Maternal perceptions about caesarean section deliveries and their role in reducing perinatal and neonatal mortality in the Upper West Region of Ghana; a cross-sectional study

Neonatal and perinatal mortality in low and middle income countries is a matter of concern. This is because in the year 2015 alone, almost half (2.7 million) of the 5.9 million under-five deaths occurred during the neonatal period [1]. In addition, about 98% of global perinatal and neonatal mortalities are reported to occur in low and middle income countries [2]. In Ghana, for instance, the neonatal mortality rate in 2017 was estimated at 29 per 1000 live births [3, 4] and it represented 48% of under-five mortality (60/1000 live births). Meanwhile, the Sustainable Development Goals (SDGs) seek to tackle this problem with the aim of ending preventable deaths of new-borns and reducing neonatal mortality to at least as low as 12 deaths per 1000 live births by 2030 [5, 6].

It is estimated that, improved care at birth has the potential of preventing 1.3 million stillbirths within these regions by the year 2020, especially since the majority of the causes of stillbirths are preventable [7]. Therefore, since neonatal and perinatal deaths are closely related to the quality of care a woman receives during pregnancy and labour, accessibility of emergency obstetric care services including caesarean section when indicated is essential for reducing these deaths [8, 9].

Studies have shown that having a skilled attendant at delivery, and institutional delivery in general, has been associated with reductions in maternal, perinatal and neonatal mortality [10]. One of the critical advantages of institutional skilled delivery is the window of opportunity for surgical intervention when needed. Access to caesarean section is recognised as an essential component of obstetric care [11, 12] and, when medically justified, it is known to prevent perinatal and maternal morbidity and mortality [13]. However, maternal perceptions about caesarean section may influence the likelihood of mothers opting for institutional delivery which in turn affects access to this intervention, especially when it is most needed. It has been reported that caesarean section rates at population levels higher than 10% were not associated with reductions in maternal and new-born mortality rates [14, 15]. However, in Africa where the median caesarean section rate is estimated to be 8.8%, the risk of neonatal death is reported to be lower in settings having higher elective caesarean section rates [16]. The national average of caesarean section rates in Ghana is estimated at 12.8% but it ranges from 11.2–14.6 [17]; even then, there are wide disparities in access and uptake of caesarean section in urban and rural areas which may be partly related to perceptions about caesarean section.

There is a widespread belief that West African women have an aversion for surgical delivery and to have a CS is regarded as a reproductive failure [18‐22]. Vaginal delivery is regarded as the ideal and a status symbol of womanhood; therefore, women who have had a CS might feel loss of the idealised birth they had hoped for, loss of part of their womanhood, and live in fear that other women may ridicule them [18‐22]. A recent at study conducted in the Upper West Region described women’s perception of caesarean section delivery as highly problematic; and that CS delivery acts as a long term disease [23]. This was because the respondents felt that having a CS incapacitated women for an extended period of time making them unable to fulfil domestic and economic roles which were inimical to the survival of their families. Such perceptions, when widespread, have the tendency of affecting the uptake of medically indicated caesarean sections aimed at preventing perinatal and neonatal mortality, especially among rural women. The aim of this study was to explore maternal perceptions about caesarean section deliveries, and their role in reducing perinatal and neonatal mortality among antenatal attendants in selected hospitals in the Upper West Region of Ghana.

Altogether 416 pregnant women took part in the study. Response rates observed in the study was 98%. In all, 50.5% (n = 210) of the expectant mothers attended antenatal clinic at St Joseph’s hospital, Jirapa, while 49.5% (n = 206) attended at the Upper West Regional Hospital. The age range of study participants was from 14 to 45 years with a mean age of 27 (SD = 6.0) years. Table 1 displays the background characteristics of study participants from the two study sites. With regard to the obstetric history, the current pregnancy bringing them to ANC ranged between the first to the ninth for study participants. About a third of study participants 34.2% (n = 142), had lost a pregnancy or had had a perinatal mortality. Among those who had had a perinatal mortality, the number of stillbirths ranged from one to a maximum of four. Table 2 displays the obstetric history of study participants and reasons ascribed for the causes of pregnancy loss or stillbirth varied. In all, 34.6% had no knowledge of the cause.

Globally, caesarean section rates increase with increasing socio-economic development and are a proxy measure for assessing progress in maternal and infant health [24, 25]. Thus one would have expected that the CS rate would be higher among women attending ANC at the regional hospital as has been reported at the Korle Bu Teaching Hospital [18]. However in this study, the proportion of ANC attendants with CS experience from the district hospital was more than twice the proportion of CS experience in the regional hospital. Data from this study showed that participants in the district hospital had a greater number of pregnancies and children compared with the regional hospital for the same comparative maternal age. Since the proportion of CS increases with the number of pregnancies, the observed higher proportion of CS among those in the district hospital can be attributed to the differential number of births or pregnancies between the two groups.

Majority of the women preferred spontaneous vaginal delivery to caesarean section though a small proportion of women preferred caesarean section to spontaneous vaginal delivery. This is not an unexpected finding and is similar to a study in Ghana which found that 55% of pregnant women indicated similar preference [26]. Other studies in Ghana found 93.3% [27] and 94% [28] and a study from Nigeria [20] reported 85.7%. This preference for vaginal delivery has been described as a reflection of the desire to have a natural birthing process rather than an aversion for CS [27], an attitude also portrayed by midwives and obstetricians in Sweden, a developed country with low CS rates [29]. There is worldwide deliberation about the significance of CS performed without medical indication [24, 25]. However, in this part of the world, maternal request due to non-medical indication seems to be of low priority. The limited access to health facilities with the capacity to conduct major surgeries, coupled with increased workload on the few trained health professional with the requisite skill, makes maternal request for caesarean section a difficult request to satisfy [30]. Also, traditional and cultural practices that discourage operative delivery, most likely contribute to the low number of CS for non-medical reasons [19, 31]. However, contrary to the current findings, a recent report indicates that CS without medical indication is gaining ground in some centres in Africa [30].

Respondents generally had inadequate knowledge about CS, a finding which has been attested in other studies [20, 28]. This is contrary to a study from Nigeria which found good knowledge among respondents [19]. The indications for CS were also not well known. This is similar to findings from a study in Cape Coast, Ghana, which found that only 45% of respondents knew at least one indication of CS [28]. Also, a substantial proportion of respondents believed that CS can have adverse effects on child survival and does not promote child survival. Almost half (45.1%), consisting mostly of those who had never had a CS, did not know or feel that CS can promote child survival and one fifth of them (21.6%) believed that CS can have adverse effects on child survival. This is similar to the findings of other studies [19, 27]. Over half of the respondents did not seem to be aware of indications for CS that prevent foetal compromise such as foetal distress and abnormal lie. Thus educative messages on CS should emphasise its role in protecting the foetus.

As expected, the mothers who had had a previous CS seemed generally more knowledgeable and well informed about CS than those with no prior CS experience [19, 28]. However, women in this study indicated that they had had several unanswered questions prior to the surgical procedure and if these had been addressed by health professionals before the surgery, it would have improved the CS experience. This suggests inadequate counselling prior to caesarean section among study the participants. Deliberate efforts should be made to educate pregnant women on CS and these efforts can be supported by the use of leaflets, posters, DVD’s and case studies of mother who have had previous CS [28]. This can be delivered by a special counselling team of dedicated midwives as is done in Sweden to allay the fears of women [29]. It can also be a part of the general education given at school on childbirth as studies have also found that the level of knowledge about CS is influenced by one’s level of education [19, 28], though others did not find a positive association [32]. A positive finding from this study is that the majority of respondents believed that adequate counselling and education during antenatal care might prepare women adequately for CS and are likely to increase the chances of success [27].

The majority of women were willing to have caesarean section if only if the need arose which is similar to findings in other more urban parts of the country and Nigeria [19, 27, 28]. Some women however would not undergo CS for any reason. This finding is similar to findings from a community-based study in the Upper West Region and one from Burkina Faso [33] and studies from Nigeria and Ghana which reported fear of death and pain as the main dangers [19, 20]. The Upper West Region shares a border with Burkina Faso, and the regional hospital has reported cases of maternal mortality from Burkina Faso so it is not surprising that these studies have similar findings [25, 33]. Long recovery time is important in these environments since many of the rural women are poor subsistence farmers with several domestic roles. Therefore, the perception that CS weakens women, thereby limiting their physical capacity to farm, carry water or do other work, and restricts their ability to generate income for their families, may make them want to avoid institutional delivery [21, 25]. This delay may be aggravated by the lack of transport facilities and poor roads which are prevalent in the region and which most likely contribute to high maternal deaths in the region [34, 35].

Several other reasons for not wanting a CS were identified in this study. Some of them are fear of pain, fear of complications, CS not being a natural procedure, fear of being mocked and the avoidance of a scar reported among others. These findings are similar to reports from other studies [19, 33]. These fears may prevent women from delivering in hospitals when they perceive a higher chance of CS and they may delay presentation for emergency obstetric care required at the individual maternal level to prevent perinatal and neonatal mortality [30]. Thus measures to improve the uptake of emergency obstetric care must give consideration to how to address these fears and socio-economic factors surrounding CS during the recovery period [21, 25, 33].

This study has some limitations. All participants in the study were from the Upper West Region and as such the findings may not be representative of the entire country, Ghana. There were variations with respect to the location and characteristics of the attendants to the facilities. Also being hospital-based study, the findings from the study may not entirely reflect the perceptions of those who deliver at home or in primary care facilities.

The majority of the respondents preferred vaginal delivery in this study and the reasons provided centred on long recovery time from CS, fears, attitudes, values, traditional and cultural beliefs. Though respondents generally had inadequate knowledge about CS, they had a positive attitude towards the uptake of CS. However, almost half of women did not know or feel that CS can promote child survival. This needs to be addressed through education to improve the perception of CS as a promoter of child survival and to discourage the notion that it causes adverse perinatal or neonatal outcome, particularly in at risk populations. It requires deliberate effort by midwives to present CS as an option for childbirth and improved neonatal survival which can be incorporated into general education on childbirth at antenatal clinics, in schools as well as public education. Additional effort should be made to reduce the recovery time and provide support systems for those who have a CS in this setting; otherwise the negative perceptions are likely to persist.