women attitude toward the mode of delivery and affect …

www.wjpps.com Vol 9, Issue 6, 2020.

154

Rana et al. World Journal of Pharmacy and Pharmaceutical Sciences

WOMEN ATTITUDE TOWARD THE MODE OF DELIVERY AND

AFFECT OF SOME SOCIAL PARAMETERS

Dr. Rana Naeem Irook*, Dr. Seenaa Mohammed Ali, Dr. Rasha Abdul Adheem

Abbas Nassar

1M.B.Ch.B. HDFM.

2M.B.CH.B. DGO.

3MBCHB.DGO.

ABSTRACT

Background: Normal vaginal delivery is natural& physiological

process, has benefits and advantages for the mother and fetus need no

interference, but when the conditions put the mother and her fetus life's

in danger, need for intervention by Cesarean section which is ither

elective or emergency is exist. the acceptable rate of Cesarean Section

which is about 10-15% recommended by the World Health

Organization (WHO) in many part of the world. recently seen there's

increasing world wide in the rate of Caesarean Section above this level.

Objective: to assess the awareness of women about the mode of delivery &the effect of

some social parameters on their choice. Subjects & methods: The cross –sectional study

involve 400 women attending teaching Hospitals from first (1st) march 2015 to first(1st)

august 2015, the data was collected by using questionnaire form included 2 part first the

demographic criteria like age, parity, residence, occupation of the women, educational level

of women, Ante-natal care attendance &the second part ask about preference of mother about

the mode of delivery and the causes of her preference, with exclusion of women with either

clear indications for Cesarean Section and complicated pregnancy that lead to difficult labor.

Results: The majority of women in this study about 297(74.25%) were prefer Normal vaginal

delivery as the best mode of delivery and the 103(25.75%) were prefer Cesarean Section, this

affected by social factor like maternal age, parity, residence, occupational categories,

educational level of women ,women attending Ante-natal care. the main causes for women

preference for Normal vaginal delivery were rapid recovery 96(24%),76(19%) were fear from

post-operative pain, 63(15.8%) were considered Normal vaginal delivery as natural &for

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 9, Issue 6, 154-197 Research Article ISSN 2278 – 4357

Article Received on

16 April 2020,

Revised on 06 May 2020,

Accepted on 26 May 2020

DOI: 10.20959/wjpps20206-16374

*Corresponding Author

Dr. Rana Naeem Irook

M.B.Ch.B. HDFM.


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healthy fetus and mother 62(15.5%) were fear from complication of Cesarean Section, while

the main causes for preference of Cesarean Section were 71(17.8%) were fear from labor

pain, 23(5.8%) were for tubal ligation and 9(2.3%) were for fetus health. Conclusions: The

majority of women has positive attitude towered Normal vaginal delivery, the most common

cause for preference Normal vaginal delivery were rapid recovery post delivery, while most

common cause for preference Cesarean Section were fear of labor pain, the most significant

factors that affect mother choice are maternal age, parity and attending Ante-natal care, all of

them had positive attitude toward Normal vaginal delivery.

1.1. INTRODUCTION

The women in child bearing period and birth considered as normal and natural physiological

state,[1]

Birth history belongs to the beginning of creation time of human so normal vaginal

delivery is spontaneous process need no interference and if its done with significant and good

preparation lead to decrease maternal and prenatal mortality.[2]

The normal delivery is birth of baby ,umbilical cord ,membrane and placenta from uterus

through birth canal, this associated with start of uterine contraction in labor .Most women

about (80%) delivered at 38 -40 week of gestation.[5]

With the development of human being and technology, alternative method of delivery

developed which is needed when specific condition of the mother and fetus life's become at

risk for normal vaginal delivery this is called assisted delivery ( instrumental and caesarian

section).[3,4]

Instrumental delivery which is operative vaginal procedures to assisting the women who

delivered vaginally by specialized instrument like forceps and ventouse which is most

conmen used in medical practice in order to avert adverse maternal and fetal outcome but it

had complication like intracranial injuries and shoulder dystocia for newborn and genital tract

laceration with post partum haemorrghe of the mother lead to decrease its used which give

some explanation about increase the caesarian section rate.[6,7,8]

In 1881 the first modern caesarian section was done by German gynecologist Ferdinand

Adolf Kehrer.[9]

The caesarian section is surgical removal of baby and placenta by incision in the abdomen

and uterus,[10]

its more frequent surgery made world wide,[11]

its divided in tow types by the


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time of operation :- elective caesarian section (planned operation) either for medical causes to

the mother like diabetes, increase blood pressure ,malpresentation like breech presentation

and previous caesarian section , or on maternal request.[9,12]

emergency caesarian section is done when pregnancy complicated during labor which

accrued suddenly like failure to progress or fetal distress and its performed to save the mother

and her fetus life, in emergency CS death rate increase eight time than in normal

delivery.[13,14]

In recent years there is increase the rate of Caesarean section more than the acceptable rate

for caesarian section which is about 10%to 15%recommended by the World Health

Organization (WHO),[15,16,17]

as in Iraq the rate about 20% in 2006[18]

& in 2010 about

32.01% and in 2013 26.80%, in Babylon province the rate of CS about30.85% in 2010 and

29.80% in 2013 according to Ministry of health-Iraq,[19]

the study in Tehran in 2009 show

44% of CS rate[20]

& in 2007 31.8% in United state[21]

and 26%in China[22]

which is higher in

comparison with WHO rate.

So when it's increase it become danger to the mother and fetus especially when unnecessarily

done as these done when the mother condition not indicated and no risk for normal labor.[12]

Increasing in the rate of caesarian section may associated with some factor like age of mother

and parity,[23]

as older maternal age at first pregnancy who increase the likelihood of

caesarean section delivery.[24,25]

other factor is the educational level as the study in Brazil

demonstrated the caesarian section rate increase in higher educational level and 31%of those

women choose caesarian section.[26]

The objective of this study To assess the awareness of women about the mode of delivery and

the effect of some social parameters on their choice.

2.1 Mode of delivery

2.1.1.Normal vaginal delivery (NVD)

Labor is a physiologic process during which the products of conception (I.e., the fetus,

membranes, umbilical cord, and placenta) are delivered from the uterus and through the

cervix and birth canal, is usually associated with pain and discomfort.[27,28 ]

Labor at the onset is spontaneous associated with a complex set of changes in structural,

biochemical connective tissue and with gradual effacement and dilatation of the uterine


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cervix as a result of rhythmic myometrium contractions of sufficient frequency , intensity and

duration and cervical ripening.[27,28,29]

The duration of pregnancy from the first day of the last normal menstrual period is 40 weeks

(280 days),[30]

most women about 80%delivered between 38-40weeks of gestation (full

term).[5]

Labor lasts 12 to 14 hours for nulliparous (I.e. A woman having her first baby) and 6 to 8

hours for multiparous (more than one baby).[29]

2.1.2. Management of Labor

At the time of labor ,the position of the fetus with respect to the birth canal is determine the

route of delivery, therefore determination of the position of fetus inside the uterine cavity at

the onset of labor.[31]

The ability of change in position of the presenting part to navigate the pelvic canal during its

passage in labor constitute the mechanisms of labor, also known as the cardinal movements,

in relation to the vertex presentation as its represent 95%of all pregnancies.[28]

Although labor and delivery occurs in a continuous fashion, the cardinal movements are

describe as 7discrete sequences.[28,30]

1. Engagement: of the presenting part when enter the maternal pelvis to at level below the

plane of the pelvic inlet ,on pelvic examination the presenting part at O station or at the

level of maternal iliac spine.

2. Descent: of the fetus into the pelvis ,this occurs intermittently with uterine contraction

and the rate increase in second stage of labor.

3. Flexion: of the fetal head as the fetal vertex descents it encounters resistance from the

pelvic bone or soft tissue of pelvic floor lead to change the presenting diameter from

occipitofrontal (11.0cm) to suboccipitobregmatic (9.5cm) foe optimal passage through

pelvis.

4. Internal rotation: of fetal head to bring the anteroposterior (AP)diameter of the head in

line with the AP diameter of the pelvic outlet.

5. Extension: of fetal head ,the base of occiput come in contact with the inferior margin of

pubic symphysis so the resistance from pelvic floor upward &forces of uterine


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contraction from down cause the occiput to extend &rotate around the symphysis thie is

followed by delivery of fetus head.

6. Restitution and external rotation: as head turns about 45 degree left or right to untwist

neck.

7. Expulsion: after delivery of fetal head bring the anterior shoulder to the level of pubic

symphysis then rotate under the symphysis followed by posterior shoulder &rest of the

body.[32]

2.1.3. Stage of labor

Labor pass in 3 stage

After the onset of true labor which is start with regular contraction and progressive frequency

and intensity as.

2.1.4. First stage of labor

Begins with regular uterine contractions that effect cervical dilatation and ends with dilatation

at 10 cm, first stage divided into a latent phase and an active phase.[32]

The latent phase begins with mild, irregular uterine contractions that soften and shorten the

cervix than the contractions become progressively more rhythmic and stronger, The active

phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid

cervical dilation and descent of the presenting fetal part.[32]

The rate of cervical dilatation is 1cm/hr in nulliparaous women &1.2cm/hr in multiparaouse

during active phase of labor according to Friedman &colleagues.[33]

During the first stage monitoring fetal heart at least every 15 min particularly during labor &

after contraction immediately

2.1.5.Second stage of labor

Begins with complete cervical dilatation and ends with the delivery of the fetus.[34]

When the women enter the second stage of labor with complete dilatation of cervix

monitoring of fetal heart should be at least every 5 min &after each contraction.[32]

In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours

if regional anesthesia is administered or 2 hours in the absence of regional anesthesia.


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While in multiparous the second stage considered to be prolong when exceeds 2 hours with

regional anesthesia and 1 hours without it.[27,34]

Studies performed to examine prenatal outcomes associated with a prolonged second stage of

labor revealed increased risks of operative deliveries and maternal morbidities, post partum

hemorrhage, but no differences in neonatal outcomes possibly because of close fetal

surveillance during labor.[35,36]

2.1.6.Third stage of labor

The third stage of labor is defined by the time between the delivery of the fetus and the

delivery of the placenta and fetal membranes. During this period, uterine contraction

decreases basal blood flow, which results in thickening and reduction in the surface area of

the myometrium underlying the placenta with subsequent detachment of the placenta.[37]

Although delivery of the placenta often requires less than 10 minutes, the duration of the third

stage of labor may last as long as 30 minutes.[38]

Active management of third stage of labor involve of delivery of placenta spontaneously

administration of oxytocine ,cord clamping &cutting ,control traction of umbilical cord so

delay cord clamping >180 second after delivery improve ion state& reduced iron deficiency

anemia at 4 month & neonatal anemia prevalence reduction.[38]

2.1.7.The benefit of normal vaginal delivery

Because of the health, social, economic benefits resulted from the spontaneous vaginal

delivery at term its considered the preferred outcome for pregnancy as[39,40]

1. shorter duration of hospital stay and rapid recovery period.

2. lower risk for infection like wound infection ,urinary tract infection and pelvic infection.

3. low risk for anesthesia and its complication.

4. less bleeding.

5. low risk for injury to the organ and no risk for placenta previa in subsequent pregnancy.

6. decrease psychological complication as emotional relationship between the mother and

baby is better after vaginal delivery and the mother see her baby soon after delivery.

2.1.8. Absolute Contraindication of normal delivery[30,41]

1. complete placenta previa which closed the internal os.


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2. infection like Herpes simplex virus associated with lesion in the genital tract or prodromal

symptom and untreated human immunodeficiency virus infection.

3. previouse classic uterine incision or extensive uterine surgery.

2.2. Assisted vaginal delivery(AVD)

2.2.1. induction of labor

Is the process of stimulating the uterus to start labor artificially by administration of oxytocin

or by prostaglandin to pregnant women who failed to initiate labor after 41 week of gestation

or when there is clear medical condition like those women with gestational diabetic mellitus

or hypertension in pregnancy &infertility treatment &other factor as pre mature rupture of

membrane (PROM), maternal age, nulliparity.[42,43]

In developed countries the proportion of delivery at term followed induction of labor is 1 for

4delivery.[44,45]

There are several methods for induction of labor depend on preference of women ,associated

condition & parity

1. use low dose of oxytocine with long interval between the dose as start with 1 ML IU/min

and increase until 1-2ML IU/min every 20-30 min until adequate uterine contraction is

abstained.[42,28]

2. vaginal misoprestol given in low dose (25mq )every 6 hr to decrease risk of uterine hyper

stimulation, uterine rupture &fetal distress ,this method use to decrease vaginal birth not

achieved within 24 hr &reduced CS.[47]

3. oral misoprestol also to achieved vaginal birth &reduced CS with low dose (up to 50 mq -

2 hr ).[48]

4. prostaglandin as (PGE2, PGF2alfa )to reduce risk of vaginal birth that not accord in 24

hr.[46]

2.2.2. acceleration of labor

Is processes of stimulation of ineffective uterine contraction after the onset labor

spontaneously to mange labor dystocia by shorten stage of labor.[49]

It start when cervical dilatation <1cm /hr give high dose of oxytocin &if uterine contraction

inefficient it start with 4ML IU/min &increase by 4 ML IU/min every 15 min until the rate of

contraction 7 contraction /15 min or rate of infusion reached to 36ML IU/min.[28]


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Although the acceleration of labor shorten the first stage in nulliparous but it not decrease the

possibility of CS.[43,50]

2.2.3. Episiotomy[51]

Surgical incision in to perineum during second stage of labor to enlarge vaginal opening and

its divided into types:-

1. midline incision which is easy made from the vagina toward rectum, with its advantage

the muscle fiber spilt with less bleeding and faster healing.

2. Mido- lateral incision which is more difficult from vagina toward one buttock and

associated with more bleeding and pain during heeling.

Indication of episiotomy

Shoulder dystocia ,breech delivery ,operative delivery (forceps and vacuum extraction) and

fetal position like occipital posterior.

Complication of episiotomy:- (perennial pain, perennial laceration, infection and decrease

sexual activity).

2.2.4. Instrumental vaginal delivery:-(IVD)

Is the procedure in which the delivery of the fetus through the birth canal (vaginal delivery),

need to assist by specialized instrument to avoid the risk of maternal and fetal outcome, the

most popular instrument of operative vaginal delivery are Forceps and Ventouse which

considered a key element of essential obstetric care, IVD used in poor countries through

training and supply of appropriate equipment more likely to reduce maternal and newborn

mortality and morbidity.[52,53]

According to WHO in recent studies show the method of delivery and pregnancy outcome in

9 countries show 3.2 %were by operative vaginal delivery.[54]

2.2.5. Type of instrumental delivery

1. Obstetrical Forceps

The earliest instrument designed to assist vaginal delivery, its undergone modification several

time and there are different type of forceps, the classification of forceps based on the depth of

pelvic cavity and applied to affect the delivery (low outlet, mid cavity, high forceps).


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Low cavity and outlet are most frequently used while the high and mid cavity forceps which

need rotation of the fetal head are rarely performed.[55]

2. The vacuum extractor

Its device to assist vaginal delivery without injury to the mother and baby by mechanism in

which an air pump with one can seize the head of the infant without injury to the mother and

baby.

The first one used the vacuum device by James Young, surgeon to the Naval Hospital in

Plymouth, England in 1655.[56]

There are different type of vacuum extractor depending on the type of section mechanism

(manual or electrical ) and type of cup used (rigid or soft).[8]

2.2.6.Indication of instrumental vaginal delivery

1. fetal indication(58)

Fetal prematurity, increase fetal weight, non-reassuring fetal status and acute fetal distress.

2. Maternal Indication[55]

A. Maternal distress.

B. Medical condition of the mother like Preeclampsia/eclampsia, mother with

cardiomyopathy, maternal cerebral vascular disease, spinal cord injury).

C. Delay progress of labor especially the second stage.

D. Nulliparous women with un tested pelvis are more likely to assist with operative delivery.

3. Other indication[55]

A. Breech presentation after coming head need for forceps to maintain the fetal head in

flexion and traction on the fetal head.

B. In caesarean section either vacuum extractor or forceps used to deliver a (floating) fetal

head.

2.2.7.Contraindication of instrumental vaginal delivery[59]

1. Abnormal fetal lie if transverse or oblique.

2. Abnormal presentation like breech ,face or brow and shoulder.

3. Not engaged head.


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4. Deflexed attitude of fetal head.

5. Fetal bleeding disorder e.g.(.thrombocytopenia).

6. Clinical evidence of cephalo-Pelvic Disproportion .

7. Incomplete dilatation of cervix.

8. Gestational age <34 week of gestation because the risk of intracranial hemorrhage and

neonatal jaundice.

2.2.8.Complication of instrumental vaginal delivery(55)

1. Maternal complication(55)

Genital tract laceration, postpartum hemorrhage

2. Fetal complication(55)

Skin bruises, neonatal jaundice, cephalo hematoma, Erb's palsy and shoulder dystocia, fetal

death, newborn injury like intracranial injury (epidural, subdural and subarachnoid)

hemorrhage.

2.3. Caesarean section delivery

Caesarean section (also C-section, Caesarian section, Cesarean section Caesar, etc) is a

surgical procedure which is used to deliver one or more babies or rarely for removal a dead

baby by an incision made through the mother abdomen (laparotomy) and uterus

(hysterotomy).[9]

The first modern CS was performed by German gynecology Ferdinand Adolf Kehrer in

1881.[9]

CS usually performed when the vaginal delivery put the life of mother and fetus in danger,

but nowadays it has also increased in the women up on request to choose the childbirth that

could otherwise to be natural.[9]

2.3.1. Classification of caesarean section

CS classified according to the type of incision made on uterus ,the classical CS is midline

longitudinal incision which allows a larger space to deliver the baby so its more prone to

complication and its rarely performed recently.[13]

Second type which is most commonly used today is the lower uterine segment section ,it’s a

transverse cut just above the bladder edge and result in less blood loss and easy to repair.[13]


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Another classification according to the time of operation

1. A crash/urgent/emergency CS is an obstetric emergency which developed suddenly when

the pregnancy complicated for NVD and done to prevent maternal and prenatal

mortality.[13]

2. A planned CS(elective/scheduled CS) most commonly arranged for medical condition

and as close to the date as possible.[13]

2.3.2 .Indication of CS[60,61]

Fetal indication:- (Prolong labor and failure to progress (dystocia) fetal distress, abnormal

presentation (breech or transverse position ), large baby weight >4000gm (macrosomia ).

Maternal indication:- (previous CS, previous uterine rupture, multiple pregnancy, bicornate

uterus, medical condition of the mother like pre-eclampsia, HIV infection and sexually

transmitted disease of the mother.

Other indication:- are placenta previa and placenta abruption or placenta accrete).

2.3.3. Complication of CS

Although CS can prevent serious mortality and morbidity of the mother and fetus when its

done in certain situation but is associated with complication and the risk of maternal death

especially in emergency CS which is about 8 time more than in NVD.[14,20]

Elective CS before 39 weeks of gestation increase neonatal mortality compared with those

delivered at 39-41(full-term).[63]

The complication of CS for the women are (wound infection, pelvic infection, lung infection,

urinary tract infection, venous thrombosis, pulmonary embolism, bleeding, susaptiblity to

organ injury, complication of anesthesia and psychological complication.[20,62]

Complication of CS for subsequent pregnancy like reduced fertility, ectopic pregnancy,

miscarriage and increase the fetal and neonatal mortality.[20]

Compilation of CS in fetus include respiratory distress, jaundice, low blood sugar and

developmental problem.[63]


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2.4. Vaginal Birth After CS: (VBACS)

The term used for women who delivered through birth canal (include assisted delivery by

forceps and ventouse) with history of pervious Caesarean delivery.[64]

2.4.1. Advantage of VBACS

About 3/4 of women (75%)with un complicated pregnancy who go in to labor give birth

vaginally after one CS.[64]

A successful VBACS increase a greater chance of normal birth in future pregnancy ,recovery

period is short and short hospitalization period and less pain after delivery. [65]

For safe labor after CS the delivery should be in the hospital where a timely CS is available

by obstetric anesthetic ,pediatric and operating staff ,and associated with appropriate

monitoring of mother and baby.(65)

2.4.2.Disadvantage of VBACS[66,67]

Include:- emergency CS which accrued due to failure of progress, the risk for blood

transfusion and uterine infection, increased risk of scar rupture which serious consequences

for the mother and fetus.

2.4.3.Contraindications of VBACS[67]

There are some situation considered to be contraindicated t o VBACS and repeated CS is

safer choice.

Women who had previous classical CS, previous uterine rupture, presence of complicated

labor like placenta previa or malpresentation and those with more than one previous CS.

2.5. Rate of CS in different countries

The rate of CS had increased in many parts in the world, as in some countries reached more

than 50%.[68,69]

The rate of CS had increased in both developed & developing countries in the past 20 years

as the rate in developed countries reported between 2.6-36%.[70]

Nowadays the women undergo CS is 3 time more than in the past 20 years.[71]

In Iraq in 2006 the survey held that 20% of women delivered by CS.[72]


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The studies by Ministry of Health- Iraq show the rate of CS was 32.01% in Iraq and the rate

of CS in Babylon government was 30.85% at 2010, but in 2013 the rate of CS in Babylon

29.8% &in Iraq 26.8%.[19]

The CS rate in Tehran is 44%,[19]

50.2%in Hamadan.[73]

The CS rate in United state increase from 5.5%in 1970 to 31.8 in 2007.(21)

In Ireland the CS rate has increased from 14.1%in 1990 to 26.5%in 2009.[16]

In China the rate increase from 6% in 1998 to 26% in 2007[22]

&in Brazil CS rate was

36%.[74]

2.6.the reasons for the continued increasing the Cesarean Section rate

The causes of increase the CS rate can be explained by the followings

1. Women with olderage and have fewer children especially in nulliparaous women who are

more likely to choice easy and safe mode of delivery including the CS.[57]

2. Fetal malpresentation as breech presentation ,most of them now delivered by CS.[57]

3. The incidence of operative vaginal delivery like forceps and vacuum has decreased.[62]

4. Induction of labor increased especially among nulliparas and decrease in women with

preeclampsia may cause increase CS rate.[62]

5. Vaginal birth after CS (VBACS) decreased from 26%in 1996 to 8.5% in 2007.[57]

6. Increase the rate of elective CS for mother request.[94]

2.7.Effect of some social factors on the mode of delivery

2.7.1. Maternal age

High rate of CS is associated with older maternal age,[75]

those whose age more than 35

years[76]

as the women with this age had low chance of pregnancy so they choose more easier

&safer method of delivery,[77]

although it is associated with high morbidity &mortality.[78]

The mortality rate increase as maternal age increase , the pregnancy related mortality is

2.5and 5.3 times higher in women age 35 years and 40 years respectively.[79]

Also the women of >35 years are more likely to have intervention during labor and all studies

show that higher maternal age increase CS delivery [85,86]

and maternal age effect on uterine

contraction intensity lead to failure of progress of labor. [87]


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2.7.2. Parity

Nulliparaous mean the women who has not given birth to a viable infant more than 24week

of gestation[24]

Multiparaous define those women who has delivered at least one a live birth after 24 week of

gestation.[24]

Grand multiparty is defined as parity more than or equal to 5 previous birth so has risk for

antepartum, intrapartum &neonatal complication.[80]

Most serious complication in grand-multiparous include diabetic mellitus, hypertension,

postpartum hemorrhage &prenatal mortality.[81]

As parity increased the pregnancy complication increased which necessitate intervention like

assisted delivery or CS.[85]

2.7.3. ANC(Ante-natal care)[ 90,91]

ANC is the comprehensive health supervision of pregnant women before ,during pregnancy

and postnatal period in order to reduce maternal and neonatal mortality.[90]

The focused ANC for essential intervention by four visit include immunization of tetanus

toxoid, detection of any infection during pregnancy like HIV, syphilis and sexually

transmitted disease, management of complication of pregnant women as preeclampsia.[90]

In ANC also, the pregnant women can obtained information about healthy behavior as

breast feeding, post natal care and for family planning.[90]

According to the WHO showed that the essential ANC at least four visit during pregnancy,[91]

the first visit as soon as possible in early pregnancy in first trimester for early detection of

specific condition and determine women need more attention and more visit and the last visit

at 37 week of gestation to prevent and mange problem as multiple birth and malpresentation

and for advise, consul the women about the mode of delivery.[90]

The rate of CS increase in women attending ANC, this due to those women even with only

one ANC visit become more aware for high risk pregnancy and more likely to advise to have

frequent visit, more consultation and more investigation which may indicate subsequent


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decision of type of labor including CS and more studies report that higher number of ANC

visit, the greater tendency of women to have CS delivery.[93,97]

SUBJECTS AND METHODS

3.1. Ethical Approval of the study

The study protocol was approved by the ethical committee of community medicine

department in College of Medicine, Babylon University . the acceptance of ethical committee

of Al-Hilla health directorate was taken to conduct this study . the verbal consents of women

included in this study were obtained after full explanation of the objective of the study.

3.2. study design ,setting and time

This cross-sectional study was done in central Hospital in AL-Hilla city (in AL-Hilla General

Teaching Hospital &in Babylon Teaching Hospital for Maternity and Children during the

period from first of March 2015 to the first of august 2015.

3.3. Method of data collection

The data collected in this study by using Arabic language questionnaire sheet included two

part, first part for demographic criteria of women like age of mother, parity, residence,

occupational categories, educational level, attending Ante-natal care (ANC), the second part

for the preference of the mother toward the mode of delivery and the cause of her choice.

3.4. Study population

A total of 400 married women(pregnant and non-pregnant) with different criteria were

admitted to the Gynecological ward of AL-Hilla Hospitals.

3.5. Pilot study

This was carried out for two weeks before starting to collect information ,the pilot study done

in gynecological ward in AL-Hilla Teaching Hospitals for a period from 1st to 14

th of March

to test the validity and reliability of questionnaire to determine any modification needed and

to estimate the time needed for collection of data and to find any other difficulties.

3.6. exclusion criteria of the subject from this study

Women who excluded from this study, those with clear obstetrical indication for Cesarean

section like repeated previous two or more CS, malpresentation as breech presentation, twin

pregnancy), and those women with complicated pregnancy like medical disease (gestational

diabetes, preeclampsia), or bad obstetrical and gynecological history lead to difficult labor.


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3.7.Statistical analysis

The data collected were entered and transferred in to computerized database and analyzed by

using the statistical package for social science (SPSS) version 18, descriptive statistic were

presented as frequency, percentage, chi square test use to compare frequency, the level of

significant p value <=0.05 were considered, using table, pie and bar chart to show the result.

RESULTS

Distribution of women by Socio-Demographic Characteristics

The mean age of respondent was 29.15±7.34 years, The majority 264 (66.00%) of women

were between the 21-35years old meanwhile 48 (12.00%) of the women were less than 20

years old & 88 (22.00%) of them were more than 35years old (>35) as (Figure-1)

Figure 1: Distrubution of women by age group.

Figure 2: Show the distribution of women by parity, the majority 256 (64.00%) were

multiparous, meanwhile 70 (17.50%) were nullparious &74 (18.50%) were grand-

multiparous (Figure-2).


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Figure 2: Distribution of women by parity.

Figure 4: Show the distribution of women by residence, the majority 229 (57.25%) of the

women from urban area &171(49.75%) of the women from the rural area. (figure-3)

Figure 3: Distribution of women by residence.

Figure 4: Show the distribution of women by occupational categories, 230 (50.75%) were

non- employed &197(49.25%) were employed (Figure -4)


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Figure 4: Distribution of women by occupational categories.

Figure 5 Show the distribution of women by educational level, the majority 158 (39.50%)

were secondary school, 128 (32.00%) were high school, 81 (20.25%) were primary school &

33 (8.25%) were illiterate. (figure -5)

Figure 5: Distribution of women by educational level.

Figure 6: Show the distribution of women how attending antenatal care (ANC), the majority

285 (71.25%) who attended ANC while only115 (28.75%) were not attended ANC.(Figure-6)


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Figure 7: Distribution of women by attending ANC.

Figure 7: Show the distribution of women by their state, the majority 286 (71.50%) were

pregnant women while 114 (28.50%) were non-pregnant (figure-7)

Figure 7: Distribution of women by pregnancy state.

Figure 8: Show the distribution of women by history of one Cesarean section, the majority

288 (72.00%) with negative history of CS &112 (28.00%) with positive history of CS.

(figure-8)


173


Figure 8: Distribution of women by history of Caesarean section (CS).

Figure 9: Show the distribution of women by preference mode of delivery, the majority 297

(74.25%) were prefer normal vaginal delivery (NVD) &103 (25.75%) were prefer Caesarean

section (CS). (figure-9)

Figure 9: Distribution of women by preference the mode of delivery.

Figure 10: Show the causes of women preference for normal vaginal delivery (NVD), the

majority of women prefer NVD 96 (32.30%) due to rapid recovery, 76 (25.60%) due to fear

from post-operative pain, 63 (21.20%) due to that considered NVD as natural and for fetus

and mother health & 62 (20.90%) due to fear from CS complication. (figure-10)


174


Figure 11: Show the causes of women preference of Caesarean Section (CS), the majority

71(69.00%) due to fear from labor pain, 23 (22.30%) due to tubal ligation & 9 (8.70%) due to

baby health (figure-11)

Figure 11: The causes of women preference caesarean section (CS).


175



176



177


Figure 12: Show the realtion of women age droup and choice mode of delivery, women with

age less than 20 years old 29 (60.41%) prefer NVD and 19 (39.6%) prefer CS, women with

age between 21-35 years old 205 (77.7%) prefer NVD and 59 (22.3%) prefer CS &the

womrn with age more than 35 yreas old 63 (71.6%) prefe NVD and 25 (28.4%) prefe CS

.(figure-12-)


178


Figure 13: Show the relation between the women parity and choice mode of delivery,

nulliparous women 40 (57.1%) prefer NVD and 30 (42.9%) prefer CS, multiparaous women

197 (77.0%) prefer NVD and 59 (23.0%) prefer CS and the last group were grand-

multiparous women 60 (81.1%) prefer NVD and 14 (18.9%) prefer CS .(figure-13-)

Figure 13: relation between women parity and choice mode of delivery.


179


Figure 14: Show the relation between the women residence and choice mode of delivery,

women in urban area165 (72.1%) prefer NVD and 64 (27.9%) prefer CS, the other group

were in rural area 132 (77.2%) prefer NVD and 39 (22.8%) prefer CS (figure-14)

Figure 15: Show the relation between the women occupational categories and choice mode of

delivery, the employed women 155(78.7 %)prefer NVD and 42(21.3%) prefer CS ,the non-

employed women 142(70.0%)prefer NVD and 61(30.0%) prefer CS .(Figure-15-)


180


Figure 16: Show the relation between the women educational level and choice mode of

delivery, illiterate women 23 (69.7%) prefer NVD and 10 (30.3%) prefer CS, women in

primary school 54 (66.7%) prefer NVD and 27 (33.3%) prefer CS, secondary school 130

(82.3%) women prefer NVD and 28 (17.7%) prefer CS and the last group with high school 90

(70.3%) prefer NVD and 38 (29.7%) prefer CS.(figure-16-)

Figure 17: Show the relation between the women attending ANC or not and choice mode of

delivery, 215 (75.4%) of women who attending ANC prefer NVD and 70 (24.6%) prefer CS,

the women not attending ANC 82 (71.3%) prefer NVD and 33(28.7%) prefer CS. (figure-17)


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Figure18: Show the relation between the women with history of pregnancy and choice mode

of delivery, the pregnant women 205 (71.7%) prefer NVD and 81 (28.3%) prefer CS, non-

pregnant 92 (80.7%) prefer NVD and 22 (19.3%) prefer CS. (figure-18)


182


Figure19: Show relation between the women with history of Cesarean Section and choice

mode of delivery, women with positive history of CS 73 (65.2%) prefer NVD and 39 (34.8%)

prefer CS, while women with negative history of CS 224 (77.8%) prefer NVD and 64

(22.2%) prefer CS. (figure-19)

DISCUSSION

The CS rate increase in many part of the world in both developed &developing countries

even with out real indication, this will carry risk &complication and increase maternal

mortality and morbidity so this study conducted to assess the awareness of women toward the

mode of delivery and the social factor that affect their choice.

The majority of women included in the study 297(74.25%) were prefer NVD as best mode of

delivery, and about 103(25.75%) were prefer CS as best mode of delivery, this agree with the

study by Nasrat done at Isra university in Pakistan[82]

that show about 373(83.6%)from total

446 pregnant women has positive attitude toward NVD as best mode of delivery73(16.4%)

and the study in AL-kadhmyia Hospital which is reveal by Huda Adnan[88]

show

384(80%)from total 480 prefer NVD and 96(20%)prefer CS.

The most frequent causes for women choice NVD 96 (32.30%) were rapid recovery which

agree to the study in Al-Kadhmyia Hospital by Huda[88]

that about 120 women from 384 that

prefer NVD due to rapid recovery, the second cause for choosing NVD 76 (25.60%) was fear


183


from post operative pain and this agree with study in Nasrat[82]

that show the most common

cause for refuse CS were fear from post-operative pain about (51.60%).

Study in south Africa[83]

that reported women agreed to attitude for NVD due to fear from

post operative pain, the third cause of women preference NVD were the CS complication

about 63(21.20%) this agree with study by Nasrat[82]

that report (70.4%) from total 446

women prefer NVD due to CS complication.

The last cause were women considered NVD as natural process and for fetus & mother health

about 62(20.90%), this agree with study of Kerman[98]

that (66.7%) and Nasrat[82]

that report

(86.1%) for the NVD as natural process .

Nasrat[82]

in those women who chose CS, the most frequent cause of their choice was fear

from labor pain 71(69.00%), this agree with the study by that report 22(4.9%) fear from pain

of NVD, study in India[95]

report (86%) of women chose CS due to fear from NVD pain, the

second cause was for tubal ligati on 23(22.30%) even its not as medical indication for CS this

agree with study in Tehran[99]

that report 168 (28%) nfrom 501 that choose delivery by CS for

tubal ligation and the least common cause for choosing CS due to safety health of fetus

9(8.70%) mean that women thought that CS safer for fetus health more than NVD which is

agree to study in Tehran[99]

and in AL-Kadhmyia[88]

that report 81(13.5%) and 46(47.9%)

cause of CS due to safety of fetal health in two studies respectively.

Socio –demographic characteristic of the study group in relation to the mode of delivery

The women included in this study with different age group, less than 20 years old about

48(12.00%), age from 21-35 years old 264(66.00%) who the major group in the study, and

age more than 35 years old 88(22.00%).

There's significant relationship between the age group and choice mode of delivery (p

value=0.055), that show all age group has positive attitude toward normal vaginal delivery,

most of them in age group 21-35 years old because this group higher number in this study

about 205(77.7%) women prefer NVD, this is agree to the study done in AL-Kadhmyia by

Huda Adnan[88]

that report the majority of age group between 26-35 years old about 233, 129

(79.1%) of them prefer NVD.

The most common cause in all age group were rapid recovery, fear from post-operative pain,

women considered NVD as natural process and for fetal and mother health and for CS


184


complication, more in age between 21-35, this agree with study by Huda Adnan[88]

that

reported most common cause of women preference NVD in this age were due to rapid

recovery, fear from postoperative pain, NVD as natural process and CS complication

respectively.

This explained that those women have other children and need to rapid healing and return to

home for care, and CS complication and pain make the mother need for more care.

while the minority has positive attitude toward CS which is more also in age 21-35 years old

59(22.3%)and the most cause were fear from labor pain this agree with finding in study by

Hildingson and Colleagues[84]

that reported only 8.2% women accepted CS as mode of

delivery and the cause were due to fear of labor pain.

Women less than 20 years old who prefer CS delivery due to fear from labor pain which is

agree with the study by Nasrat[82]

and India[95]

that show (4.9%), (86%) of women prefer CS

due to fear of labor pain respectively ,while main cause for CS in age >35 years old for tubal

ligation because those women may complete their family and had certain contraindication to

other form of contraceptive, this agree with Nasrat study[82]

that report cause of CS for tubal

ligation.

Regarding the parity of women as high parity associated with increase CS rate,[96]

so women

included in this study with different parity to assess the effect of women parity on choice

mode of delivery, the majority of women in this study were multiparous 256(64%), second

were grand-multiparous (those who delivered >5 children ), the other were nulliparouse.

There's significant relation-ship between the parity &choice mode of delivery (p value

=0.001) all women with different parity has positive attitude toward the NVD and the

majority in multiparous women about 197(77.0%) because large number of data were

multiparous, the most common cause of their choice were rapid recovery in all group because

more women have another children need for her care and post operative morbidity and pain

makes the women need more care and take along period to recover from the operation, The

other cause for preference NVD were due to fear from post-operative pain , NVD as natural

process and for fetal and mother health and CS complication.


185


This agree with AL-Kadhmyia study by Huda[88]

that reported 120(3.0%) were due to rapid

recovery and NVD as natural process and for fetus and mother health and agree with India[95]

that report the cause of preference NVD due to fear from post-operative pain and CS

complication.

The women with different parity that prefer CS and the most common cause were fear from

labor pain because the nulliparous women lack of delivery experience and not fully aware

toward the CS complication, this agree with study in india[95]

that report more women were

nulliparous and prefer CS due to fear from labor pain.

While multiparous women prefer CS due to fear from labor pain, as those women with

previous delivery and experience of labor as NVD associated with pain and discomfort, this

agree with AL-Kadhmyia study[88]

that reported women prefer CS due to bad experience of

NVD, and the common cause in grand -multiparty for tubal ligation, this explained by women

with grand multiparty have more than 5 delivery and complete her family number and do

tubal ligation as they had certain contraindication to other form of contraceptive, this agree

with study by Nasrat,[82]

Tehran[93]

that reported women choice of CS for tubal ligation.

Regarding the women residence, most of them live in urban area 229(57.25%) and other live

in rural area 171(42.75%)this due to data collected in the central Teaching Hospitals in AL-

Hilla city and women in rural area may delivered in other place like hospital in rural area.

There's significant relation-ship between the women residence and choice mode of delivery

(p value =0.047) both group prefer NVD more in urban area due to rapid recovery and NVD

as natural process followed by fear from post-operative pain and complication of CS, as

women in urban area highly educated and be aware for advantage of NVD and most of them

attend ANC so they have more information toward the risk and complication of CS, this

agree with study in India[95]

that report most women prefer NVD live in city and the cause

due to complication and fear from post-operative pain, and agree with study by Huda[88]

in

AL-Kadhmyia Hospital that report most women prefer NVD for rapid recovery and NVD as

natural process and for fetus and mother health.

Meanwhile women live in rural area prefer NVD due to rapid recovery to return to home

quickly, fear from post-operative pain, CS complication and NVD as natural process and fetal

and mother health, also agree with study in AL-Kadhmyia.[88]


186


While main cause for women choosing CS was fear from labor pain and more in urban area,

this explained by those women higher in this study and can delivered in hospital and

associated with high education and high socioeconomic state and can pay the cost of

operation, this agree with study in Karbala by Nebras.[94]

Occupational categories of women in this study are 2 group employed and non-employed,

there's significant relationship between the occupation of women and choice mode of delivery

(p value =0.013), both has positive attitude for NVD as best mod of delivery more in non-

employed women, this may be non- employed women need for rapid return to their home,

this agree with AL-Kadhmyia[88]

reported NVD are more in non –employed women, while

employed women may associated with high education and be aware toward the advantage

and disadvantage of different mode of delivery.

The most common cause for preference NVD in both group were due to rapid recovery, fear

from post-operative pain, NVD as natural process and for fetal and mother health, CS

complication.

While women choice CS also more in non-employed and the cause in both categories were

due to fear of labor pain 42(68.9%) this may be non-employed women not delivered in

hospital and most of them referred as complication of labor and need for CS as management,

this agree with study in Pakistan[92]

which reported that non –employer women less interested

in ANC and associated with labor complication lead to high CS rate, this study not agree with

study in India[95]

were there's no significant relationship between choice the mode of delivery

and women occupation as those women collected regardless the occupational categories,

while employed women choice CS due to fear from labor pain as those women can pay the

cost of CS. the other causes for tubal ligation and safety of fetus, more in non-employed

women as those have more child and chose CS for tubal ligation as they have

contraindication to other type of contraceptive, this agree with Nasrat[82]

study.

The women included in this study with different educational level ,secondary school followed

by high school, this is because data collected in central hospital, the less common were

primary school and illiterate, this may be those attended for home deliveries.

There's significant relationship between the women educational level and choice mode of

delivery (p value =0.043), all women with different education prefer delivery by NVD more


187


in secondary school and high school due to high number included in this study and the cause

of their preference were due to fear from post –operative pain, rapid recovery followed by

NVD as natural process and fetal and mother health and CS complication, this explained as

those women with high educated level more attended for ANC and advise for advantage of

NVD as it's associated with rapid healing and to avoid post operative pain also agree with

AL-Kadmyia by Huda[88]

and Brazil[89]

that reported the women with high education has

frequent ANC visit and more aware about the real indication of CS delivery.

While women with primary school and illiterate choice NVD due to rapid recovery , NVD as

natural process and for fetal and mother health and CS complication with post -operative

pain, this may be women with low education and most of them with multiparous living in

rural area so need for rapid return to home.

Meanwhile women with different education prefer CS, most in high school and secondary

school and the cause for their preference were fear from labor pain , this explained that those

women with high income and attend privet hospital to do CS, this agree with study in

Tehran[86]

and Brazil[26]

that showed women with high education prefer CS as can offered the

cost of operation.

While women with primary school and illiterate choice CS for fear from labor pain and for

tubal ligation, and for safety of fetus.

The CS rate increase in high education due to those women delivered in hospital and attend

ANC so they have awareness about real indication of CS and in women with low education

as primary school and illiterate more attend for home delivery and referred to hospital as

complicated labor and need for CS as management , this agree with study in Brazil[26]

that

report women with high education about 31% chose CS delivery.

The majority of women included in this study were attending ANC, the significant

relationship between the women attending ANC and choice mode of delivery (p value

=0.047) both woman choose NVD as mode of delivery ,more in women attending ANC, this

agree with AL-Kadhmyia by Huda study[88]

and in Brazil[89]

that report women attended ANC

prefer NVD, The cause for their preference were due to rapid recovery , fear from post-

operative pain and complication of CS and NVD as natural process and for fetal and mother

health, this explained women who attend ANC more aware about early sign of pregnancy and


188


seek medical advise and be aware about the advantage of NVD as associated with rapid

healing and obtained information about real indication and complication of CS, While The

women not attend ANC also prefer NVD, this because those women attend home delivery as

they live in rural area and less interested to ANC visit.

The rate of CS increase in women attending ANC, this due to those women even with only

one ANC visit become more aware for high risk pregnancy and more likely to advise to have

frequent visit, more consultation and more investigation which may indicate subsequent

decision of type of labor including CS and those women not attend ANC prefer delivery at

place other than hospital and referred as complicated labor and CS considered as part of

management, this agree with Tehran[93]

and agree with Britten study[97]

reported that higher

number of ANC visits, the greater tendency of women to have CS.

The common cause that both women attend ANC or not choice of CS were due to fear from

labor pain , for tubal ligation and for safety of fetal health, although this not medical

indication for CS, this agree with AL-Kadhmyia study by Huda[88]

the women state (pregnant

and non- pregnant ) included in the study, to show the effect of pregnancy on mother choice

mode of delivery as it's significant (p value =0.018), both woman prefer NVD more in

pregnant women and the cause for their preference were due to rapid recovery, fear from

post-operative pain and CS complication followed by NVD as natural process and for fetal

and mother health , this agree with AL-Kadhmyia by Huda[88]

study that reported most

common cause for preference NVD is rapid recovery and the second cause is fear from post-

operative pain, and agree with India study that reported pregnant women prefer NVD due to

CS complication.

While non- pregnant women prefer NVD also for rapid recovery followed by their

consideration NVD as natural process and for fetal and mother health and fear from operation

pain and CS complication respectively, no similar study that all study taking pregnant

women.

Women chose CS in both group were due to fear from labor pain, this agree with India [95]

and

for tubal ligation as pregnant and non pregnant women may planned for doing CS for this

cause, this agree with study in Pakistan by Nasrat[82]

and in Tehran[93]

that reported women

choosing CS for tubal ligation.


189


Regarding the previous mode of delivery, women included with positive history of one CS

and with negative history of CS, to show the effect of previous experience of delivery which

is significant (p value =0.004 ), both prefer NVD more in women with negative history of CS

and the cause were due to rapid recovery and considered NVD as natural process and for fetal

and mother health followed by fear from post operative pain and CS complication, this agree

with AL-Kadhmyia by Huda[88]

that reported women choice of NVD as positive experience

with it, while women with positive history of CS prefer NVD due to fear from post-operative

pain and CS complication as bad experience with CS as it associated with more pain and

complication.

This agree with India study[95]

that reported the cause of CS were due to fear from post-

operative pain and CS complication.

The cause of preference CS, women with negative history of CS prefer CS due to fear from

labor pain as in previous NVD delivery associated with sever pain and prolong labor this

agree with AL-Kadhmyia by Huda[88]

that reported fear from labor pain and bad experience

of NVD was the cause of preference CS, and the other cause for tubal ligation as these

women planned to do CS for this cause, and for safety of fetal health as they thought fetus

delivered by CS more healthier than NVD, this not agree with Nasrat study.[82]

While women with positive history of one CS prefer it and the cause were due to fear from

labor pain as they considered CS is less painful than NVD , this agree with study in Tehran

[93] that report choice of CS as it's less pain than NVD.

Limitations of the study

1. Time limitation lead to small sample size included in this study.

2. The data collected in the AL-Hilla city only and large area should be included more than

one province, this is because the data collected during the period of practical training.

CONCLUSIONS

1. The majority of women has positive attitude towered the Normal vaginal delivery (NVD),

the most common cause of their preference due to rapid recovery post delivery.

2. The minority of women has positive attitude towered Cesarean Section (CS)

delivery and the most common cause for preference due to fear from labor pain.


190


3. Women choosing mode of delivery affected by many social factors like the maternal age,

parity, regular ANC, all of them had positive effect on attitude toward Normal vaginal

delivery.

Recommendations

1. Education of women before and during pregnancy about the advantage of Normal vaginal

delivery as it's considered as physiological process.

2. pregnant women should be aware about the complication of Cesarean Section.

3. encourage health worker in ANC in health center to encourage women to attend ANC to

be aware about advantage on mode of delivery and the importance of frequent visit to

discover those with risk and complication during pregnancy.

4. Providing accurate and good facilities in obstetric and gynecological hospital for painless

vaginal delivery.

5. Further study required to compare the awareness of women toward the mode of delivery

and the actual rate of Cesarean Section.

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