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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 104-110

Acceptance of repeat cesarean section and its determinants among a Nigerian pregnant women population


1 Department of Obstetrics and Gynaecology, Central Hospital, Agbor, Delta State, Nigeria
2 Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Submission26-Jan-2020
Date of Decision06-Apr-2020
Date of Acceptance30-May-2020
Date of Web Publication29-Oct-2021

Correspondence Address:
Dr. Nosakhare Osasere Enaruna
Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Edo State
Nigeria
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DOI: 10.4103/smj.smj_4_20

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  Abstract 


Background: Many women who need caesarian section in most sub Saharan Africa do not get it or do so too late, thereby resulting in an unnecessary increase in maternal and perinatal adverse outcome. Refusal of caesarian section has been attributed to poverty and sociocultural factors. Objective: The objective of the study was to determine the level of acceptance of repeat cesarean section (CS) among pregnant women attending care in a government-funded health facility with a policy of free maternity care services. Materials and Methods: This cross-sectional study surveyed 157 consecutive consenting antenatal clinic clients with previous CS presenting for booking in Central Hospital, Agbor, Delta State, Nigeria. The women completed a questionnaire with sections on sociodemographic attributes, inquiry about previous CS outcome and associated factors, a desire to accept a repeat CS if clinically indicated in index pregnancy, as well as reasons to decline a repeat CS. Results: The acceptance rate of repeat CS was 54%. Women with two or more previous CS were more likely to accept repeat CS (71.8% vs. 48.3%, prevalence ratio: 1.5; P = 0.02). There was no sociodemographic variable or any event related to the previous CS which was significantly associated with the women's choice regarding repeat CS. The rejection of repeat CS was mainly due to concerns about postoperative pain and being tagged with “failure of womanhood.” Conclusions: The level of acceptance of repeat CS in Central Hospital, Agbor, is low despite the policy of free maternity care. Along with the increasing effort to make health care affordable, attention needs to be paid to the role of patient and community engagement in the form of health education and continuous counseling to address noncost barriers to achieving improved maternal and perinatal health indices.

Keywords: Acceptance, free maternity service, Nigeria, repeat cesarean section


How to cite this article:
Maduka RN, Enaruna NO. Acceptance of repeat cesarean section and its determinants among a Nigerian pregnant women population. Sahel Med J 2021;24:104-10

How to cite this URL:
Maduka RN, Enaruna NO. Acceptance of repeat cesarean section and its determinants among a Nigerian pregnant women population. Sahel Med J [serial online] 2021 [cited 2021 Nov 28];24:104-10. Available from: https://www.smjonline.org/text.asp?2021/24/3/104/329515




  Introduction Top


Almost everyone with a keen interest in obstetrics and perinatology now accepts that the rates of cesarean section (CS) worldwide have maintained a rising trend in the past few decades. Even so, in most of sub-Saharan Africa, one can still argue that many women who need CS do not get it, or do so too late, thereby resulting in an unnecessary increase in maternal and perinatal adverse outcomes.

The widespread appeal which CS now enjoys, especially in sub-Saharan Africa where CS rates were not considered significant enough to attract any attention or merit decisions to modify the application of CS for delivery barely three decades ago, is perhaps driven by improved safety of the procedure, as well as several other personal and social reasons.[1],[2],[3],[4] Today, CS is arguably the most performed surgical procedure in Africa, but the overall rate still appears low[5] despite hospital reports suggesting higher rates.[6],[7],[8],[9]

In the face of improved outcomes with CS, occasional negative impact on maternal and perinatal health remains a real possibility in our environment with CS maternal case fatality of 0.7% reported in one study.[8] This is especially so with respect to increased risk of perioperative bleeding requiring blood transfusion, peripartum hysterectomy, postoperative infection, or thromboembolic events, and these complications could be increased further in women with previously scarred uteri who have had failed attempts with vaginal birth after cesarean (VBAC) section; hence the opinion of some researchers that unsuccessful VBAC carries a greater risk of complications than elective repeat CS in our environment.[10]

A large part of the challenge with acceptance of repeat CS among pregnant women stems from a strong sociocultural mindset which discourages women and their families from accepting CS. They would rather attempt to achieve VBAC at all costs to prove a point and win back the favor of their community for having failed once in the past. This potential for aversion to delivery by CS has been studied by various authors.[11],[12],[13],[14] The reasons for preferring an unconventional quest for VBAC despite adequate evidence in favor of the contrary have been highlighted by these previous researchers to include the cost of the procedure, perceived failure of womanhood, and cultural aversion.[12],[13],[14],[15]

Perhaps, the issue of cost is a major stumbling block for many women and families considering that most people live below the poverty line in Nigeria.[16] Hence, it is pertinent to inquire what other factors will remain as strong influencers of attitude regarding the acceptance of CS delivery in women with previous CS when the role of cost is relatively minimized. It is instructive to know that many of the studies previously conducted to explore perception and attitude toward CS in our locale surveyed the women around the time of the procedure or shortly after the CS, without much room for attitude change or behavior modification. Moreover, most of the previous studies were conducted in settings where patients either paid out of pocket or had some form of health insurance taking care of the bills for the procedure.

Central Hospital, Agbor, where the present study was conducted, is a government-funded secondary health-care facility with an intervention to increase access to maternal and child health care in place, one of the components being free antenatal care and delivery. Therefore, this study is intended to focus attention on the current situation of perception and acceptance of CS in the setting of free access to antenatal care and delivery. We hope to be able to highlight the potential barriers to appropriate decision-making for women who need to have repeat CS as an alternative to vaginal delivery in our environment.


  Materials and Methods Top


Study setting

Central Hospital, Agbor, was established in the year 1906. It is a 250-bedded hospital located in the South–South region of Nigeria. It provides general medical care and specialist services to indigenes of Delta State and neighboring parts of Edo State. The obstetrics and gynecology department has two consultants who are fellows of the National Postgraduate Medical College of Nigeria and the West African College of Surgeons, respectively. Training of medical officers and interns forms part of the activities of the hospital. Central Hospital, Agbor, attracts a monthly antenatal booking of over two hundred women, and the delivery rate in the past 5 years has been approximately 2000/year with a CS rate of about 28%. The postnatal clinic attends to about fifty women per week.

Agbor is a kingdom in Delta State, Nigeria, occupying a part which has boundary with Edo State. The people of Agbor town are Ika and they speak the Ika dialect of the Igbo language. Agbor has a population of about 67,000 people who are predominantly Christians of different denominations. Some of the indigenes practice African traditional religion, and there are a few migrant Hausa/Fulani Muslims. The main occupational activities of the indigenes of Agbor town are farming and trading.

In November 2007, the Delta State Government introduced a free maternal health program in the state. The intervention covers the cost of antenatal care, delivery including CS, postpartum, and postnatal care up to 6 weeks after delivery/birth, drugs, and other supplies, laboratory investigations as well as surgical management of ruptured ectopic pregnancy and blood transfusion. The program has been sustained till date by the successive governments.

Study design

A cross-sectional study was conducted at the antenatal outpatient unit of the Department of Obstetrics and Gynecology, Central Hospital, Agbor, Delta State, Nigeria, from October 2018 to September 2019.

Inclusion and exclusion criteria

The target population consisted of all women who came to book their pregnancies at the antenatal clinic. The inclusion criteria were confirmed pregnant, presenting to the antenatal clinic for booking, having had at least one previous CS, and having signed informed consent.

Data collection

The study population was the women presenting for the first time for antenatal care. Women with one or more previous CS were counseled to participate in the study, and those who consented were recruited. Thereafter, an anonymous semi-structured pretested questionnaire was administered to the women by trained medical officers. Confidentiality was ensured during the process.

The sample size was determined based on the 87% proportion of pregnant women who would accept CS as an alternative to vaginal delivery reported by Ezeome et al.,[14] using the formula for cross-sectional design: n = 8 P (1 − p)/(p0 − p1)2, where P = (p0 + p1)/2, p0 is the proportion in a previous population, and p1 is the anticipated proportion in the present study. We expected that CS acceptance rate in the present study will be higher by 10%. Accepting 5% Type 1 error which gives a normal standard deviate of 1.96 at 95% confidence interval and with a power of 80%, the multiplier factor will be 8. Assuming an attrition rate of 20%, the sample size was determined to be 104 women who were recruited using a simple random sampling technique. The sample size was increased to 157 surveyed women who met the inclusion criteria and consented to participate in the study to further increase the power and improve the external validity of the study.

Sociodemographic characteristics and outcome of delivery following the previous CS, including complications, were documented. Complications of interest were the necessity for blood transfusion, surgical site infection and wound breakdown, prolonged hospital stay, and adverse neonatal outcomes. Further inquiry included type of anesthesia, place of CS (private or public facility), cadre of surgeon for the CS (nurse/midwife, medical officer, obstetric resident, or consultant obstetrician), experience of domestic violence in relation to the previous CS, and a desire to accept a repeat CS if clinically indicated in index pregnancy, in addition to reasons to decline a repeat CS.

Ethical consideration

Ethical approval for the study was obtained from the Research and Ethics Committee of Central Hospital, Agbor, on October 12, 2018, with protocol no: E. Comm/C/0/AMZ/187/18. The study was executed in accordance with the guidelines of the Declaration of Helsinki, 2013.

Data analysis

A database was generated from the completed questionnaires. Analysis of data was done using SPSS version 20 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean or median with differences measured using Student's t-test. Categorical variables were expressed as frequency with differences in effects of sociodemographic factors, clinical variables such as maternal complications and adverse perinatal outcome following CS, as well as the experience of violence related to prior CS assessed using Chi-square test or Fisher's exact test as appropriate and expressed as a prevalence ratio. P < 0.05 was considered statistically significant.


  Results Top


Over the study period, a total of 157 women were surveyed. The mean age of participants was 31.86 ± 4.45 years with a range of 18 years to 42 years. The median parity was 2 and the range was 1–6. Only over half (51.6%) of the study population was multiparous. The women with one previous CS consisted (118/157) 75.2% of the participants.

Almost half (45.9%) of the women interviewed were not agreeable to a repeat CS for an appropriate indication. Comparison of sociodemographic and clinical attributes of the patients who would accept repeat CS with those who would not accept repeat CS revealed that women who had two or more previous CS were more likely to accept a repeat CS (71.8% vs. 48.3%, prevalence ratio 1.5; P = 0.02) as shown in [Table 1].
Table 1: Sociodemographic and clinical characteristics of the respondents in relation to acceptance of repeat cesarean section

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Maternal age, parity, educational status of the patient, and the type of anesthesia used in the previous CS did not seem to influence refusal or acceptance of a repeat CS. Similarly, the experience of domestic violence in relation to the previous CS and complications following the previous CS or the occurrence of perinatal death in the previous delivery did not significantly differ between the women who agreed to have a repeat CS when offered as an alternative to vaginal delivery and those who declined having a repeat CS, as seen in [Table 1].

The most common reason given by the women who would decline a CS was postoperative pain (14.6%). Other reasons included being labeled with “failure of womanhood” (12.1%), fear of death (7%), postoperative discomfort (3.2%), and fear of complications (2.5%) as well as religious influence (1.9%), long duration of stay in hospital following cesarean delivery (1.3%), and dissatisfaction with the previous CS (0.6%) [Table 2].
Table 2: Reasons for refusal of repeat cesarean section

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  Discussion Top


In our study, 46% of the women will not accept repeat CS when offered as an alternative to vaginal delivery. This is rather worrisome, considering the important role of a timely CS in improving maternal and perinatal outcome. Moreover, this concern is especially germane in our environment where the majority of emergency CSs are carried out on women who either did not attend antenatal care or were referred when complications arose. Women who had two or more previous CS were more likely to accept repeat CS, but age, parity, or educational status did not significantly influence the decision on repeat CS.

In a previous study by Enabudoso et al.,[11] 24.5% did not accept CS, while Olofinbiyi et al.[17] reported a CS refusal rate of 30.8%. In these two studies, the cost of surgery was a significant concern for 23.5% and 5.9% of the respondents, respectively. The two studies were conducted in public teaching hospitals in urban centers with a relatively high cost of health care including CS. In contrast, the present survey was carried out in a semi-urban government health center where there was a policy of free antenatal care and delivery services including CS. It is against this background that our study could have explored the roles of factors like fear of postoperative pain and concerns about a label of “failure of womanhood,” as potential barriers to improved maternal and perinatal health by limiting access to and utilization of a life-saving intervention like repeat CS, having theoretically eliminated the impact of cost of care on decision to accept CS previously documented by other researchers.[11],[17]

Interestingly, the women surveyed in the present study reported a very high level of rejection of repeat CS. This significantly higher proportion of women who did not favor repeat CS in our study probably reflects the structure of the sociocultural and religious attributes of the women who participated in our study. Furthermore, it may also be connected to the negative perception of CS as an intervention which is often viewed with suspicion and seen as a design by the health-care worker to take away the patient's autonomy of choice and decision regarding their health. Hence, an evaluation of the role of microculture and religious proclivity in the setting of utilization of CS as an intervention will be instructive in further research in this area of interest.

Similar to the finding by Enabudoso et al.,[11] the age did not influence the decision to accept or reject repeat CS among the women we studied. Other sociodemographic characteristics like parity and educational attainment did not significantly differ between the women who accepted or declined CS in our study. Perhaps, there are more important considerations for the women which are not often promoted such as negative attitude of the health-care team, a perceived imposition of a previous CS, and poor communication by health-care workers. This apparent lack of communication with patients was shown by Enabudoso and Orumwensodia[18] who documented poor counseling about the safety, complications, and postoperative pain management reported by women interviewed shortly after CS in a teaching hospital.

In the present study, women with two or more previous CSs were more likely to accept repeat CS. It stands to reason that patients who have had two or more previous CSs are more enlightened about the procedure and its safety and so will be more willing to accept it in subsequent deliveries, especially considering the current standard of care that does not favor vaginal birth after two or more previous CSs. Even so, the proportion of women in this category who still did not want repeat CS is worrisome. In the present study, almost 30% of women with two or more previous CSs did not want repeat CS in the next delivery. Unconventional birth requests, including a desire to have vaginal delivery after two previous CSs, are likely to rise in the coming years should this observation reflect what is obtainable in other parts of the country. Unfortunately, we do not yet have the capacity to respond adequately to major obstetric emergencies, especially in the rural communities.[5]

By mitigating the effect of cost in having repeat CS, the expectation is that the acceptance of CS among those with two or more previous CSs will be very high. Whereas one can imagine that financial constraints played a huge part in the decision to refuse intervention in the study by Lawani et al.,[15] the reason for 3 of 10 women with two previous CSs offered a free procedure to reject CS merits further examination. In addition, this observation clearly demands urgent need for obstetricians, midwives, and allied health practitioners to scale up a coordinated package of maternity health education and counseling, especially for patients with previous CS, emphasizing the place of every woman's desire for best maternal and perinatal outcome, as well as empathy toward the experience of women during pregnancy and childbirth. This is expected to have a positive impact on the utilization of CS and reduction in morbidity and mortality associated with vaginal delivery after two or more previous CSs, considering that the outcome of delivery appears to be worse when there is a failed attempt at vaginal birth after CS, especially in the setting of two previous CSs, than following a planned elective repeat CS.[10]

Postoperative pain has been reported as a common reason for not accepting repeat CS by many of the previous studies. The management of immediate postoperative pain in our environment is particularly poor, and the development of chronic pelvic pain has been associated with the intensity of acute pain experienced in the postoperative period.[19] Increasing the availability and uptake of epidural analgesia for labor and the ready utilization of regional anesthesia for CS as well as the use of potent parenteral analgesics including opioids will remarkably improve postoperative pain care and hopefully improve the overall acceptance of indicated repeat CS.

Failure of womanhood, fear of death, and fear of complications were the other common reasons why women with previous CS will not accept repeat CS;[12],[13],[14],[15] and the need for effective counseling of patients billed for repeat CS cannot be overemphasized. The apparent lack of expression of their femininity and a perceived failure of womanhood experienced by women who failed to achieve a vaginal birth previously could become a barrier in subsequent quest for a baby. It may be important to emphasize the possible complications like rupture of the gravid uterus and its sequelae while at the same time promoting the proven safety of the procedure in contemporary obstetric practice.

Perhaps, designing a counseling protocol for uniformity and consistency in a particular health facility can advance the acceptance of repeat CS. This approach of consistent content counseling has been shown to impact positively on the decision to initiate and continue contraceptive methods by women counseled during antenatal and postpartum periods, especially when there have been multiple opportunities for such counseling sessions.[20] And of particular importance is the expected impact of community engagement in the form of advocacy, public enlightenment, and shared responsibility for the overall health of the community directed toward a determined effort to discard myths and strengthen correct information about the place of CS as an intervention. The corollary will be a positive attitude toward CS by the stakeholders in the communities to remove the stigma associated with delivery by CS, which has the potential of improving the uptake of repeat CS.

The present study has shown that aversion to CS which stems from fear of postoperative pain, an overwhelming desire to experience labor and vaginal birth, and uncertainty about the outcome, remains high in our environment, and this observation may be a contributory factor to the high maternal mortality indices in this part of the globe. The expressed concerns of the surveyed women appear well founded, but nearly all of these can be formidably addressed in a coordinated approach to client-oriented maternity care with consistent counseling protocol in a setting of community engagement.

Strengths and limitations

The elimination of cost as a major barrier previously documented in other studies[12],[15] made this study unique in its ability to examine the complexity of provider–patient engagements regarding offering and accepting CS for delivery. This study is limited by the fact that it was carried out among a subset of the population with previous CS, attending a particular health facility, and probably with a predetermined notion about CS, so that their responses may not reflect the level of awareness and acceptance of the procedure in the general population. Furthermore, parous women who have yet to experience CS or did not access antenatal care were not captured in the surveyed population.


  Conclusions Top


The level of acceptance of repeat CS in our district hospital is low despite the availability of free labor and delivery services. This study has shown the impact of noncost client concerns in decision-making for CS. A facility-based counseling protocol for CS instituted and continued during the antenatal period is advocated for improved maternal and perinatal outcome.

Acknowledgments

The authors would like to appreciate the medical officers who assisted with data collection, Mrs. Iyore Osayande for her role in the secretarial work, and the patients–volunteers who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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