4. Discussion
The maternal’s awareness about CS was measured in this study and the
respondents stated clearly with high percentages that their source of
knowledge was mainly the internet followed by social engagements with
family and friends. Interestingly, little knowledge input was delivered
from proper health care providers. Therefore, it is evident that the
information they accessed was not from a reliable or evidence-based
source and it is obvious that they may have had no clear information
about CS. Health care professionals need to ensure that the information
given to women is accurate and imparted at a level that is appropriate
to the women concerned.
Most of the respondents didn’t have clear knowledge if CS carries risks
on the mother (34.7%), and about 31.6% of them thought that the CS
carries no risks on mothers’ health. Their knowledge about this issue
was wrong as CS carries short and long term risks on mothers’ health
(4, 10,
11). In a population-based study, the
risk of severe postoperative bleeding is two to three times greater than
normal delivery (10). Another study
showed that severe maternal morbidity was two times higher and the risk
of hysterectomy was four times higher with CS compared with normal
delivery (4). Postoperative
thromboembolism risk also increased five folds in CS compared with
normal delivery (12).
The majority of the respondents (56.9%) thought that CS is safe for the
infant. However, it is known that babies can be affected adversely after
CS (13,
14). This indicates that women need to be
educated about CS risks on mothers and babies to increase their
awareness.
Moreover, most respondents disagree with performing CS under maternal
request (59.2%) and think that CS should be performed only under
medical reasons (59.6%). This indicates that mothers are likely to
accept the decision for a CS by the attending physician. This finding
parallels the findings of Levinson et al in Canada, who found that half
of the respondents (52%) preferred to leave the final decision to their
physicians (15). Deber et al also found
that the majority of patients wished physicians to do the
“problem-solving tasks”, which include using the medical information
to make a diagnosis (16). It is therefore
essential that the health care providers should engage pregnant women in
a meaningful way to use the information that they possess to make shared
decisions, which the mothers will be ultimately satisfied with.
Furthermore, the respondents believed that the most common reason
leading them to request CS is the fear of pain as they think the CS is a
painless method of birth. In agreement with that, Gosh and James
reported that pregnant women who don’t want to bear massive pain during
labor have a strong preference for CS
(17). Zhao and Chen also reported that
the fear of labor pain remains one of the most cited reasons for
avoiding spontaneous vaginal delivery (3).
We believe that this issue may largely be avoided during the antenatal
clinic visits if pregnant women are well educated on the available
delivery methods and how to reduce the stress and fear before and during
delivery.
The higher percentage of the respondents (75.3%) had their CS in
private hospitals, and (44.4%) of respondents had full coverage
insurance. Multiple studies have shown that private sectors are
motivated by financial incentives
(18-21). For example, the financial
benefit associated with longer hospital stays after CS and private
hospitals may incentivize physicians to favor their decision with
institutional strategies (20,
21). Physicians are also known to be
motivated by higher fees paid for CS compared with normal vaginal
delivery (20). They are also in a
position to take advantage of the asymmetrical information between them
and patients which may lead to recommendations that are not always
parallel with patients’ needs (19). There
is also evidence that physicians with higher numbers of privately
insured patients will tend to perform more CS
(19). Implementing non-clinical practices
like obtaining a second opinion before undergoing the CS procedure
(11) and the Robson classification in
clinical practice in hospitals (22) can
help in reducing the CS rates. However, further studies should be
performed in the future to shed light on the real reasons leading to
increased CS rates in private hospitals in Jordan.
Finally, the majority of the respondents were satisfied with their
experience (56.3% were satisfied and 16.5% were strongly satisfied).
This is expected as obstetricians noted that women did not consider CS
as major surgery and they were not afraid of the procedure,
alternatively, they look at CS as a routine practice. Bayes et al also
showed in their research that CS is a long-anticipated and very special
occasion (23).