Caesarean section a better pathway to safe motherhood: perception of adults in Ekiti state, South Western Nigeria

INTRODUCTION

The pride of every woman is to reproduce her kind through the pure act of child bearing and delivery. Most pregnancies are usually uneventful; however, some can become complicated.¹ The complications or risks associated with pregnancy and can be classified into maternal, fetal and placental complications. In 2016, complications arising from pregnancy, childbirth and puerperium resulted globally in 230,600 deaths, down from 377,000 deaths in 1990.² A good number of these will require intervention with caesarean section (CS) in order to save the life of the mother and child.

Caesarean section also known as C-section or CS, is a surgical procedure in which incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies.⁴ CS safety profile has largely been due to better anesthetic techniques as well as availability of blood transfusion and antibiotics.⁵ The rising prevalence of CS is worthy of note. Globally, about 18.5 million CS are performed yearly, 18.6% of all births is by CS in Africa, 7.3% births are via CS, in Nigeria, the rate of CS is 2.1%, at a regionally level, the South West had the highest prevalence.^6-8 In Ado Ekiti, the rate of CS was 19.9%.⁹ The World Health Organization (WHO) recommended CS rate has been between 10% and 15%.

The cultural, religious and societal norms, of individuals in a community, coupled with the fear of possible complications, all contribute immensely to the overall delayed presentation of women for emergency obstetric care, especially CS. This study will therefore assess the attitude and acceptance of CS among adults in Ekiti state so as to tackle maternal mortality. Most studies on CS acceptance in literature were conducted among pregnant women hence neglecting the perception of the general population. Thus, findings from this study will serve as a baseline data for knowledge, attitude and acceptance of CS in the general public.

The study, conducted in South-Eastern Nigeria shows that the average CS rate in the hospital was 16.6%. Only 4 (1.4%) had a positive attitude to CS and viewed it as very good and elected to undergo CS. 34 (12.3%) had a negative attitude and would reluctantly undergo the procedure.¹⁰ The study equally showed that all the respondents believe that CS is done for the safety of the mother/baby. 13% had negative attitudes and rejected the procedure for themselves no matter the circumstance.¹⁰ A descriptive study carried out in South western Nigeria, reported that majority of the respondents agreed that vaginal delivery creates more mother-baby relationship than caesarean section. 69.5% had positive attitude and stated that caesarean CS is preferable to vaginal delivery as the pain in vaginal delivery is usually unpleasant, 66.0% disagreed that babies born through CS are healthier than their other counterparts that are born through vaginal delivery.¹¹

METHODS

The study is a cross-sectional study design among consented adults residing in selected study population of Ekiti State. Adults who have stayed for less than 6 months and those with speech/communication problems were exempted from the study.

Sample size determination

The sample size was determined using Fisher’s formula.

Here, n is the sample size required, Z is standard normal deviation, set at 1.96 corresponding to 95% confidence level, p is proportion of adults in Ido, 50%, and e is level of precision set at ±5%.

Non response sample size was calculated as 10% of total sample size, approximately 38. The total sample size was approximately 422.

Sampling technique

A multistage sampling technique was used to select eligible participants. The technique was in four stages.

Data collection, management and analysis

A pre tested, validated, semi structured, interviewer administered, questionnaire was used for data collection. All data collected were sorted, coded and analyzed using International Business Machine (IBM) statistical package for the social sciences (SPSS) statistics version 25. Results were presented through charts, proportion, percentages, frequency tables, mean and standard deviation. P value was pre-determined at 0.05.

Ethical considerations

Ethical approval to carry out the study was obtained from Federal Teaching Hospital Ido-Ekiti, ethical review committee. Informed consent was obtained from participants. Participants were allowed to withdraw at any point in time without threat or consequence. Confidentiality was maintained.

RESULTS

A total of four hundred and twenty-two (422) questionnaires were administered. Out of these, three hundred and eighty-six (386) were completely filled, returned and analyzed, indicating an attrition rate of 8.5%.

Figure 1 shows the likely people that can influence respondents’ decision to accept CS. Family had the highest influence follow by religious leaders and friends respectively.

DISCUSSION

The mean age of respondents in this study was 45 years. This finding is slightly different compared to the mean ages in studies done in Ogbomosho Southwest Nigeria where it was 29 years.¹¹ The different study areas can account for this disparity and different study population. Majority of the respondents had tertiary level of education, 65%, which was similar to a study carried out in Ogbomosho where 68.5% also had tertiary level of education but in contrast to findings obtained in a study done in North West Nigeria which had 7.8%.^11,12 The study had 37.6% never married and 62.4% ever married participants This result is difference from the study carried out in Ghana where 94% were married or cohabiting while 6% were single.¹³ Majority of the respondents in this study were civil servants (42%).

Attitude towards CS was broadly grouped into two: positive attitude and negative attitude. A slight majority of the respondents (50.3%) have a positive attitude towards CS while 49.7% had a negative attitude towards CS. Our results were similar to that of a study carried out among primigravidas as regards their attitude towards vaginal delivery and caesarean section in Kubang Kerian Kelantan, Malaysia where 52.4% of the respondents had a positive attitude towards caesarean delivery but 47.6% had a negative attitude.¹⁴ Our study is also in contrast to a study conducted in Nepal where 24.2% of the respondents had an overall positive attitude and 75.8% had either a neutral or negative attitude towards caesarean delivery.¹⁵ This is possibly due to the presence of a tertiary health care facility in Ido-Ekiti which overtime has created awareness in the community. Among those with a positive attitude towards Caesarean section in our study, 52.6% felt it was as safe as vaginal delivery. This shows similarity to a hospital-based study done in Punjab, India which showed that 47.3% of the respondents viewed CS to be safe compared to vaginal delivery.¹⁶ This is possibly due to the fact that majority of our respondents (65%) were educated up to the tertiary level.

Regarding acceptance, our study showed that 68.1% respondents were willing to accept caesarean section if necessary while 31.9% were unwilling to accept it. The major reasons why these respondents were unwilling mostly bordered on concerns regarding pain during the procedure (42.3%), fear of death (40.7%), prolongation of recovery time following childbirth (26.8%) and the society’s perception of their choice (23.6%). Our study further revealed that 16.3% and 11.4% of respondents will not accept caesarean section even if it is to save the life of the mother and baby respectively. These findings were similar to the findings in a study conducted to assess the acceptance of caesarean delivery among women in Abakaliki, Ebonyi state, Nigeria.¹⁷ This is also similar to the study done among pregnant women in Ogbomoso where 24.5% indicated that they will be unwilling to accept caesarean section irrespective of the circumstance.¹¹ However, the findings of our study were in contrast with a study conducted in Rajasthan, India where 73.5% of the respondents did not accept CS as a delivery method.¹⁸ This could be as a result of the educational background, economic situation of respondents and their knowledge on CS. The result of our study is also different from a study conducted in in the Cape Coast Metropolis, which showed that majority of the pregnant women (66%) will not accept CS as a delivery method.¹⁹

Limitations

Some respondents refused to participate in the study since they have no financial gain.

CONCLUSION

Significant number of the study population still have negative attitude towards CS. Some were willing to accept CS if indicated. Effort should be made by stakeholders in the community especially, religious organizations and health workers to help in improving the attitude and acceptance of people towards CS.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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