A survey of preference of parturients in labour

Oladokun A. ,Adesina O. A , Odukogbe A.A. ,Morhason-Bello I.O. Kolawole K. ,Adewole I.F.

Department of Obstetrics and Gynaecology, College of Medicine, University College Hospital, Ibadan, Nigeria.

ABSTRACT
Background:
There is a growing concern among parturient women to have labour management modified to accommodate some of their preferences based on their previous experience of information obtained from others.

Objectives: As service care providers, we sought to identify women's attitude to some important aspects of childbirth, namely: the preferred place or environment of delivery; reasons for dislike of modern labour management; as well as attitudes (cognitive, affect and behaviour) to operative delivery, particularly caesarean deliv ery.

Methods: A survey of women's attitude to some important aspects of childbirth was carried out with the use of questionnaires among women attending antenatal clinic at the University College Hospital, Ibadan, Nigeria.

Results:The study showed a great desire by women to have someone they already know in labour (spouses 58.80%; mother/mother figure 88.68%). Forty percent of those who prefer to deliver outside hospital settings would do so due to unfriendly attitudes of doctors and midwives.

Conclusion:There is the need to appropriately train doctors and midwives who attend to women in labour as regards the anxieties and needs of the women in labour.

Key words: Childbirth; Parturient; Intrapartum; Women's attitude; Labour.

INTRODUCTION
Childbirth, all over the world is an important milestone in a woman's life, especially in the developing countries where much premium is placed on childbirth. The success of a marriage is usually measured by number of children born. However, bringing forth a child is sometimes associated with certain degree of anxiety. This is so because in developing countries, including Africa it has become a hazardous event[1,2], since an unacceptable proportion of women die from complications of childbirth. Though, good antenatal and intrapartum care have been shown in the developed societies to reduce not only maternal mortality but also maternal and parinatal morbidity[3]. The reasons for the high mortality ratio in this environment are traceable to certain socio-cultural and medical factors[4]. In Nigeria for example, it’s been observe that a good number of women who use modern health centres arrive in advanced labour, with complications[1,5], usually having attempted delivery at home, at a traditional midwifery service or at a spiritual or at a spiritual centre or church[2]. Many of these women die undelivered.

The reluctance at utilizing these modern facilities vary as some have come to associate health care providers with negative attitudes towards their patients or the use of artificial or unnatural methods (i.e. caesarean delivery). When women resent a potentially life saving service and modern maternity care, for various reasons[4,6] then there is cause for concern. The women may end up having childbirth phobia, which, if not properly managed, may further lead to advanced maladjusted behaviour.

As service care providers, we sought to identify women's attitudes to some important aspects of childbirth, namely: the preferred place or environment of delivery; reasons for dislike of modern labour management; as well as attitudes (cognitive, affect and behaviour) to operative delivery, particularly delivery.

MATERIALS AND METHODS

This was a cross-sectional survey conducted with the use of a pre-tested questionnaire. All respondents were antenatal patients in the third trimester, at the University College Hospital, Ibadan, Nigeria, currently carrying a second pregnancy after a successful first one (i.e. Para 1).

Information obtained included the socio-demographic data, their responses to some pertinent issues on labour management and their childbirth experience. The completed questionnaires were coded, and the information analysed using simple percentages therein summarized in tables.

RESULTS
Of the 415 women interviewed, 244 (58.80%) were aged 30 years and below. Three hundred and sixty-five women (87.95%) had had vaginal deliveries while 50 (12.05%) had Caesarean deliveries. Of the former group, 272 (74.52%) had delivered at maternity homes, 20 (4.8%) delivered at church missions*, and 5 (1.2%) delivered at home or enroute in a vehicle.
Seventeen (34%) of those with previous CS and 82 (22.5%) of those with previous vaginal delivery were health professionals**. Two hundred and Sixty nine (64.8%) respondents had educational attainments of high school and above, while 43 (10.35%) had no formal education.
Table 1 showed a summary of responses to the structured questions related to the childbirth experience.
The pattern of answers to the questions on the childbirth environment and Caesarean delivery options are shown on Table II.

*Church/Mission Houses: These are childbirth centres that do not apply any scientific principles or practice to the childbirth experience. There is no formal licensure for these outlets, and the qualification of caregivers may range from learning on the job to a professed “spiritual gift” to manage the most difficult labour.

**Health Professional: A term that refers to care givers in this study, who attended either a school of  Nursing/Midwifery; or medicine at Degree level.

DISCUSSION
The population of women studied would appear rather fairly educated as only 43 (10.4%) had no formal education. They also live in a largely urban setting with the attendant exposure to non-formal continuing education and exposure to modernization, all factors having high correlation with the utilization of modern health care facilities[4]. This is corroborated by the present study since the respondents were those attending antenatal clinics in orthodox institutions.

The preferred delivery environment in this study generally appeared favourable towards hospital confinements 288 (69.4%). Likelihood for caesarean operation (48.9%), unfriendly attitude of doctors and nurses (40.1%) were given as reasons by 127 respondents for disliking hospital environment. This would underscore the attachment of these respondents to 'natural' delivery. It should also be noted the contribution of unfriendly attitude of doctors and nurses' to reasons why some would not want to deliver in a hospital setting. Childbirth is associated with certain degree of pain especially if it is by caesarean delivery. This is why having a child might be anxiety provoking and conflictual. It is quite unfortunate that women see caesarean  delivery as a mere 'knife-brandishing' exercise rather than as genuine attempts to relieve suffering and improve maternal and fetal outcome. It is striking, however, that majority (95.9%) of women mentioned pain as probably the reason for their dislike of caesarean delivery, while (85.8%) believed that caesarean operation is “unnatural”.

Anecdotal influences may play an important role in women's childbirth experience, at least in non-orthodox care settings. It is suspected that inadequate intra-operative and post-operative analgesia for women who had caesarean births may contribute to fear and dislike. Twenty percent of patients remembered the pain of skin incision in a series where the main induction delivery interval was less than 3 minutes7. It is possible that this proportion is higher in most hospitals in Nigeria where skilled anaesthetics are few and far in between. Furthermore, the severity of postoperative pain may add to the patients' general interpretation of surgery-related pain complex. In a studied obstetric population, post-operative pain may be related to the occurrence of “scoline pains” and/or an inadequate, poorly timed post-operative analgesic administration8. The implications of these points as related to current anaesthetic and surgical care are obvious. This could explain why more women in the studied population, who had a previous CS would want some form of pain relief in labour. This calls for concern among caregivers. Though the pain may not be totally removed, reduction in the experience may facilitate option for and cooperation with caregivers whenever pregnant/labouring women require operation at delivery. Perhaps the most striking finding of this study is the preference for the presence of spouses in labour. Hitherto, men are culturally forbidden from being present where their wives are in labour. Many studies have looked at this issue, albeit in a largely non-Negroid population. Kennel, et al (1991)[9] found out that women rate their partners' presence during labour as extremely important and helpful. This preference may be explained by the social and psychological theory of diffusion of responsibility. This theory states that in an uncertain situation, the presence of others helps in reducing anxiety and fear that is being anticipated as a consequence of that situation. This is due to the perception by the individual, that whatever that would be experienced is going to be shared by others, and in this case a very significant other (i.e. the husband). A South African study similarly reported a facilitatory effect of companionship during labour not only on the perception (of pain) but also on the breast-feeding experience[10].

Women's greatest desire is to have with them (during labour) someone they already know and have received care from. In addition, young women delivering their first babies in some cultures for religious and cultural reasons shy away from hospitals probably because they do not want to appear naked before the hospital delivery staff whom they are not familiar with. However, some other workers believe that because of a lack of experience with labour, male partners may not have the same impact[11].

CONCLUSION
The results of this attitude survey hold some practical implications for policy makers and care providers. It is probably time to re-evaluate our labour ward practices as regards the anxieties and needs of the women in labour. A good number of doctors and midwives who attend to women in labour simply lack the requisite feeling, empathy and communication skills. Appropriate training in this area should be addressed. It would seem especially prudent, that the decision to deliver a woman abdominally be taken with a clear understanding of the problem by the woman, and her appreciation for this panacea as being best as at that time.

Finally, we must strive to make the childbirth experience safe for all women, wherever they choose to undergo it. This will involve organizing workshops and seminars periodically for midwives who will be supervising confinements outside hospital settings among other things.

REFERENCES

1. Aboyeji, A.P. & Fakeye, O.O. Avoidable factors in maternal mortalty in Ilorin. Nig Med. Pract. 1995;  29:2-4
2. Babarinsa IA, Adewole IF, Ajayi AB: Church-based confinements in Ibadan, Nigeria: A significant factor in maternal mortality?  In: Proceedings of 10th Confederation of African Medical Associations and Societies (CAMAS) Congress.  Abdijan, Cote D'Ivoire. (Eds: I.F. Adewole, Babarinsa IA, Adekunle OO), 1994; pp 55-70.
3. Neilson J.P. Statistics and effective care in Obstetrics. In: Dewhurst's Textbook of Obstetrics and Gynaecology for Postgraduates. 6th edition, edited by Edmonds DK; 1999; 384  360. London. Blackwell science.
4. Kisekka, M. Ekwempu, N., Christoper, C., Essien e.S. & Bola, M. Determinants of maternal; mortality in Zaria area. In: Kisekka, M. (ed). Women's Health issues in Nigeria Zaria. 1992; Tamaza. Pp 51-56.
5. Briggs, N.D. Maternal death in the booked and unbooked patients:  The University of Port Harcourt Teaching Hospital experience.  Tropical Journal of Obstet Gynaec, 1988; 1, 26-28
6. Brieger, W.R. Lucjij, K.J. & Eng. E. Use of maternity services by pregnant women in a small Nigerian community.  Health Care Women International, 1994; 15 (2), 101-110.
7. Magno, R. Selsam, U. & Karisson, K.  Anaesthesia for caesarean section ll: Effects of induction delivery internal on the respiratory adaptation of the newborn in elective caesarean section.  Acta Anaesth Scand. 1975; 19, 250  259.
8. Famewo, C.E  Study of post-operative pain among Nigerian patients. African Journal of Medicine and Medical Sciences, 1985; 14: 175  179.
9. Kennel, J., Klaus, M. & McGrath, S Continuous emotional support during labour in a US hospital. JAMA. 1991; 265 (7) 2197  2201.
10. Hofmeyr, G.J., Nikodem, V.C. & Wolman, W. Companionship to modify clinical birth environment: Effects on progress and perceptions of labour and breast-feeding. Br J. Obstet Gynae. 1991; 98, 756  764.
11. Bersch, T.D., Nagashima-Whalen, L. & Dykeman, S. Labour support by first time fathers: Direct observations. J. of Psych, Obst and Gynae. 1990; 251  260.