Why Do Pregnant Women Choose a Planned Caesarean Section in Burkina Faso? A Qualitative Study ()
1. Introduction
The complications associated with [1] [2] caesarean section continue to grow worldwide [3]. Developed and developing countries are both concerned by this rise [4] [5]. The caesarean section is clinically required in order to reduce maternal and infantile deaths. In a Nigerian study only 7 (3.3%) attributed refusal of caesarean section to the complications of the procedure [6]. Except for clinical reasons, the benefits of caesarean section are not asserted [7] [8]. The optimal rate of caesarean section to mitigate the risks of maternal and neonatal complications recommended by the World Health Organization (WHO) is 15% [7]. However, in most resource-limited countries such as Burkina Faso, the rate of caesarean section is above the WHO recommendations [9]. In Africa, the caesarean section rate is about 5% [10] with unequal access among the regions and disparate indications [11]. Worse still, planned caesarean sections without medical indications (desirable caesarean section or caesarean section by convenience) are gaining in importance [12] [13]. Women are steadily claiming planned caesarean section as their rights [14]. In 18.5 million of caesarean section carried out in the world about a third of them is performed without medical indications [1]. Then the caesarean section makes women physically, economically and socially vulnerable in resource-limited contexts [11]. In Burkina Faso, the rate of caesarean section rose from 0.7% in 2003 [15] to 2.2% in 2017 [16], and the highest rates of caesarean section performed without medical reasons were recorded in private hospitals [17]. Few studies explain women’s motivation to choose a planned caesarean section without medical indications in Burkina Faso. This growing issue should prompt health authorities. This article aimed to understand the maternal reasons for requesting a planned caesarean section at Tingandogo Teaching Hospital in Burkina Faso.
2. Methods
2.1. Study Design
A qualitative descriptive design was applied to this study.
2.2. Participants
Reasoned sampling was used to select the participants. Participants were delivered women who had planned a caesarean section by convenience. In order to achieve theoretical saturation, twelve participants were selected [18]. The first step for participants’ recruitment was to consult the medical records of women who gave birth by caesarean section to identify those who had chosen it for convenience. Subsequently, the women were contacted by telephone to ask them to participate in the study. An appointment for an interview at their convenient location was made with those who accepted. Included in the study were patients who: 1) were notified as a case of elective caesarean section, 2) chose elective caesarean section and 3) agreed to participate in the study.
2.3. Data Collection
An interview guide developed iteratively and pretested was used to ensure the reliability and consistency in the data collection. In the interview guide, the main themes were facilitating factors, predisposing factors and services. These themes were the different dimensions from Andersen and Newman’s model [19] and included sub-themes and follow-up questions. Interviews were conducted in French and transcribed verbatim.
2.4. Data Analysis
An inductive thematic analysis based on the six steps of Braun and Clarke was performed [20]. The principal investigator (NB) read through all transcripts and identified possible themes (step 1). NB developed a coding scheme inductively from the data based on an independent review of three transcripts. Agreement on a final coding scheme was reached by discussions with the research team. NB used this to code all transcripts using QDA Miner software of Provalis to assist with data management (step 2). Together, NB and PN discussed and identified recurring and converging themes across participants. The refined themes were then discussed and agreed upon with other members of the research team (steps 3 and 4). Finally, each theme was named, defined and a written report generated. Key quotes that illustrated each theme were extrapolated from the data (steps 5 and 6).
2.5. Ethical Considerations
The research ethics committee of the Burkina Faso health ministry approved the study (N˚2019-3-023). The hospital manager gave an agreement. Each participant has signed a written consent form. We have certified anonymous data collection and ensured participants confidentiality.
3. Results
Twelve (12) participants were involved in the study with a mean age of 33 years, half were employees; and the majority were married. Paucigravida were highly represented (n = 8). Two participants had benefited from only one caesarean section. The mean stay duration was 72 hours, with an estimated cost of FCFA 300.000 (457,347 EUR). Characteristics of the participants are presented in Table 1.
Three major themes have emerged from the data analysis. These themes can be grouped into individual, interpersonal and organizational factors.
- Tokophobia and planned desirable caesarean section
The request of a maternal caesarean section without medical indication is motivated by the fear of vaginal delivery. Furthermore, the caesarean section is viewed only through its positive aspect. According to the participants, vaginal bleeding increases their doubts as future mothers and child safety during delivery:
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Table 1. Characteristics of participants.
“My choice of the planned caesarean section based on just what I know. The nasty comments about vaginal delivery finally convinced me. I fear losing my baby” (Participant 2).
Other women were afraid that vaginal delivery would cause undesirable aesthetic changes to their body and for negative impacts on their relationship:
“There are many advantages to choosing a caesarean section today. For example, we avoid long labour, tears […] the men will not cheat anymore because of body changes (laughs) […] the vaginal delivery leads to enlargements which can cause quarrels in the couple” (Participant 11).
- The doctor-patient relationship and planned desirable caesarean section
Participants are also motivated by their beliefs in the mastery and use of surgical techniques and technology by physicians. This conviction leads to an assurance of safe delivery and giving birth to a healthy baby.
“Nowadays this is possible, and our doctors are used to do it like in Europe. It is necessary to notice that the surgical material is adequate and reassure me. Techniques used in caesarean section contribute to rely trust on the practice” (Participant 4).
- Healthcare services and planned desirable caesarean section
Results have revealed that the quality of healthcare services is very important in the choice of a caesarean section. The quality of health facilities infrastructures such as hygiene, technical skills, and legal structure recognition have influenced future mothers in their choice of a planned caesarean section.
“A clean hospital, we are at least sure to get out without a nosocomial disease…I mean Infection. Moreover, you know, our hospital must be clean; in any case about my caesarean section I do not want to drag and bear a wound that will fester afterwards and become a problem for me, my child and husband too” (Participant 8).
Women have stated that doctor-pregnant woman communication contributes to the choice of a planned caesarean section when the decision is taken.
“At the last antenatal visit, I informed my gynaecologist about my decision to benefit from a caesarean section. He agreed and has not objected to my request. He just said that I have to provide a check-up at the right time, and that was done” (Participant 5).
The quotes based on reasons for requesting planned caesarean were presented in Table 2.
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Table 2. Quotes based on reasons for requesting planned caesarean.
4. Discussion
This study aimed to understand the maternal reasons for requesting a planned caesarean section in a Burkina Faso teaching hospital. Results have shown that the reasons for choosing a planned caesarean section are multifactorial. Tokophobia (intense fear of childbirth and is the main psychological cause) associated with a lack of knowledge about caesarean section indications and consequences was the major motivator [21] [22]. In addition, participants have viewed the hospital technical equipment as a positive contributor to request for a planned caesarean section. The hospital characteristics such as the quality of healthcare and the pregnant women confidence in the judgement of their doctor have also influenced the decision to request a planned caesarean.
A large part of caesarean section cases could be avoided if a birth plan is set up by the gynaecologist and the expecting mother [22]. The concept of emergency caesarean section scares women which pushes them to take the lead by choosing caesarean section in advance [23]. The delivery preparation can also help mothers to improve their knowledge if its proceedings count in the process [24]. Other reasons root in the planned caesarean section choice in fear of vaginal delivery pain, the family pressure, poor previous experience, seek of better healthcare services in order to keep pelvic floor integrity [24].
Our results have shown that technology induces the caesarean section choice by participants and appears nowadays to be a safe way to avoid complications to the mother and child during the delivery. Surgical techniques, anaesthesia, asepsis, antibiotic therapy and caesarean section enabling maternal safety have always moved up [25]. Some mothers and caregivers think that technology can prevent a set of risks bound to pregnancy and childbirth. Confidence in medical technology and modernity hide the risk lies in any surgery [14]. In Brasilia, the protected side of the caesarean section is faced to the static pelvic troubles or sexuality itself, which lead to undermining any positive viewpoint [25]. In China, the one-child policy encourages caesarean section practice, which is seen as an optimal safety guaranty for the child [25].
Our findings have shown that the request of a planned caesarean section depends on the doctor communication way about caesarean section and how he describes vaginal delivery. Previous studies had found the same results [26]. On one hand, the doctor attitude had mattered in the women choice of caesarean section [26]. On the other hand, even if the caesarean section was not allowed by medical indication, it was generally admitted through the relationship between doctor-patient [14].
This study contributed to improving knowledge-producing. The qualitative approach made it possible to explore deeply all the factors that influenced a request for a planned C-section. The author’s subjectivity probably impacted data analysis.
5. Conclusion
This study allows us to know factors which lead to planned caesarean section choice by future mothers. Planned caesarean section choice comes to be multifactorial. Desire and beliefs are strongly linked to the caesarean section choice coming as an unquestionable means to avoid pain and complications for mother and child during delivery. Additional reasons such as the hospital framework and its performance associated with the available technological equipment, caregivers welcome combined with the facilities hygiene contribute to the caesarean section requests. Furthermore, doctor-patient communication is also not neglecting factor of the planned caesarean section request. Finally, an information, education and communication strategy on the mode of delivery at the end of pregnancy may contribute to reducing this problem. A quantitative study on planned C-section in Burkina Faso could be such a useful contribution by being like a complement to enrich the results.
Funding Sources/Sponsors
This research received no specific grant from any funding agency.
Acknowledgements
We acknowledge all colleagues who offered guidance and technical support when this manuscript was being drafted.