CHAPTER ONE
INTRODUCTION
Background to the Study
Pregnancy is a time of excitement, anticipation and planning interspersed with periods of anxiety, fear and stress all of which are quite normal (Tiran, 2010). Generally, expectant mothers spend the early pregnancy coping with various physiological discomforts like early morning sickness and backache while trying to continue with their day to day lives. It is not until later in their pregnancy that they begin to think about the impending birth, perhaps worrying about pain and its relief during labour and the actual delivering of the baby and also planning for how they would want it to be (Tiran, 2010).
Childbirth is a unique experience for any parents and along with it are beliefs and expectations that have cultural variations (Callister, 2009). It is often glamorized as a spiritual journey, but physically it is called labour for a reason because it can be a transcendent experience for many women. Cara, (2014) also posits that childbirth without adding any other stressful or complicating circumstances, has all the necessary ingredients to be bewildering, frightening and emotionally exhausting; and yet because of the subjective nature of the experience, two mothers can have the same event happen during birth and one can emerge merely rattled while the other emerges with great fulfillment (Hunter, 2012). According to Blaaka and Schauer (2009), childbirth is a complex life event characterized by rapid biological, social and emotional transition and it is a great stress to many women especially the first time mothers.
Childbirth expectation as defined by Sarah (2013), is an event a pregnant woman thinks will happen during labour. According to Main, Oshiro & Bingham (2010), it is a wish a pregnant mother has about her labour and delivery. This is why many pregnant women have concerns about the pain they may encounter and method of pain relief available to them during labour; lack of appropriate knowledge about the various methods of pain relief can heighten anxiety (Carter, 2010). Mothers develop expectations regarding midwives’ care during labour and delivery. The pregnant mothers expect midwives to provide professional and emotional support and in addition they expect their partner and significant others to provide them with support (Gibbin & Thomson, 2008). Pregnant women also expect to participate in decisions about their healthcare, including pregnancy and childbirth (Paink, 2014). Tiran (2010), asserts that many women expect to have a “natural childbirth” which means a labour that starts, progresses and is completed without medical intervention, and one which empowers the mother to make choices about the way her labour is managed. Unfortunately the reality of childbirth is not always in keeping with maternal expectation because labour is a dynamic event where things can change quickly and so things may not work out as the mother expected.
While the healthcare around childbirth has recently been concentrating on complications and risk for mothers and children, little attention has been focused on women’s experiences and expectations. Meeting a pregnant woman’s childbirth expectation is the most valuable part of her satisfaction (Saliday, 2014). A satisfied pregnant mother is one who has her labour and birthing expectations met. Carter (2010) and Tiran (2010) described the resulting grief from an unexpected childbirth as devastating to mothers. This may increase their risk of post natal depression. Thus congruence between maternal childbirth expectations and reality of the actual experience has an important impact on perception of severity of labour pain, subsequent evaluation of pain itself, the childbirth experience and on mother-baby relationship, (Beaton and Gupton, 2000).
Almost every first time pregnant woman has a preset notion of what labour will be like and that is normal. Many of them believe they will go through labour and give birth without medical intervention and more often than not labor often do require interventions; and new mothers who experience unexpected obstetric intervention have reduced feeling of confidence and fulfillment. The multiparous women also entertain many expectations about the experiences and outcome of childbirth as one pregnancy differs from another. It is important to note that individual women have varying capacities to handle challenges, disappointments and sorrow connected with childbirth and if the experience of labour does not respond to expectations, anxiety usually results (Carter, 2010). The challenge in this context is the feeling and fear in approaching subsequent labour by the distress experienced by these women. The potential source of this distress and fear is not limited to pain or pain relief option but to such challenges as emotional, social and economic implications which has great impact on the woman. The disappointment, if the expectations are not met, can be obvious and easily observed by healthcare providers but the psychological (emotional and mental) challenges are subjective (Beaton et al 2000). Paink, (2010) asserted the need for women to develop realistic expectations about pain, pain relief and support from significant others during labour. Bennet and Brown (2009), observed that expectations and emotions expressed during childbirth are greatly influenced by a combination of several factors such as level of mother’s education, values, religion, cultural beliefs and accumulation of past experiences from previous deliveries especially for the multiparous mothers, and fear for the first time pregnant women.
Childbirth in America and United Kingdom is generally considered to be safe or at least a safe enough event, but whilst women and their babies thankfully rarely die, the psychological morbidity for mothers whose labours have been less than satisfying can be long term and in turn create fear in the mind of the mother especially first time ones (Nock, 2009). Most women of African culture see childbirth as a guarantee of continuation of the lineage and clan. They believe also that children provide helping hands for farm work, housework and childcare. Being able to produce many children therefore, adds to their sense of importance and helps them feel a strong sense of belonging within their clan. Children are very highly celebrated in some cultures as some of them believe in reincarnation, (Quincy, 2010)
In most countries of Africa, 1 in 39 women risk dying from pregnancy or childbirth related causes compared to 1 in 4,300 in developed countries, (Miller, 2009). With this staggering figure, there is still high rate of maternal and infant morbidity and mortality resulting from intractable poor health indices including psychological and emotional feelings arising from failed childbirth expectations (Ayers & Pickering, 2009). The anxiety and emotional feelings in the primiparous are more obvious and intense than in the multiparous mothers (Kitzinger, 2012). This experience plays a major role on how she will develop good self-esteem, positive feeling for the baby and an easier adjustment to motherhood and also future childbirth experiences (Oweis & Abushaikha, 2005). All these emotional and psychological issues can affect a patient’s quality of life.
In different parts of the world, more especially in developed countries such as UK and Denmark, spousal participation is common practice during labor and delivery with about 95% attendance, (Somers, 2009). Studies conducted in these developed countries show that women who had continuous spousal labor support are reassured, comforted and emotionally encouraged to overcome pain associated with labor and delivery, (Hodnett, Gates, Hofmeyr, Sakala, 2007) but in low income countries like Nigeria, which is known to be a patriarchal male dominated society where pregnancy and childbirth are regarded as exclusively women’s affairs, spousal participation in labor and delivery remains acutely low (Iliyasu, Abubakar, Galadanci and Aliyu, 2010). Men traditionally do not accompany their wives for antenatal care and are mostly absent in the labor room during delivery, leaving their support roles to relatives and midwives, (Somers, 2009). Umeora, Ukaegbe, Eze and Masekoameng, ( 2011) posit that status and acceptability of spousal participation in labor and delivery in Nigeria is quite low due in part to socio-cultural drawbacks.
Consequent upon this, issues surrounding childbirth need to be considered from the mother’s point of view in terms of birthing environment, pain, pain relief, spousal support, support from significant others, medical intervention as well as labour outcome as these are vital in ensuring ideal expectations. However, despite other research works done on childbirth expectations in America, UK and Canada, little data exist for studies on childbirth expectations in Nigeria and in Enugu specifically hence this study sets to compare the childbirth expectations of primigravidae and multigravidae in selected health facilities in Enugu State.
Statement of Problem
The World Health Organization (WHO) estimates that worldwide, as many as 1500 women die every day due to complications related to pregnancy or childbirth. Interestingly, more than 90% of these deaths occur in developing countries, most of them in Africa (Harrison, 2007). Unmet childbirth expectations remain a major cause of maternal death resulting from intractable poor health indices and psychological and emotional problems arising from failed childbirth expectation.
Women are highly concerned about the care they receive from midwives while in labour and they feel valued when they are provided with an expected care and when these are not met mothers become dissatisfied and eventually have negative experiences of their labour. According to Maputle and Nolte (2008), once mothers seek midwifery care during childbirth, they are expected to follow set standards, midwifery protocols and procedures that do not always manifest the experiences, needs, expectations and priorities of mothers during childbirth. Furthermore, they also explained that where care is appropriately organized, and midwives hold interpersonal relationships with mothers, clinical skills and knowledge, care is more likely to be positive. If care is fragmented, oriented to technology, protocols and standards rather than human relationship, many mothers feel unsatisfied.
Mothers feel little control in labour and this is related to inadequate information provision during antenatal period, poor communication with mothers in labour by medical staff and lack of opportunity to influence decision making during labour. Many mothers are also worried about the negative attitudes and behaviours of maternity staff and these may be linked to mothers’ negative feelings such as fear, anger, disappointment, stress, guilt and inadequacy.
In Nigeria, drug method of labour pain relief is underutilized and unpopular among skilled birth attendants (Okeke, Merah, Cole, Osibogun, 2005). Onah, Obi, Oguanuo, Ezike, Ogbuokiri and Ezugworie, (2007) assert that parturients in Enugu have a large unmet need of labour pain relief. Labour pain is an intermittent, regular, rhythmic pain occurring during the process of childbirth so with effective labour pain control, women in labour report a more satisfying labour experience (Anarado, Ali, Nwonu, Chinweuba and Ogbolu, 2015). Morhason, Adedokun, Ojengbede, Olayemi, Oladokun and Fabamwo (2008) also assert that there is increasing desire of parturients for satisfactory labour pain relief as well as routine care and companionship.
The researcher in clinical practice observed that male companion at antenatal care is unusual and spousal participation during labor and delivery is poor in Nigeria. This can be attributed to amongst other things, the belief that labor is exclusively women affairs. Majority of women desire their spouses as birth companions and attest to having emotional comfort and support when their spouses participate in their labor and delivery. Olayemi, Bello, Aimakhu, Obajimi and Adekunle (2009) assert that continuous support by spouses makes parturient women experience shorter labors, reduced need for oxytocin, anesthesia, analgesia, instrumental deliveries and decreased by 50% their chances of being admitted to a cesarean section. Umeora, Ukaegbe, Eze and Masekoameng ( 2011) posit also that status and acceptability of spousal participation in labor and delivery in Nigeria is quite low due in part to socio-cultural drawbacks.
In addition the researcher also observed that most mothers expect to have safe and satisfying childbirth experience without medical interventions. All these expectations if not met, lead to feeling of low self-esteem and dissatisfaction with labour experience, postpartum depression and negative perception of labour. Deluca and Lobel in Carter 2014, posit that women who had unexpected caesarean section during deliveries are associated with more complications, longer recovery, lower satisfaction and greater risk of postpartum mood disturbances and psychological outcome. Expectations met influence women’s overall measurement of satisfaction with the childbirth experience. Prior studies have focused on positive or negative experiences in developed countries like America, Canada and UK but in Nigeria satisfaction with labor and birth in Enugu and its associated factors have not been fully explored. Moreso, the volume of research literatures in Nigeria relating to spousal participation in labor and research findings as to how the practice ameliorates labor and delivery pain is very limited, this is an important gap and as such, it is pertinent to underline that fact. It is on these premises that the researcher sets to ascertain empirically, childbirth expectations of primigravidae and multigravidae in selected facilities of Enugu State as the view of the care they would like to receive during labour is needed in order to help them make realistic plan for their childbirth; and also help midwives to issue out their advocacy role very well during the process of childbirth thus ensuring good labour outcome.
Purpose of the Study
The purpose of the study was to compare the childbirth expectations of primigravid and multigravid women in some selected hospitals in Enugu State and specific objectives were to
- Determine the childbirth expectations of primigravidae and multigravidae as regards to coping with pain.
- Determine the childbirth expectations of primigravidae and multigravidae as regards support from spouse and significant others
- Determine childbirth expectations of primigravidae and multigravidae regarding support from midwives.
- Determine childbirth expectations of primigravidae and multigravidae as regards to medical interventions.
- Determine childbirth expectations of pimigravidae and multigravidae as regards labour outcome.
- Identify factors that influence the childbirth expectations of pimigravidae and multigravidae.
Research Questions
The following Research Questions will be addressed:
- What are the expectations of primigravidae and multiparas as regards coping with pain?
- What are the impact of spousal support on childbirth expectations of primigravidae and multigravidae?
- What are the expectations of primigravid and multigravid women regarding midwives’ care?
- What are the expectations of primigravid and multigravid women regarding medical interventions?
- What are the expectations of primigravid and multigravid women regarding labour outcome?
- What factors influence the childbirth expectation of these mothers?
Hypothesis
- There is no significant difference in the childbirth expectation between the primigravidae and multigravidae.
- There is no significant difference in the child birth expectations of primigravidae and multigravidae across different educational level.
- There will be no significant age difference in childbirth expectations between primigravidae and multigravidae.
Significance of the Study
Findings from the study did reveal the childbirth expectations of pregnant women (both primigravidae and multigravidae) in Enugu State. When the findings are communicated with full evidence of what women expect during labour, the stake holders in health professions will be fully committed in contributing their quota by designing staff development program that will equip them towards reducing maternal mortality arising from failed childbirth expectations. The findings from the study will be useful in understanding the importance of expectation directed care which will lead to a good patient outcome and patient satisfaction. Findings from this study will also help healthcare professionals to appreciate the peculiarities of individuals thus helping to individualize care of clients. Information from this study will equally act as empirical reference for further studies. The result of the study will also add to literature for further research studies.
Scope of the Study
This study was confined to pregnant women attending antenatal clinic in UNTH, Ituku Ozalla, ESUT hospital and Poly Subdistrict Hospital, Asata, Enugu. The study was delimited to child birth expectations of primigravid and multigravid women and factors associated with it.
Operational Definition
The following definitions will assist the reader in clarifying terms and information used in the study.
Childbirth – Refers to the end of period of pregnancy with expulsion of one or more babies
Childbirth expectation– Refers to what a pregnant woman hopes will happen at the end of her pregnancy and labour as measured by childbirth expectation questionnaire.
Actual experience – What a pregnant woman eventually observes or sees occurring during labour.
Multigravid Women ( or multigravidae) – Refers to pregnant women who have had previous deliveries and reports at the antenatal clinic of ESUTH Teaching Hospital, UNTH Ituku Ozalla and Poly Sub-district Hospital.
Primigravidae Women – Refers to women who are pregnant for the first time who reports to Antenatal Clinic at ESUTH Teaching Hospital, UNTH Ituku Ozalla, and Poly Sub-district Health facilities.
Medical intervention – Refers to any assistance by the doctors or midwives regarding the use of machines, drugs and instruments to enhance labour outcome.