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).