|Year : 2015 | Volume
| Issue : 4 | Page : 489-492
Maternal views and experiences regarding repeat Caesarean section
BA Olofinbiyi1, RO Olofinbiyi2, OP Aduloju1, BP Atiba3, OD Olaogun1, OR Ogundare2
1 Department of Obstetrics and Gynaecology, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
2 Department of Nursing, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
3 Department of Family Medicine, Accident and Emergency Unit, Federal Medical Centre, Ido Ekiti, Ekiti State, Nigeria
|Date of Acceptance||28-Nov-2014|
|Date of Web Publication||13-May-2015|
B A Olofinbiyi
Department of Obstetrics and Gynecology, Ekiti State University Teaching Hospital, P.M.B 5355, Ado Ekiti, Ekiti State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim was to determine maternal views and experiences regarding repeat caesarean section.
Methods: A pretested and validated semi-structured questionnaire was administered to women with prior cesarean section by trained research assistants and resident doctors; anonymity and confidentiality were strictly observed. The questionnaire comprised information reflecting patients' sociodemographic structure, level of education, number of previous cesarean section, maternal complications following previous cesarean and opinions about acceptance and refusal of cesarean section.
Results: Two hundred and twenty-seven women participated in the study out of which 157 (69.2%) would accept a repeat cesarean section and 70 (30.8%) would not accept. Significant proportion of respondents above 35 years of age would refuse a repeat cesarean section (58.6%). Religious belief (39.7%) and pain (26.5%) were the most common reasons for refusal of cesarean section.
Conclusion: Appreciable proportion of women with previous caesarean section will decline a repeat cesarean section. Re-orientation, reappraisal and appropriate corrective action in the areas of religious belief and postoperative pain management will positively influence our women's acceptance of a repeat cesarean section.
Keywords: Experiences, maternal views, Nigeria, repeat caesarean section
|How to cite this article:|
Olofinbiyi B A, Olofinbiyi R O, Aduloju O P, Atiba B P, Olaogun O D, Ogundare O R. Maternal views and experiences regarding repeat Caesarean section. Niger J Clin Pract 2015;18:489-92
|How to cite this URL:|
Olofinbiyi B A, Olofinbiyi R O, Aduloju O P, Atiba B P, Olaogun O D, Ogundare O R. Maternal views and experiences regarding repeat Caesarean section. Niger J Clin Pract [serial online] 2015 [cited 2021 Dec 1];18:489-92. Available from: https://www.njcponline.com/text.asp?2015/18/4/489/156883
| Introduction|| |
All women with prior cesarean section may not be eligible for trial of vaginal delivery, and even when selected for vaginal birth after cesarean (VBAC) section, vaginal delivery may not be successful in about 23.5% and 28.9% of women undergoing trial of delivery after one and two previous cesarean scars, respectively.  The number of women requiring primary cesarean section is increasing.  There is evidence of a link between prior cesarean delivery and the rising rate of repeat cesarean delivery,  it, therefore, means more and more women with prior cesarean section will need repeat cesarean delivery. 
Despite the improvement in the safety of cesarean delivery associated with advances in anesthesia, antibiotics, surgical techniques and blood transfusion,  women in low-income countries continue to show strong aversion to cesarean section.  On the evidence of recent publications from sub-Saharan Africa, the willingness of women to accept repeat caesarean delivery is low. ,
A woman's refusal of cesarean section can create a challenging situation for obstetric care providers.  In addition, refusal of cesarean delivery, especially when medically indicated, can be a problem for the woman herself. A study from Nigeria reported a caesarean section refusal rate of 11.6% among all cesarean deliveries.  This study documented adverse perinatal and maternal outcomes in women declining cesarean delivery.
Most of the previous studies done on acceptance or refusal of caesarean section focused on either women within reproductive age group or pregnant women with no prior cesarean section; there is dearth of data on the subset of pregnant women with previous caesarean section ,,,
This present study exploring the perception and attitude of women with prior cesarean section becomes necessary as women with previous experience of cesarean section (s) seem to hold superior opinions about the procedure; thus the information from this present study will provide further insight into the management of this sub-group of obstetric population.
| Methods|| |
This cross-sectional study was carried out at the antenatal clinic of the obstetric unit of Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria from January 2013 to December 2013. Women with previous cesarean section (s) were mobilized from January 1, 2013 to December 31, 2013. Following an informed consent, eligible women were recruited at the first antenatal visit to our obstetric unit.
At every first prenatal visit clinic, information regarding the present study was collected using a semi-structured questionnaire, which was developed based on the literature search on perception and attitude of women with or without prior caesarean delivery toward primary or repeat caesarean delivery.
Self-administered pretested and validated semi-structured questionnaire was administered to the women by trained research assistants and resident doctors; anonymity and confidentiality were strictly observed. The questionnaire comprised information reflecting patients' sociodemographic structure, level of education, number of previous caesarean section, maternal complications following previous caesarean section and their stand on acceptance and refusal of a repeat caesarean section.
Data obtained from this study were analyzed using SPSS Version 17 (SPSS inc. version 17, Chicago, IL, USA); while categorical variables were expressed as frequency, continuous variables were expressed as mean, median and ranges. Influence of clinical variables and demographic factors were analyzed using Chi-square or Fisher's exact test. Statistical significance was set at 0.05.
| Results|| |
Two hundred and twenty-five (227) women participated in the study, of which 157 (69.2%) would accept a repeat cesarean section and 70 (30.8%) would not accept. The mean age of the women was 32.11 years (standard deviation ± 4.2, range: 23-40). More than half (54.2%) of the study population were primipara and 103 (45.8%) were multipara. Respondents who would accept a repeat cesarean section and those that would not accept were compared using their demographic and clinical characteristics [Table 1]. Women who would accept a repeat caesarean delivery were significantly younger than those who intended to refuse it (79.6% vs. 20.4%, P = 0.001). Parity, maternal educational status, number of previous cesarean section and outcomes of previous deliveries did not show a significant association with acceptance or refusal of repeat caesarean delivery.
|Table 1: Characteristics of the respondents who accepted repeat CS versus those who refused |
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[Table 2] shows reasons for refusal of caesarean section. Religious belief (39.7%) was the leading reason for refusal of a repeat cesarean section, followed by fear of pain of surgery (26.5%). Other reasons include desire for vaginal delivery (14.7%), cost of surgery (5.9%), stress of surgery (5.9%), fear of death (4.4%), and postoperative scar (2.9%).
| Discussion|| |
A relatively considerable proportion of women with previous cesarean section would decline a repeat cesarean delivery when medically indicated for maternal or fetal reasons. About a third (30.8%) of the study population would refuse repeat cesarean delivery in index pregnancy, indicating one in every three pregnant women who experienced cesarean delivery would not readily accept repeat cesarean section in subsequent pregnancy.
The incidence of intention to refuse repeat cesarean delivery in this current study bears a definite similarity to a reported incidence of 24.46% in only one study that has explored perception and attitude of women with prior caesarean section (s) towards a repeat caesarean section procedure.  An obvious explanation for the similarity between our report and the previous aforementioned study by Enabudoso et al. is the fact that the two studies were carried out in the same country; although in different geopolitical zones. Furthermore, two previous studies among general, pregnant population within Nigeria found that up to 19% of women attending antenatal clinic would not accept cesarean section if needed for maternal or fetal survival. ,
The high rate of refusal of cesarean section among women with previous cesarean section delivery may be related to unsatisfactory experience that emerged from previous caesarean section.
With respect to demographic and clinical characteristics of the respondents, refusal of repeat caesarean delivery is significantly higher compared to the acceptance among respondents with advanced maternal age (58.6% vs. 20.4%, P < 0.001). This is not consistent with the findings of the only study on this topic among women with prior cesarean section (s) which found age not closely associated with refusal or acceptance of cesarean section.  The implication of nonacceptance of indicated repeat caesarean section by women of advanced maternal age may be the amplification of commonly associated obstetric complications in this age group, which could be averted by repeat caesarean section. Multiple previous cesarean sections and perinatal mortality did not significantly influence acceptance or refusal of repeat caesarean section as compared to the findings by Enabudoso et al.  Our findings of lack of significant association with respect to parity, education, previous cesarean morbidity and mode of delivery are in keeping with that of the previous study.  While education and previous mode of delivery were not significantly related to nonacceptance of indicated repeat cesarean section, Aziken et al.'s study on general prenatal population (women with or without cesarean section) identified these two maternal factors as likely predictors of refusal of indicated cesarean section. 
Appreciable segment of our respondents gave pain as a reason for refusal of repeat caesarean section. This result is still relatively in agreement with the study in South-Eastern Nigeria.  It is interesting in this study that the cost of caesarean section is never a strong reason for respondents' refusal of cesarean section, unlike we had in other similar studies done in other states of the country. This is not surprising because the state government in vogue in the area of study has made maternal health care cost (caesarean section bill inclusive) free for all pregnant women at all levels of health care (the tertiary institution of study inclusive).
Since religious belief was the commonest reason given by respondents for not accepting a repeat caesarean section, strategies should be mounted at various levels not only to re-orientate the thinking and perception of the various spiritual and religious leaders about caesarean section but also the attitude and perception of these pregnant women toward a repeat caesarean section. There should be a social forum of education and enlightenment for various religious leaders with a view to achieving flexibility of the already existing dangerous rigid faith of achieving vaginal delivery in the face of absolute contraindication to VBAC section. Effective postoperative pain handling will go a long way to make pregnant women accept a repeat caesarean section. Antenatal psycho-education and epidural analgesia have been found to play an indispensable role in effective management of pain following cesarean section. ,, Psycho-education and the concept of epidural analgesia should be well taught at antenatal clinic. The use of epidural analgesia at delivery is still grossly rudimentary in this part of the world, therefore, facilities and manpower to effect the conduct of effective epidural analgesia and anesthesia at caesarean section should be put in place. These will, no doubt, positively change the attitude and perception of women toward repeat caesarean section. As cost was one of the commonest reasons for caesarean delivery refusal in the prior studies, making caesarean section cost free or reducing the cost would have additive effect on people's acceptance of repeat caesarean section, since we are in an environment where poverty is still the order of the day. ,
Compared to the similar study mentioned above,  this study is strengthened by the relatively larger sample size. In addition, evaluating the opinions of women with previous caesarean section, compared to women with no prior experience of caesarean section, seems to hold more superior explanation on the perception and attitudes of women towards repeat caesarean section. This study may be limited by the fact that it was conducted at a tertiary/referral center and thus women with previous cesarean section attending the tertiary center may just represent a higher risk sub-group among the group of women with previous caesarean section in the general population. Therefore, the population studied is not fully representative of virtually all women with previous caesarean section in the environment of study.
A wider and qualitative study reflecting the same aim and objective may be needed for newer findings in the area of refusal or acceptance of repeat cesarean section.
In our environment, women with previous caesarean section will refuse a repeat caesarean section for religious reasons, pain of surgery, desire for spontaneous vaginal delivery, cost, stress of surgery, fear of death and surgical scar. Information from this segment of women with previous caesarean section, compared to general population, should be appreciated as a better clue to the basis of women's refusal of caesarean section; as people with prior experience of caesarean section hold a more superior and concrete opinion about cesarean section. Re-orientation, reappraisal and appropriate corrective action in the areas of religious belief, postoperative pain management and community socioeconomic status will positively influence our women's acceptance of a repeat cesarean section.
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[Table 1], [Table 2]
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