surgery performed in Obstetrics and it has contributed to improved obstetric care throughout the world; there are still concerns about the attitude of rural Nigerian women towards it.
Objectives: To ascertain what is known about CS and the attitude to it among pregnant women attending antenatal care in a rural health facility.
Design: Descriptive cross sectional
Setting: The antenatal clinic of a semi-urban health facility in Nigeria.
Methodology: An interviewer administered semi-structured pretested questionnaire was used to assess knowledge and attitude to CS among 401 pregnant women, which included first timers to experienced mothers. Each respondent’s level of knowledge was determined using a scoring system and the total knowledge was categorised as inadequate (0 - 49%) and adequate (50-100%).
Results: Of the 401 respondents, 376 %(93.8) had heard of CS; 355( 94.4%) were aware that vaginal delivery was feasible after CS; 325( 86.4 %) knew that blood may be required during or after the procedure while only 10(2.7 %) were aware that the woman was required to give consent for CS. The total knowledge score was adequate in 154(40.9 %) and inadequate in 222(59. 1 %) respondents.
Conclusion: Although majority of the women surveyed were aware and would accept to have CS if indicated, knowledge about CS is still low in our setting. The need for birth preparedness and complication readiness with the involvement of men is crucial to influencing the perception of women in this setting towards CS.
Keywords: Knowledge, Attitude, Caesarean section, Nigeria , Northwest
Introduction
Caesarean section (CS) is the delivery of a foetus through a surgical incision into the uterine wall after 28 weeks of gestation1. It was reported sporadically throughout medical history and was only rendered safe for both mother and foetus during the 20th Century 2. It is the most commonly performed major obstetric operation in the world 3 and there is no doubt that it has contributed to improved obstetric care throughout the world 4. CS is usually performed when vaginal birth is deemed hazardous either to the foetus or the mother.
The CS rate varies worldwide, from country to country and within a country. The National CS rate of Great Britain and America have been reported as 23.8% and 32.8% respectively5,6 while 0.6% national CS rate was reported from Ethiopia 7. In Nigeria, CS rates ranging from 12.2% to 34.5% were reported in some tertiary health facilities8,9 and in recent times the CS rates globally have been on the rise. This has been noted in Ghana,2 Britain5 and similarly in Nigeria,10-12 although there are still some concerns with accessing this service in the rural areas. CS is commonly done in Nigeria as an emergency procedure for indications like foetal distress, ante-partum haemorrhage, previous CS and obstructed labour 8-12. Interestingly, previous CS and obstructed labour are also important risk factors for ruptured uterus which is common in rural settings in northern Nigeria13 due to issues relating to the accessibility and utilization of essential obstetric care services. Some of the reasons often cited for non-utilization of health facility by women in northwest Nigeria include the distance to the health facility, the need to pay for service and the fear of surgery 14, 15.
Traditionally, Nigerian women are unwilling to have CS because of the general belief that abdominal delivery is reproductive failure on their part16 regardless of the feasibility of vaginal birth after CS and the decreasing mortality from Caesarean sections. Imperative to the average pregnant woman irrespective of her level of education and parity therefore is CS. Available reports on knowledge of CS amongst women are mainly from tertiary health facilities situated in cities and in the southern parts of the country while little is known about the perception and attitude of rural women from Northern Nigeria towards Caesarean birth.
This study aims at ascertaining what is known about Caesarean section and the reasons for dislike by our women. The findings from this study would be used in planning strategies towards improving the knowledge, perception and attitude towards CS in the community in order to possibly reduce the delay in presentation to the health facility when CS is needed, improve utilization of this mode of delivery and limit the avoidable maternal and foetal complications.
Materials and Methods
Setting
The study was conducted in Federal Medical Centre Birnin Kudu, a tertiary institution located in a semi-urban setting in Jigawa state, northwest Nigeria. The hospital is a 250 bedded facility established in 2000 and it serves the health care needs of people in the state and other neighbouring states such as Kano and Bauchi. The Obstetrics and Gynaecology department is one of the 4 clinical departments and it provides free antenatal care services while childbirth and post partum services are highly subsidized. An average of 1,400 women give birth annually in the facility.
Subjects
The study population consisted of pregnant women attending the antenatal clinic of the hospital from the 5th August to the 16th September, 2013. A systematic sampling technique was used to select women to participate. Based on the average attendance at the booking clinic, a sampling interval of three was obtained. The first respondent for each day was selected by balloting and picking a number between one and three. Subsequently, every third pregnant woman that registered with the records department was recruited and the questionnaires were administered to them before they received health counselling. The participants were assured of confidentiality and that non-participation in the study would not in any way affect the care they would receive.
All eligible pregnant women were included in this study while women that were critically ill and those that did not consent were excluded.
Study design
The study was descriptive and cross sectional in design. The sample size was calculated from the expression n= z2pq/d2 where z is the normal standard deviation set at 1.96, confidence level specified at 95%, the tolerable error margin (d) at 5%, (q = 1.0 – P) and P was 59% based on the prevalence from a previous study17. A sample size of 372 was obtained and adjusted to compensate for a non-response rate of 10% to give the final minimum sample size of 409.
Research Instrument
A structured interviewer-administered questionnaire was used to assess pregnant women’s knowledge and attitude to CS. The questionnaire was in English language, though another version in Hausa language was made available for natives and those who preferred the version. The questionnaire was pretested for sensitivity of questions, comprehensibility, and appropriateness of language. No woman was interviewed twice and the questionnaires were administered by female students of the school of Nursing who had been trained on questionnaire administration technique. The questionnaires were anonymised.
Ethical Consideration
The study proposal was approved by the Ethics and Research committee of the institution and informed consent was obtained from the participants prior to recruitment into the study.
Data Analysis
The data obtained was analysed using SPSS version 17.0 statistical software. Qualitative variables were summarized using frequencies and percentages, while mean and standard deviation were used to summarize quantitative variables. Association between level of knowledge on Caesarean section and socio demographic characteristics were carried out using the Chi square and Fisher’s exact tests where applicable. Statistical significance was said to be achieved when P value was <0.05. Eight questions assessed knowledge of CS, each correct answer scored a point and each wrong answer scored zero. Each respondent’s level of knowledge was determined using a scoring system previously used in a study18 and the total knowledge was categorised as follows: scores of 0 - 49% (i.e. 0 to 4 points) = inadequate, 50 -100% (i.e. 5 to 8 points) = adequate.
Reports
During the study period, 409 respondents were approached to participate in the study and 401 (98.0%) agreed to participate.
Sample description: The ages of the respondents ranged from 15 to 45 years with a mean of 23.5 ± 5.6 while the parity ranged from 0 to 12. Three hundred and ninety three (98.0%) were married with 387(96.5%) being Muslims and 382(95.2%) were of Hausa ethnicity. Of the respondents, 234(58.4%) had Quranic form of education only 72(17.9%) had primary education, 64(15.9%) with secondary education while 31(7.8%) had tertiary education. Two hundred and fifty nine (64.4%) were housewives, 97(24.3%) were petty traders, 29(7.4%) were seamstresses while 16(3.9%) were employed in the civil service. Table 1 shows the socio-demographic characteristics of the respondents.
Knowledge of caesarean section (CS)
Have you heard of CS? Majority 376(93.8%) were aware of caesarean section out of which 32(8.5%) had experienced it.
Indications for CS: About two-thirds of the respondents recognized prolonged labour due to big baby (244/376; 64.9%) and bleeding per vaginam before delivery (237/376; 63.0%) as indications for CS
Blood may be transfused during or after the procedure: Majority of the respondents (325/376; 86.4%) were aware that blood may be required for the procedure.
Normal hospital stay after delivery: Most of the respondents 274(72.8%) were aware of the normal duration after the procedure of a week or less while 15(14.6 %) did not know.
Vaginal birth after CS: Majority 355(94.4%) knew that vaginal delivery was possible after a caesarean section.
Who is required to give consent for CS? There were multiple responses to this question but majority of the respondents 355(93.1%) felt that their husbands should give consent for the procedure, 18(4.8 %) were of opinion that the wives’ relatives should give consent for CS, 10(2.7%) knew that the woman to be operated upon should give consent while 20(5.3%) would expect the husbands’ relatives to give the consent.
Of the respondents, 154(40.9%) had adequate knowledge about CS while 222 (59.1%) had inadequate knowledge.
Table III shows no statistically significant association between respondents’ socio-demographic characteristics and knowledge of CS (p>0.05).
Attitude to CS
Willingness to undergo CS: Majority of the respondents (99%) were disposed to having the procedure if indicated and 307(82%) would also have a repeat CS as shown in Table IV
Reasons for not willing to have repeat CS: In about half of the respondents who would not have repeat CS, the fear of dying and fear of pain were given as reasons as shown in Table IV.
Potential response to having a repeat CS: Varying proportions of the respondents would pray not to have it, some would discuss with their husbands about it while others would seek help from religious leaders or traditional birth attendants as shown in Table IV.
How do you view a woman who delivered by cs? Two hundred and eight (55%) of the respondents would be pathetic while 123(33%) of the respondents view her as a weakling as shown in Table IV.
Discussion
Although this study revealed that 93.8% of the respondents were aware of CS, 40.9% had adequate knowledge of it while 2.7% knew that the woman undergoing CS was required to give consent for the surgery. This may be explained by the fact that most of the respondents surveyed were not educated and were unemployed hence they solely depended on their husbands for guidance and financial support. This would imply that in the event that an emergency CS is required, obtaining consent for the procedure would constitute a form of delay at the health facility as the patient may wait for her husband to come and give consent. This buttresses the findings of Bako and Umar19 in a cross sectional study among women who presented with obstetric emergencies at a tertiary hospital in northeast Nigeria to determining the informed consent practices and implication. They found out that consent was significantly delayed when given by husbands, in-laws and relatives and this contributed significantly to increased maternal and foetal morbidity and mortality among the group with delayed consent. It is also interesting to note that 98.9% of the respondents were willing to have CS if indicated; this is contrary to the widely held belief of unwillingness to have CS by Nigerian women20,21. About one in five respondents would not accept to have repeat CS due to the fear of post-operative pain and the fear of dying during the surgery. About four in ten respondents would rather pray and hope to achieve vaginal birth while about a third would seek the opinion of their husbands. This attitude further explains the role men play in their women’s utilization of health services in the community, apart from paying of bills that may be incurred they also provide psychological and moral support hence the need to involve them when the need arises.
Though this study was conducted in a semi-urban setting in northwest Nigeria where little is documented about the knowledge and attitude to CS, the design is subject to bias. The very high acceptance level of CS noted may be due to information bias in which the women report acceptance since obviously they knew that the researcher was interested in positive attitude towards CS. Also, since only a third of pregnant women in northwest Nigeria utilize antenatal care14, caution should be exercised in extrapolating the findings to the whole community. Nevertheless, useful information regarding CS in this setting was generated.
There is general awareness about CS; the 94% awareness of CS observed in this study is similar to the 96% reported in Ghana22 however the 99% acceptance rate noted in this study is higher than 91% in the same report from Ghana. It also higher than the 85% from Ibadan in southwest Nigeria,23 81% from Abakaliki in southeast24 and much higher than the 68% reported from Port Harcourt in southsouth17. Eighty-two percent of the respondents surveyed would accept to have a repeat CS compared to the 65% noted in the study from Port Harcourt however the reasons highlighted by these women for not accepting a repeat CS were similar. Fifty-two percent of the respondents in this study would not accept a repeat CS due to fear of pain compared to the 19% noted in Port Harcourt while 49% of the respondents in this study would not accept repeat CS due to concern about dying which is higher than the 36% observed in the study from Port Harcourt.
It is important for health workers to explain to patients that having a primary CS does not preclude the possibility of achieving a vagina birth afterwards; however subsequent deliveries must be in a health facility equipped to provide adequate monitoring in labour and immediate recourse to CS. This point should also be understood by the husbands. Emphasis should be on the couple having birth preparedness and complication readiness plan which should also take into cognizance who gives consent for emergency surgery if the need arises. All these need to be stressed to all women attending antenatal care in this setting.
Though this study utilised a scoring system which grouped the respondents’ knowledge to adequate and inadequate, a prospective study to determine the implication of this categorization on the maternal and foetal outcome is recommended. Also it would be worthwhile to further explore the reasons why women in rural setting won’t like to give consent for CS; the belief and attitude of men to women who have had a CS since majority of the respondents surveyed believed that the men should give consent for CS.
Conclusions
Although majority of the women surveyed were aware and would accept to have CS if indicated, knowledge about CS is still low in our setting. The need for birth preparedness and complication readiness with the involvement of men is crucial to influencing the perception of women in this setting towards CS.
Legends to Tables
Table I: Socio – demographic characteristics of respondents
Table II: Respondents’ knowledge of caesarean section
Table III: Association between level of knowledge about Caesarean section and socio-demographic characteristics
Table IV: Attitude of respondents to Caesarean section
Table I Socio – demographic characteristics(N=401)
| Socio-demographic characteristics | n(%) |
| Age | |
| 15- 19 | 87(21.7) |
| 20 – 24 | 153(38.2) |
| 25 – 29 | 95(23.7) |
| 30 – 34 | 36(8.9) |
| 35- 39 | 24(5.9) |
| ≥40 | 6(1.6) |
| Parity | |
| 0 | 89(22.2) |
| 1 | 89(22.2) |
| 2 | 53(13.4) |
| 3 | 62(15.5) |
| 4 | 35(8.8) |
| ≥5 | 72(17.9) |
| Ethnicity | |
| Hausa | 329(82.0) |
| Fulani | 58(14.5) |
| Others | 14(3.5) |
| Religion | |
| Islam | 387(96.5) |
| Christianity | 14(3.5) |
Table II. Respondents’ knowledge of Caesarean section (N=376)
| Questions | N (%) |
| Have you heard of Caesarean section?(n=401) | |
| Yes | 376(93.8) |
| No | 25(6.2) |
| Have you experienced Caesarean section? | |
| Yes | 32(8.5) |
| No | 344(91.5) |
| *Indications for Caesarean section | |
| Prolonged labour due to big baby | 244(64.9) |
| Eclampsia | 222(59.0) |
| Bleeding per vaginam before delivery | 237(63.0) |
| Small pelvis for the size of baby | 229(60.9) |
| Blood may be transfused during or after the procedure | |
| Yes | 325(86.4) |
| No | 51(13.6) |
| Usual hospital stay after CS | |
| Within 1 week | 274(72.8) |
| Two weeks | 36(9.7) |
| Three weeks | 11(2.9) |
| Don’t know | 55(14.6) |
| Can a woman achieve vaginal delivery after a CS? | |
| Yes | 355(94.4) |
| No | 21(5.6) |
Table III. Association between level of knowledge about Caesarean section and socio-demographic characteristics (N=376)
| Socio-demographic characteristic | Knowledge | Chi-square test (χ2) | p-value | |
| Inadequaten(%) | Adequaten(%) | |||
| Age in years | ||||
| < 30 | 131(85.0) | 182(81.9) | 0.62 | 0.43 |
| ≥30 | 23(15.0) | 40(18.1) | ||
| Ethnicity | ||||
| Hausa/Fulani | 149(96.8) | 215(96.8) | Fishers | 1.0 |
| Others | 5(3.2) | 7(3.2) | ||
| Religion | ||||
| Islam | 148(96.1) | 215(96.8) | 0.15 | 0.69 |
| Christianity | 6(3.9) | 7(3.2) | ||
| Education | ||||
| Informal | 85(55.2) | 133(59.9) | 0.83 | 0.36 |
| Formal | 69(44.8) | 89(40.1) | ||
| Occupation | ||||
| Unemployed | 93(60.4) | 154(69.4) | 3.25 | 0.07 |
| Employed | 61(39.6) | 68(30.6) | ||
| Parity | ||||
| 0 | 33(21.4) | 50(22.5) | 1.77 | 0.41 |
| 1 – 4 | 96(62.3) | 125(56.3) | ||
| ≥5 | 25(16.3) | 47(21.2) | ||
Table IV. Attitude of respondents to Caesarean section (N=376)
| Questions | N (%) |
| Are you willing to undergo CS if indicated? | |
| Yes | 372(98.9) |
| No | 4(1.1) |
| Are you willing to undergo a repeat CS? | |
| Yes | 307(81.6) |
| No | 69(18.4) |
| *Reasons for not willing to undergo a repeat CS (n=69) | |
| Fear of dying | 34(49.2) |
| Fear of been mocked | 1(1.4) |
| Fear of pain during and after surgery | 36(52.2) |
| Expensive | 14(20.3) |
| Not Gods wish | 6(8.7) |
| *Response to opposing repeat CS (n=69) | |
| Pray about it | 30(43.5) |
| Discuss with Husband | 19(27.5) |
| Seek help from religious leaders | 14(20.3) |
| Seek help from Traditional birth attendants | 12(17.4) |
| How do you view a woman that was delivered by CS? | |
| Weak | 123(32.7) |
| Feel sorry for her | 208(55.3) |
| God’s wish | 45(12.0) |
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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