Knowledge construction of Caesarean Section among women in Northern Ghana

doi:10.21203/rs.3.rs-1757137/v1

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Knowledge construction of Caesarean Section among women in Northern Ghana

https://doi.org/10.21203/rs.3.rs-1757137/v1

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Introduction: The study sought to determine the prevalence of cesarean section among women who delivered at the Tamale Teaching Hospital. Cesarean section is performed when a vaginal delivery is risky to the baby and mother. Even though the benefits of Caesarean section are known to women, many would often opt for vaginal delivery to boost their social recognition as women.

Methods: The design was a hospital-based descriptive cross-sectional study among women within the Tamale Metropolis. The study employed a qualitative method. There were four focus group discussions to elicit information from women who experienced Caesarean Section.

Results: Many of the participants had good knowledge about the risk and effects of a Caesarean Section. Respondents with cesarean section experience did not have a choice to decline in the study hospital because all were emergency cases. The belief of respondents about cesarean section was influenced by friends and relatives. Some of the reasons assigned for not opting for a cesarean section were; fear of complications, uncertainty regarding the pain during and after the procedure, and the fact that it is not a natural phenomenon. The perception of society regarding womanhood strongly emerged as an order of socialization and revealed that women who experienced Caesarean section go through ridicule in their respective communities.

Conclusion: There is a growing trend of misconception about cesarean section. The Ministry of Health in Ghana should ensure that all health personnel, especially nurses and midwives, have location-based training on sociocultural beliefs about Caesarean section.

Women

Knowledge

Experience

Social Construction

Caesarean section

Maternal mortalities mostly occur during labour, delivery, and the post-delivery period. A woman dying during pregnancy or dies within 42 days after the termination of pregnancy is maternal death. This definition does not depend on the location or duration of the pregnancy. It does not also depend on factors aggravated or worsened by the pregnancy or the management of the pregnancy. It, however, excludes death as a result of incidental or accidental events [1]. Maternal mortality is a serious problem for low and middle-income countries (LMICs) and accounts for 99% of maternal deaths worldwide [2]. Significant factors contributing to maternal mortalities in LMICs, including Ghana, are mainly due to the availability and accessibility of obstetric services. Poor road network and inadequately equipped facilities [3].

Among the challenges women face during child delivery is the choice of the mode of delivery and its acceptability within the social context [4]. The choice between spontaneous vaginal delivery and Cesarean section is crucial, especially when women are approaching their delivery time [5]. It is worth noting that choosing one birth method over another may be explained differently, but the obvious fact is that women would ordinarily prefer spontaneous vaginal delivery. According to WHO [6], CS may be an unavoidable option for pregnant women and recommends it at a 10% to 15% rate of total births. Among high-income (HIC) countries and some low- and middle-income countries (LMIC), studies have revealed that the provision of CS exceeds the rates recommended. In recent times, however, the trend is changing due to women's changing lifestyles and social roles. Some may opt for cesarean sections on personal grounds other than health issues [7]. A Caesarean section is usually advised when there is a potential risk to the mother or baby if the woman is to deliver through the vagina [8]. Some of the conditions that may influence the advice for Caesarean section include obstructed labour, twin pregnancy, hypertension in the mother, breech, issues concerning the placenta, pelvic shape, and history of Caesarean section [9]. The World Health Organization (WHO) recommends that Caesarean sections are indicated on medical needs [10].

Defining the third sustainable development goal with a negative trickle-down effect on all the remaining 16 as adequate health and wellbeing is the pivot of the Sustainable Development Goals. Women prefer Caesarean Section over normal birth because it relieves them of the pain in normal vaginal delivery. Their life and the baby are protected from danger [11]. Vaginal delivery, on the other hand, is a choice of birth that creates a bond between the mother and the baby from the moment the baby is delivered. It is easier for mothers to get back to their daily work routine, and it frees them from the danger associated with cesarean delivery [12].

Cesarean delivery rates of less than 2% indicate a real deficit in access to quality obstetric care and is associated with high maternal mortalities [13]. It stands to reason that Ghana's rate of 3.22% may reflect a deficit but may not be highly significantly associated with it. Research suggests that one of the very effective ways to reduce maternal mortality is to increase access to CS for women who need it [14]. It involves a low CS rate and increases the rates of emergency CS. A study by Gulati and Hjelde on indications leading to Caesarean sections at the Korle Bu Teaching Hospital in Ghana in 2012 showed that from 08/12/2010 until 10/02/2011, there were 548 CS; 70% of which were emergency [15].

Some studies in Ghana have reported the aversions by women regarding CS, which may lead to prolonged delays or complete refusal to undergo CS [16]. Aversion seems to be grounded in the fear that CS may result in serious health complications, infertility, or death [16]. From the social angle, the attachment of social and cultural meanings to CS [17]. This study sought to further the understanding of the influence of social and cultural factors that determine the acceptance or refusal of CS. The study hinges on the classic arguments by anthropologist Kleiman that systems in medical practice are similar to cultural systems, including kinship and religion, and go with meanings, behavioural norms, and values [18].

Moreover, medical systems embrace multiple areas within which people manage sickness. Many health problems are solved in what is described as the 'popular arena,' which means the social networks provided by families. Social experience reactions eventually determine health-seeking behaviours. The success of 'Folk healers' in some communities may be related to their ability to 'cure' the symptoms of illnesses instead of curing the actual diseases. The study sought to examine the social construction of knowledge of cesarean section among women who have undergone the process of cesarean section in the Tamale Teaching Hospital.

The social construction of reality

Social construction seeks to explain how individuals and groups assign meaning, views, and concepts to situations and events accepted as standards in society. The idea only came to be because society created it to serve a purpose. The meaning society attaches to situations forms part of societal principles and is being adhered to and practiced by members of the society. Therefore, it is possible to assign different meanings to events in society based on interests. It also means existing views and meaning assigned to social events could give way to new ones if they do not meet societal needs [19].

The jointly developed ideology is transmitted and made meaningful through language during daily interaction as human beings [20]. However, the same meaning assigned to a given situation cannot be replicated in another environment, and it only pertains to the society that constructed it.

The social construction of reality theory seeks to describe how ideas, beliefs, and values in each society are created by its inhabitants and influence how they perceive, act, and react to a situation in their everyday lives. In social construction, the theory's central tenets are on how meaning is assigned to an event or situation that is not a real character but one ascribed to it by society [21]. It also emphasizes the belief that what an individual acquires as knowledge depends on socialization within the social network. Thus, the larger extent of how individuals view and embrace life situations is how the social context perceives and accepts them [22]. The social construction theory was originally proposed by [20]. There are three major ways to generate reality: externalization, objectivation, and internalization.

In the model context, new practice emerges when individuals share their beliefs, norms, and principles with significant others that become socially acceptable with time. Through socialization, individuals' beliefs and labels about events and situations inform what is considered appropriate and meaningful in a social context [20].

According to [20], human beings are born into an environment that is both natural and of humankind. The individual thus grows biologically, and the constant association and interaction with significant others influence his life (values, beliefs, rules). Naively, the individual interacts with the societal norms, beliefs, and practices and, with time, conforms to them as the ethics of the society. Thus, the individual's beliefs about an event or situation are influenced by the culture and acquired through interaction with significant others.

As used in the model, internalization seeks to explain the process of practicing what others have practiced before; their objectified norms, values, and beliefs direct society's way of life. [20] emphasized that once reality exists in any given society, individuals are members of a society only when they can identify with their neighbours and society, by believing and engaging in their practice. Once the individual becomes conscious of these predetermined realities, it becomes part and parcel of his life. Subsequently, the inherited reality impacts how the individual behaves and identifies with significant others in emotional ways [20].

The social construction of reality theory as postulated by Berger and Luckman is suitable for this study because the women's conception of CS as a reality stemmed from their beliefs as gathered from society, suggesting that an ideal woman is someone who gives birth vaginally (externalization). These beliefs spread through significant others using socialization (objectivation). The significant others tend to influence the spread and sustenance of the beliefs. In the long run, the beliefs manifest in society's ideals. Every woman would want to deliver vaginally as a reality to be regarded as a "woman" in their social context. This pre-ordered arrangement may make women want to deliver through the vagina, such that women may not prefer CS even if there is a need (internalization).

Study area

The research took place at the antenatal and postnatal care units of the Obstetrics and Gynaecology department of the Tamale Teaching Hospital. This tertiary health care hospital serves the people of Tamale and its environs. The Obstetrics and Gynaecological department is one of the clinical departments, and it provides free antenatal care services, childbirth and postpartum services, and child health services. It also serves as a referral hospital for several health centers and polyclinics and the hospitals within the Northern, Savanna region, Upper East, Upper West, and North-East regions. The hospital has a bed capacity of over one thousand and serves as a clinical teaching institution for all health training institutions in the Northern Region. It is equipped with state-of-the-art and modern health care delivery services such as ECG, CT scan, MRI, and major surgical procedures. Midwives and doctors attend all deliveries. Whiles located in an urban area, the community represents a mixture of urban and rural life.

Population

The study population comprised all women who underwent cesarean section within the Tamale Metropolis at the time of the study. All participants were recruited within the hospital premises.

Sample Size Technique

The study employed a purposive sampling technique to recruit 24 participants for four focus group discussion interviews. The researchers contacted the participants in the child welfare clinic (CWC) of the Tamale Teaching Hospital. Participants with knowledge and experience with CS were sampled [23]. This sampling method ensured that women who had undergone a cesarean section were selected to share meanings and experiences after the procedure.

Data collection and Analysis

The researchers used a focus group discussion guide to elicit information from participants. Dagbani, a local language that all the participants understood, was used during the interview. A trained translator transcribed the audiotaped data verbatim into the English language. Data were cross-checked for accuracy and completeness by replaying the audiotape information and comparing it with transcribed data. Thematic Analysis was employed for the interpretation of the transcribed qualitative data. Both descriptive themes and analytical themes were identified and coded.

Major themes and sub-themes were identified were; the meaning of Caesarean Section (CS), Beliefs about CS, Beliefs about the restriction on family size, and Beliefs about the outcome. Source of perception about CS; Significant others, Perceived order of socialization about CS; Social perception of womanhood Emotions associated with CS; Fear, Anxiety, Sadness, Post CS consequences; Marital and Social consequences.

Meaning of Caesarean Section.

Participants expressed different understanding of CS based on their experiences and knowledge. The understanding was associated with CS being a type of delivery that involves cutting open the mother's womb to remove the baby. A focus group discussant indicated that;

When you are in labour, and you are unable to deliver per vagina, they cut your abdomen open and remove the baby without the baby moving or turning to come out by itself." "It's another way of giving birth that they cut your abdomen open, remove the baby, and leave a big wound. (Discussant FGD 4)

These descriptions show knowledge of basic understanding of CS and how it is carried out.

Beliefs about Caesarean Sections

Different reasons were advanced about CS: Caesarean Section, to some of them, is performed on promiscuous women, lazy women, those who fear pain, and a curse on a disrespectful woman. All participants recognized the role CS plays in saving the lives of both mothers and babies. They were, however, concerned about the sociocultural implications of undergoing a Caesarean Section. A discussant averred that;

Though CS saves mother and baby, one will need assistance after the procedure because, after CS, you are not able to do arduous work. When I deliver, I must go back to my father's house because nobody will help me in my husband's house, which is my big challenge. (Discussant, FGD 2)

The findings revealed that even though women knew the benefits of CS to save their lives and their babies, they were very particular about its effects on them. They reported that CS comes with some burdens and restrictions. Participants also reported that socially, it is the belief that CS is for the weak, lazy, and women who fear pain.

"As for my family, they believe 'operation' is for weak and lazy women who are not mature enough to marry and deliver." (Discussant, FGD 3)

These beliefs about the reasons for Cesarean Section, as expressed above, give an impression that people might not understand why CS is performed or why it is medically necessary.

Restriction of family size

The study results revealed that undergoing CS restricts one's ability to have the desired number of children. These sociocultural perceptions were a source of worry to some participants and their significant others. The following extracts make clear how Caesarean Section limits one's ability to achieve her ideal family size;

"Now that I understand, it is not about the number of children I deliver but the future of the children and how you raise them. I don't care what they say. If it is operation God has destined me to deliver, they should talk". (Discussant, FGD 4)

These findings are an indication that they viewed Caesarean Section negatively, given that it deprives them of having their ideal family size.

The outcome of Cesarean Section

The findings have revealed that even though women know the benefits of Caesarean Section to save their lives and their babies, they are very particular about its effects. They reported that Caesarean Section comes with some form of complications:

"Operation is a good and another form of delivering, but I first didn't know, and I ran home because I was scared I would die and later when it became critical, and I was in severe pain, I went back and asked them to save me. Today I sit alive with my son, glory be to God". (Discussant, FGD 4)

This finding indicates that most women are not happy after Caesarean Section because they believe that Caesarean Section comes with restrictions and complications.

Role of significant others

The study revealed how most women got information on CS from the community in which they live. Participants' expression of the community members as a source of their information on beliefs about CS was based on instances where family members, neighbours, and friends gave them information on CS.

"I was afraid of the pain during and after the operation and that people say they will kill you and remove your baby. I didn't want to die". ((Discussant, FGD 1)

Participants heard about beliefs about CS from friends and family, which put fear in them before they went through it. Some indicated that their sources of information on CS were from social gatherings. These findings are an indication that beliefs and information on CS were obtained from various sources by the participants, and based on the information received, participants reacted differently toward the procedure.

Perceived order of socialization about Caesarean Section (internalization)

This theme sought to describe the cultural perceptions surrounding CS and motherhood, which may significantly influence women's decision-making on a birth method. Social perception of womanhood emerged strongly as an order of socialization.

Socially women have been made to believe that a 'strong woman' can deliver vaginally and can give birth to many children. As such, though they knew the benefits of CS, women in this study were interested in vaginal delivery to be recognized as women in their social context. The following expressions by participants exemplified the societal perception of a woman as one who can deliver vaginally:

"I prefer vaginal delivery because, with the operation, you have a limited number of children to deliver, about 4, but in our cultural setting, our husbands prefer having many children". (Discussant, FGD 2).

These findings from the above theme clearly define a woman and womanhood as largely based on a woman's ability to deliver vaginally and give birth to many children, which most participants wanted to achieve.

Emotions associated with Caesarean Section

Participants exhibited different emotions towards CS, leading to three main themes: sadness, anxiety, and fear. This theme relates to how the women reacted to hearing that they were to undergo a CS. The theme also indicates the level of acceptance of CS as a birth method. Most of the participants in the study reported that they were anxious after receiving the information that they were going to undergo CS. Their description of anxiety cantered on worry, being scared, afraid, and expressions of a heartbeat.

"I was afraid and sad of the outcome of the operation because I heard of people dying during the operation but eventually accepted upon my family's advice and encouragement." (Discussant, FGD 4)

These findings revealed under emotions associated with CS suggest that, despite knowing the benefits of CS, it comes with different emotions for these women. While some showed signs of sadness, others were anxious because they did not know what the outcome of a Cesarean Section might be. That notwithstanding, the news on CS was welcomed by a few participants because they felt they stood to gain should they agree to go through the procedure. This attitude of a few participants emanated from their earlier refusal to undergo the procedure, resulting in a negative outcome.

Post Caesarean Section consequences

The participants expressed that the number of children a woman could give was important to the family in the prevailing social context. People who had gone through CS had their marriages threatened based on the perception that CS restricted a woman's ability to give birth to many children. For some of these women, their in-laws were advocating a second wife for their sons to give birth to additional children, others were verbally abused.

Marital Consequences

The participants expressed that the number of children a woman can give was important to the family in the social context in which they found themselves. For some of these women, their in-laws were advocating a second wife for their sons to give birth to additional children. Others were abused verbally. Their marriages were being threatened based on the perception that CS restricted a woman's ability to give birth to many children.

"Madam, I'll prefer vagina to the operation because you know this is our setting. We are many wives, and operation delays our return to active sexual relationship with our husbands about three months which can drive your man away from you". (Discussant, FGD 2)

Social Consequences

The study results showed that women also experienced social abuse in their respective communities after the CS. While some women were mocked and teased for undergoing CS, others, because they underwent SC for the second time, were poorly upon their arrival to their homes. The expressions below illustrate how socially women are treated after CS;

"For me, they use it to insult me that I'm weak and should not be counted as part of women who have delivered, I don't even have respect in the side of my co-wives and that I can't bear the pain. They mock at me that I haven't delivered yet". (Discussant, FGD 3)

The social construction of Cesarean Section

The women had meanings for CS, beliefs about the procedure, and the reasons for CS. The rest were restrictions on ideal family size and physical impairment. Participants' different beliefs about CS tend to influence the acceptability or otherwise of CS as a birth strategy during the gestational age. Similarly, the study results indicate that women believed that CS involved "killing" the woman to remove the baby and "waking her up later." This finding supports the proposition by [24], whose findings suggest that these women interpret the process of women undergoing CS under general anesthesia as "killing" the woman and waking her after the procedure. Also, Participants' reasons for not opting for CS include promiscuity, laziness, fear of childbirth, pain, and a curse to a disrespectful woman. These findings compare favorably with [25-26, 2]. These findings suggest that a woman may avoid CS because of the negative societal construction of CS. For instance, women in the study area may avoid Caesarean Section to escape being labeled as promiscuous or being cursed by their ancestors. Respondents also reported that socially, it is the belief that CS for weak, lazy, and women who fear pain. Another reason women declined CS was that the social perception of womanhood emerged strongly as an order of socialization. Similarly, in a mixed-method study [2], the findings showed that women suffered in their martial homes after undergoing CS. The undesirable, different views of the social construction of CS may jeopardize the fight against maternal and infant mortality because it can lead to the underutilization of surgical births as an alternative means of childbirth when complications occur. This finding corroborates that of [24]. The impression is created that this group of women may not understand the indications for CS, or they might have the conviction that nothing happens by chance. Based on this belief, it is unlikely for such women to return to such hospitals for delivery. Proper education is needed for pregnant women attending antenatal services on the indications for CS. Women viewed CS negatively regarding the number of children they can have, suggesting that CS deprives them of their ideal family size. The view is attributable to the importance attached to large family size within the study area's social context, which is contrary to finding by [24] in which they found that women will prefer smaller family sizes resulting from CS to give them better care. Some participants were worried about these sociocultural perceptions, which was also a worry for women in previous studies [27, 2].

In a social context where most household chores are solely the woman's responsibility, especially in the study area, a woman may refuse CS because of the perceived physical burden. Similar research revealed that; this prevents them from carrying out their daily activities at home and engaging in economic ventures [12, 5]. This may also increase the delay in seeking hospital health care when complications develop during home delivery or even lead to women seeking health care from alternative providers when complications are perceived, including prayer centers.

Source of perception about Caesarean Section

Participants' beliefs about CS in this study came from significant others (community members). It was revealed that participants heard about beliefs on CS from friends and family, which put fear in them before they went through it. Some indicated that their sources of information on CS were from social gatherings. Others were afraid; some tried resisting the CS altogether. The rest attempted running from the hospital. This revelation is in tandem with those of [28, 4], where four women absconded from the hospital after being informed of the planned procedure to deliver their babies.

Perceived order of socialization about CS

Socially women have been made to believe that a woman can deliver vaginally and one who can give birth to many children. As such, women in this study, even though they knew the benefits of CS, were interested in vaginal delivery to be recognized as women in their social context. These findings from the above theme clearly define a woman and womanhood as largely based on a woman's ability to deliver vaginally and give birth to many children, which most of the participants wanted to achieve, as reported previously [25, 27, 2]. These women may resist CS in their subsequent deliveries, given that CS deprives them of being recognized as "women." The undesirable views about womanhood may be rooted in sociocultural beliefs that can hinder attempts to refer women in situations where there are threatened complications during delivery requiring surgical intervention. This is because undergoing a cesarian section, according to the participants, is a perceived reproductive defeat.

Emotions associated with Cesarean Section

While some showed signs of sadness, others were anxious because they did not know what the outcome might be. The social belief that one is not a woman after CS, being a perceived adulterous woman, was the concern of these women, which resulted in their worry. The women expressed being afraid because they did not know how CS is done and what the outcome of CS might be as also revealed in the case of [29,30] in the United States of America, eight women of African descent complained bitterly and felt frustrated when they were faced with CS as a choice of delivery. For those unhappy about CS, unplanned CS delivery coupled with longer hospital stay was a factor. The unexpected lengthy stay at the hospital could challenge these women, preventing them from fulfilling their socially-expected responsibilities at home.

The study identified marital and social consequences suffered by the women in their social context after the procedure. Interestingly, some in-laws were advocating second wives for their sons after their wives had undergone CS to give birth to many children. This corroborates the finding of [2], which also showed that women in the study experienced some form of social abuse in their respective communities after undergoing CS. While some were seen as less of a "woman," others were teased [25], and others were poorly received at home. In a previous study, women similarly reported this issue [27]. Generally, the results bring the urgent need for intensive education among women and the community on the right indications for CS as a birth strategy medically.

The prevalence of CS in the study was found to be high (27.4%). This could be because the hospital serves as a referral centre for other hospitals, clinics, and maternity homes. Thus, it may receive complicated pregnancies or referred women because they may need CS. The majority of respondents had adequate knowledge about cesarean sections (risks and effects) and expressed different understanding of cesarean sections based on their experiences and knowledge with a significant influence of culture. Women did not have a choice to decline cesarean section in Tamale Teaching Hospital because they were performed as emergency CS or with indications such as prolonged labor, breech presentation, foetal distress, and previous CS. Most of the respondents preferred vaginal delivery, and the reasons provided centered on long recovery time from CS, fears, attitudes, values, and traditional and cultural beliefs. Most of the study's findings conformed to the constructs of the social construction of the reality model. These include the social construction of CS, sources of perception about CS, and perceived order of socialization about CS. Those that were not consistent with the social construction of the reality model were emotions associated with CS and post CS consequences. The findings indicated that women had varied beliefs about CS that tend to influence their acceptability of the procedure as a birth strategy. Women obtained beliefs about CS from various sources and based on the information obtained, they reacted differently toward the procedure. Furthermore, women's decisions about their preferred mode of delivery had cultural and social dimensions.

Ethical clearance: Ethical clearance was obtained from the University for Development Studies Institutional Review Committee before data collection commenced. Before conducting the survey, permission to carry out the study was also sought from the health care facilities. informed consent was also sought from all the participants before the study was conducted. Respondents were free to decline or opt out of the study without any intimidation.

Consent for publication: All authors have consented to the submission and possible publication

Availability of data: Data is available on request. The request should be sent to the corresponding author on [email protected].

Competing of interest: There is no competing interest

Source of funding: The study was self-financed

Authors contribution: JA conceived the idea of the study. AY and JA developed the proposal, and AY read through it. JA carried out the development of tools and data collection. JA did data analysis. AY did the proofreading of the manuscript.

Acknowledgment: We acknowledged the role played by the participants in this study area. We also acknowledged the contribution of the healthcare staff who helped us in the study.

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No competing interests reported.

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Knowledge construction of Caesarean Section among women in Northern Ghana

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Abstract

Background

Methodology

Results

Meaning of Caesarean Section.

Beliefs about Caesarean Sections

Restriction of family size

The outcome of Cesarean Section

Role of significant others

Perceived order of socialization about Caesarean Section (internalization)

Emotions associated with Caesarean Section

Post Caesarean Section consequences

Marital Consequences

Social Consequences

Discussion

The social construction of Cesarean Section

Source of perception about Caesarean Section

Perceived order of socialization about CS

Emotions associated with Cesarean Section

Conclusion

Declarations

References

Additional Declarations

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