Fear, guilt, and debt: An exploration of women’s experience and perception of cesarean birth in Burkina Faso, West Africa

International Journal of Women's Health, Volume 6 ., No. 1, Year 2014

Interpretation

Background: This paper explores women’s experience and perception of cesarean birth in Burkina Faso and its social and economic implications within the household. Methods: Five focus groups comprising mothers or pregnant women were conducted among residents of Bogodogo Health District in Ouagadougou to assess the perceptions of cesarean section (CS) by women in the community. In addition, 35 individual semistructured interviews were held at the homes of women who had just undergone CS in the referral hospital, and were conducted by an anthropologist and a midwife. Results: Home visits to women with CS identified common fears about the procedure, such as “once you have had a CS, you will always have to deliver by CS”. The central and recurring theme in the interviews was communication between patients and care providers, ie, women were often not informed of the imminence of CS in the delivery room. Information given by health care professionals was often either not explicit enough or not understood. The women received insufficient information about postoperative personal hygiene, diet, resumption of sexual activity, and contraception. Overall, analysis of the experiences of women who had undergone CS highlighted feelings of guilt in the aftermath of CS. Other concerns included the feeling of not being a “good mother” who can give birth normally, alongside concerns about needing a CS in future pregnancies, the high costs that this might incur for their households, general fatigue, and possible medical complications after surgery. Conclusion: Poor quality of care and the economic burden of CS place women in a multifaceted situation of vulnerability within the family. CS has a medical, emotional, social, and economic impact on poor African women that cannot be ignored. Managers of maternal health programs need to understand women’s perceptions of CS so as to overcome existing barriers to this life-saving procedure. © 2014 Richard et al. We conducted a qualitative study using focus groups and individual semistructured interviews (Supplementary material). This study was part of a larger multidisciplinary action research project (AQUASOU)22 aiming to improve the quality of and access to emergency obstetric care in the health district of Bogodogo, Burkina Faso. It was based on the coordination and synergy of three complementary approaches, ie, public health, social anthropology, and political and social mobilization. Bogodogo district is one of five districts in the Center Health Region and covers a population of approximately half a million people, of whom 67% are from rural areas. The district comprises 41 first-level facilities (public and private) which refer complicated cases to the district hospital. The district hospital in Bogodogo has 57 beds for pediatrics, surgery, medicine, maternity (24 beds), an outpatient clinic, a laboratory, and a medical imaging unit (radiography and ultrasound). The operating theater opened on August 1, 2003, but emergency obstetric surgery has only been possible for 24 hours on 7 days a week since October 1, 2004. Admissions to the maternity ward (operational since November 2001) have increased rapidly, doubling in number between 2002 and 2005 (from 2,053 to 4,182). In 2004, the hospital performed 193 CS versus 506 in 2005 and 735 in 2009. The interviews and focus groups were conducted 10 years ago when the hospital was increasing its CS offer but out-of-pocket expenditure was still high. No exemption system was in place in 2003 and 2004 to decrease the financial burden to the household. In 2005, the district initiated a cost-sharing system to decrease the direct household costs for a CS from 74.000 CFA (US$136) to 25.000 CFA (US$46). In late 2006, the government launched a national subsidy for delivery and emergency obstetric care so as to cover 80% of the direct costs, and the direct costs of CS were officially reduced to 11.000 CFA (US$22). These women’s views on CS can be considered as a baseline prior to introduction of the national subsidy. Given that some research teams are now evaluating the impact of exemption policies on the perception of CS in West Africa, this paper will allow comparison “before and after the introduction of an exemption policy for obstetric services”. A team of one anthropologist and one health provider (midwife or theater nurse) conducted home visits for patients who underwent a cesarean birth at Bogodogo District Hospital in Ouagadougou. Interviews started in September 2003 and continued until September 2004. A health care provider was added to the research team following a situational analysis conducted during the first year of the AQUASOU project that demonstrated a lack of health provider knowledge of patients’ social conditions.23 The objective of the home visits was two-fold: the first was to collect the women’s experience of cesarean birth and second to “open the eyes” of health care providers by observing the women’s living conditions and listening to their testimonies and individual perceptions of care. The expected outcome of the second objective was an improvement in relationships between health care providers and patients. This paper mainly focuses on the first objective. The majority of health care providers agreed to participate in the home visits. Ten of 15 midwives joined the team. Only the maternity ward staff took part initially, but operating theater personnel subsequently came on board. Thirty-five of 112 women who underwent CS in the operating theater between September 2003 and September 2004 were visited in their homes. One of the anthropologists proposed a home visit to the women before they left the facility, and most agreed after consultation with their husbands. The exact address of the household and (if applicable) a mobile phone number were then recorded by the researcher to ensure location of the home. Interviews were conducted in Moore (the national language) and written notes were taken by the interviewer. After each visit, a report was drafted in French by the interviewer and he/she was expected to provide feedback to his/her colleagues during a subsequent team meeting. In February 2004, five focus groups were conducted with women who attended various maternity wards in the Health District of Bogodogo (four urban facilities and one rural facility). These focus groups collected data to assess the perceptions of CS by women in the community. Home interviews were embedded in the action research and served as an exploratory phase to prepare for user-provider meetings in the second part of the project. Each group consisted of about 15 women, which allowed us to look into the subject in greater depth. The composition of the groups was determined during antenatal consultations in the four urban facilities and one rural facility. The activity was proposed to the women, and if they accepted, details, days, and hours of the discussion were given. The meetings were held outside the hospital in a public place. The objective of the focus group was two-fold. The first objective was to collect data on women’s perception of pregnancy, childbirth, and associated problems, including the different views on social support received during pregnancy, ie, who are the people involved in the financial expense of pregnancy and childbirth. The women were asked whether they were satisfied with the care they received and what they would like to see changed regarding access to and organization of the facilities they used. The existence and running of the district hospital’s operating theater was also discussed. The second objective was to secure input for the next step, which was organization of user-provider meetings to improve the quality of care. These focus groups allowed the project’s promoters to identify the main “touchy” or problematic issues from the women’s perspective to be discussed with the providers, eg, informal payment and lack of communication. Individual home visit interviews and discussions in the user focus groups were conducted in Moore (the national language), audio-recorded, and transcribed into the French language using Microsoft Word. A content analysis was undertaken manually according to the analysis methodology of qualitative data.24,25 No software was used. The authors first read all the interviews to identify the different themes, and each interview was then analyzed according to the themes identified during the first round of reading. The results were triangulated by the two social anthropologists (FO and SZ). Permission to perform the AQUASOU action research and its different nested studies was obtained from the Ministry of Health of Burkina Faso (MS/SG/DGSP/DSF/27.02.2002) and the Regional Directorate of the Health Center Region. Ethical regulations regarding participant consent and treatment of the data were followed according to the tenets of the Declaration of Helsinki.

AI Digest

Study Justification:

– The study explores women’s experience and perception of cesarean birth in Burkina Faso and its social and economic implications within the household.
– It aims to understand the barriers and challenges faced by women in accessing and receiving quality care during cesarean birth.
– The study provides valuable insights into the impact of cesarean birth on women’s physical, emotional, social, and economic well-being.

Highlights:

– Home visits and focus groups were conducted to gather data from women who had undergone cesarean birth.
– Common fears and concerns about cesarean birth were identified, including the perception that once a woman has a cesarean birth, she will always have to deliver by cesarean.
– Communication between patients and care providers was found to be lacking, leading to insufficient information about postoperative care and potential complications.
– Women expressed feelings of guilt and concerns about being a “good mother” who can give birth normally.
– The economic burden of cesarean birth was highlighted, including the high costs incurred by households.
– The study emphasizes the need for improved quality of care and understanding of women’s perceptions to overcome barriers to cesarean birth.

Recommendations:

– Managers of maternal health programs should prioritize understanding women’s perceptions of cesarean birth and address the existing barriers.
– Improvements in communication between patients and care providers should be implemented to ensure women receive clear and comprehensive information about cesarean birth and postoperative care.
– Efforts should be made to reduce the economic burden of cesarean birth on households, such as implementing cost-sharing systems or subsidies for obstetric services.

Key Role Players:

– Health care providers: Midwives, theater nurses, and other medical professionals involved in cesarean birth and postoperative care.
– Anthropologists: Researchers who conducted home visits and focus groups to gather data and insights from women.
– Policy makers: Government officials and decision-makers responsible for implementing changes in maternal health programs and policies.

Cost Items for Planning Recommendations:

– Implementation of improved communication strategies: Training programs for health care providers, development of educational materials, and communication tools.
– Cost-sharing systems or subsidies for obstetric services: Funding for reducing the direct costs of cesarean birth for households.
– Research and evaluation: Funding for further research and evaluation of the impact of interventions and policies on women’s perceptions and access to cesarean birth.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study using focus groups and individual semistructured interviews. The study provides detailed information about the methods used and the results obtained. However, the evidence could be strengthened by including information about the sample size, the demographics of the participants, and any limitations of the study. Additionally, the abstract could benefit from a clearer statement of the research question and objectives. To improve the evidence, the authors could consider conducting a larger-scale quantitative study to validate the findings and provide more generalizable results.

Abstract

We conducted a qualitative study using focus groups and individual semistructured interviews (Supplementary material). This study was part of a larger multidisciplinary action research project (AQUASOU)22 aiming to improve the quality of and access to emergency obstetric care in the health district of Bogodogo, Burkina Faso. It was based on the coordination and synergy of three complementary approaches, ie, public health, social anthropology, and political and social mobilization. Bogodogo district is one of five districts in the Center Health Region and covers a population of approximately half a million people, of whom 67% are from rural areas. The district comprises 41 first-level facilities (public and private) which refer complicated cases to the district hospital. The district hospital in Bogodogo has 57 beds for pediatrics, surgery, medicine, maternity (24 beds), an outpatient clinic, a laboratory, and a medical imaging unit (radiography and ultrasound). The operating theater opened on August 1, 2003, but emergency obstetric surgery has only been possible for 24 hours on 7 days a week since October 1, 2004. Admissions to the maternity ward (operational since November 2001) have increased rapidly, doubling in number between 2002 and 2005 (from 2,053 to 4,182). In 2004, the hospital performed 193 CS versus 506 in 2005 and 735 in 2009. The interviews and focus groups were conducted 10 years ago when the hospital was increasing its CS offer but out-of-pocket expenditure was still high. No exemption system was in place in 2003 and 2004 to decrease the financial burden to the household. In 2005, the district initiated a cost-sharing system to decrease the direct household costs for a CS from 74.000 CFA (US$136) to 25.000 CFA (US$46). In late 2006, the government launched a national subsidy for delivery and emergency obstetric care so as to cover 80% of the direct costs, and the direct costs of CS were officially reduced to 11.000 CFA (US$22). These women’s views on CS can be considered as a baseline prior to introduction of the national subsidy. Given that some research teams are now evaluating the impact of exemption policies on the perception of CS in West Africa, this paper will allow comparison “before and after the introduction of an exemption policy for obstetric services”. A team of one anthropologist and one health provider (midwife or theater nurse) conducted home visits for patients who underwent a cesarean birth at Bogodogo District Hospital in Ouagadougou. Interviews started in September 2003 and continued until September 2004. A health care provider was added to the research team following a situational analysis conducted during the first year of the AQUASOU project that demonstrated a lack of health provider knowledge of patients’ social conditions.23 The objective of the home visits was two-fold: the first was to collect the women’s experience of cesarean birth and second to “open the eyes” of health care providers by observing the women’s living conditions and listening to their testimonies and individual perceptions of care. The expected outcome of the second objective was an improvement in relationships between health care providers and patients. This paper mainly focuses on the first objective. The majority of health care providers agreed to participate in the home visits. Ten of 15 midwives joined the team. Only the maternity ward staff took part initially, but operating theater personnel subsequently came on board. Thirty-five of 112 women who underwent CS in the operating theater between September 2003 and September 2004 were visited in their homes. One of the anthropologists proposed a home visit to the women before they left the facility, and most agreed after consultation with their husbands. The exact address of the household and (if applicable) a mobile phone number were then recorded by the researcher to ensure location of the home. Interviews were conducted in Moore (the national language) and written notes were taken by the interviewer. After each visit, a report was drafted in French by the interviewer and he/she was expected to provide feedback to his/her colleagues during a subsequent team meeting. In February 2004, five focus groups were conducted with women who attended various maternity wards in the Health District of Bogodogo (four urban facilities and one rural facility). These focus groups collected data to assess the perceptions of CS by women in the community. Home interviews were embedded in the action research and served as an exploratory phase to prepare for user-provider meetings in the second part of the project. Each group consisted of about 15 women, which allowed us to look into the subject in greater depth. The composition of the groups was determined during antenatal consultations in the four urban facilities and one rural facility. The activity was proposed to the women, and if they accepted, details, days, and hours of the discussion were given. The meetings were held outside the hospital in a public place. The objective of the focus group was two-fold. The first objective was to collect data on women’s perception of pregnancy, childbirth, and associated problems, including the different views on social support received during pregnancy, ie, who are the people involved in the financial expense of pregnancy and childbirth. The women were asked whether they were satisfied with the care they received and what they would like to see changed regarding access to and organization of the facilities they used. The existence and running of the district hospital’s operating theater was also discussed. The second objective was to secure input for the next step, which was organization of user-provider meetings to improve the quality of care. These focus groups allowed the project’s promoters to identify the main “touchy” or problematic issues from the women’s perspective to be discussed with the providers, eg, informal payment and lack of communication. Individual home visit interviews and discussions in the user focus groups were conducted in Moore (the national language), audio-recorded, and transcribed into the French language using Microsoft Word. A content analysis was undertaken manually according to the analysis methodology of qualitative data.24,25 No software was used. The authors first read all the interviews to identify the different themes, and each interview was then analyzed according to the themes identified during the first round of reading. The results were triangulated by the two social anthropologists (FO and SZ). Permission to perform the AQUASOU action research and its different nested studies was obtained from the Ministry of Health of Burkina Faso (MS/SG/DGSP/DSF/27.02.2002) and the Regional Directorate of the Health Center Region. Ethical regulations regarding participant consent and treatment of the data were followed according to the tenets of the Declaration of Helsinki.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health in Burkina Faso:

1. Improved communication between patients and healthcare providers: Ensuring that women are informed about the possibility of cesarean section (CS) in the delivery room and providing clear and explicit information about the procedure, postoperative care, and contraception can help address fears and misconceptions.

2. Enhanced training for healthcare providers: Providing additional training to healthcare providers, including midwives and theater nurses, on patient-centered care, cultural sensitivity, and understanding patients’ social conditions can improve the quality of care and strengthen relationships between providers and patients.

3. Introduction of exemption policies: Implementing exemption policies for obstetric services, similar to the national subsidy for delivery and emergency obstetric care, can help reduce the financial burden on households and increase access to CS for women who need it.

4. Community engagement and awareness campaigns: Conducting community engagement activities and awareness campaigns to educate women and their families about the importance of maternal health, the benefits and safety of CS when necessary, and the availability of improved healthcare services can help address stigma, fear, and guilt associated with CS.

5. Strengthening referral systems: Improving the referral system between first-level facilities and the district hospital can ensure timely access to emergency obstetric care, including CS, for women in need.

These innovations aim to address the social, economic, and communication barriers identified in the study and can contribute to improving access to maternal health in Burkina Faso.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health in Burkina Faso is to address the following issues:

1. Improve communication between patients and healthcare providers: Women in the study reported not being adequately informed about the possibility of a cesarean section (CS) during delivery. Healthcare professionals should ensure that women are fully informed about their options and the reasons for a CS, as well as provide clear and explicit information about the procedure and postoperative care.

2. Provide comprehensive information about postoperative care: Women in the study expressed a lack of information about postoperative personal hygiene, diet, resumption of sexual activity, and contraception. Healthcare providers should ensure that women receive thorough information and guidance on these topics to promote their overall well-being and recovery.

3. Address feelings of guilt and stigma associated with CS: Women in the study reported feeling guilty and inadequate as mothers after undergoing a CS. Maternal health programs should include counseling and support services to address these emotional concerns and promote positive self-perception among women who have had a CS.

4. Reduce the economic burden of CS: The study highlighted the high costs associated with CS, which can be a barrier to accessing this life-saving procedure. Maternal health programs should explore strategies to reduce the financial burden on households, such as implementing exemption policies or cost-sharing systems.

5. Enhance the quality of care: The study identified poor quality of care as a contributing factor to women’s vulnerability within the family. Maternal health programs should prioritize improving the quality of care provided during CS and ensure that healthcare providers are knowledgeable and sensitive to patients’ social conditions.

By addressing these recommendations, it is possible to improve access to maternal health and enhance the overall well-being of women in Burkina Faso.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Improve communication between patients and healthcare providers: Ensuring that women are well-informed about the procedures and potential outcomes of cesarean birth can help alleviate fears and concerns. This can be achieved through clear and explicit communication during antenatal consultations, delivery room discussions, and postoperative care instructions.

2. Enhance postoperative support and education: Providing comprehensive information about postoperative personal hygiene, diet, resumption of sexual activity, and contraception can help women recover more effectively and reduce anxiety about future pregnancies. This can be done through educational materials, counseling sessions, and follow-up visits.

3. Address financial barriers: The high costs associated with cesarean birth can be a significant barrier for women in accessing maternal health services. Implementing exemption policies or cost-sharing systems, as mentioned in the study, can help reduce the financial burden on households and improve access to cesarean birth.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of cesarean births, maternal mortality rates, satisfaction levels of women with the care received, and financial burden on households.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the perceptions and experiences of women regarding cesarean birth, communication with healthcare providers, postoperative care, and financial barriers.

3. Implement interventions: Introduce the recommended interventions, such as improving communication, enhancing postoperative support, and addressing financial barriers. Ensure that these interventions are implemented consistently and effectively.

4. Monitor and evaluate: Continuously monitor the impact of the interventions on the defined indicators. This can be done through surveys, interviews, and data collection from healthcare facilities. Evaluate the changes in access to maternal health services, including any improvements in women’s perceptions and experiences.

5. Analyze and compare data: Analyze the collected data to assess the impact of the interventions. Compare the baseline data with the post-intervention data to determine the effectiveness of the recommendations in improving access to maternal health.

6. Adjust and refine: Based on the findings, make any necessary adjustments or refinements to the interventions. This could involve further improving communication strategies, enhancing postoperative support programs, or modifying financial policies.

7. Repeat the process: Continuously repeat the monitoring, evaluation, and adjustment process to ensure ongoing improvement in access to maternal health services.

By following this methodology, researchers and policymakers can simulate the impact of the recommendations on improving access to maternal health and make informed decisions on implementing and scaling up effective interventions.

Author

Dima Health

Statistics:

Citations: 19

Identifiers:

DOI: 10.2147/IJWH.S54742

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Burkina Faso, Multi-Countries

Study Design:

Cross Sectional Study, Exploratory Study

Study Approach:

Qualitative

Participants Gender:

Female