Women’s perception of support and control during childbirth in the Gambia, a quantitative study on dignified facility-based intrapartum care

Background: In The Gambia, a woman faces 1 in 24-lifetime risk of maternal death due to pregnancy and childbirth, yet, only 57% of deliveries are conducted by skilled birth attendants. However, poor provider attitude has been identified as one of the contributing factors hampering the efforts of the government in improving access to skilled care during childbirth. This study, therefore, explored women’s perception of support and control during childbirth in The Gambia. Methods: A descriptive cross-sectional study was employed. A convenience sampling method was used to select participants in two regions in The Gambia. A sample size of 200 women who met the eligibility criteria was recruited after informed consent. The demographic-obstetric information sheet and the Support and Control in Birth scale (SCIB) were used to collect data. Data analysis was done using SPSS software version 23.0. Results: Women’s perceptions of support and control were low. External control 1.85 (SD ± 0.43) recorded the least perception compared to internal control 2.41 (SD ± 0.65) and perception of support 2.52 (SD ± 0.61). Participants reported the lowest perceptions in pain control, involvement in decision making, information sharing and the utilization of different position during birth. Women’s age (p <.001) and mode of delivery (p =.01), significantly predicted women's perception of internal control. Educational status (p =.02), mode of delivery (p =.04), place of delivery (p <.001) and perception of support (p <.001) significantly predicted women's perception of external control, whilst birth plan (p =.001), mode of delivery (p =.04), and perception of external control (p <.001) significantly predicted women's perception of support. Conclusion: This study concluded that an environment that promotes women feeling a sense of control and support during childbirth should be created in order to ensure a dignified intrapartum care in The Gambia. This can be achieved through effective training of skilled birth attendants on non-pharmacological pain management, effective communication with clients and promoting women's participation in decision-making regarding their care throughout the process of childbirth. A quantitative, cross-sectional descriptive approach was employed. Due to the limited time available and the lack of funding to conduct this study, convenience sampling was used to select the study areas and recruit participants, between August 2016 and September 2016, at three major health centers in Western and Lower River Regions in The Gambia. Western Region is located in the western part of The Gambia, with nearly 75% of the total population [14] and the highest number of deliveries (approximately 27,200 per year) [15]. Lower River Region which is in the southern part of the country has a population of 82,361 [14] and a number of about 2000 deliveries annually [15]. Based on the two stated objectives to this paper; (1) to assess women’s perception of support and control during childbirth; (2) to identify related factors influencing perceptions of support and control during childbirth, the researchers calculated a sample size that will achieve both the descriptive and inferential statistics needed to analyze the data. The researchers used a 95% confidence level, an estimated number of deliveries of 29,200 per year in Western and Lower River Regions [14, 15], an estimated confidence interval of 10% from a previous study on a similar population [16] and a 10% non-response rate. The minimum sample size required for the descriptive statistics was 165 participants. The G-power 3.1.9.2 was used to calculate the sample size for the inferential statistics using an F test, a linear multiple regression with fixed model and R2 increase, effect size of 0.2, alpha of 0.05, a power (1-β err prob) of 0.95, 9 predictors (all tested), and a 10% non-response rate. A minimum sample size of 140 participants was required. However, we recruited 200 participants in this study to ensure that all statistical analysis for the two research objectives required were achieved. The predictors used in this study included the independent variables (demographic and obstetric characteristics of participants). The operational definitions of these predictors are clearly stated in the research instrument section in this paper. Women between the ages of 18 and 35 years, with no medical or obstetric complication during pregnancy, were eligible to participate. They were also eligible if admitted for at least 3 h in a public major health facility in Western and Lower River Regions prior to delivery. Women with multiple pregnancies and those who delivered before arrival at the health facility were excluded. Ethics approval was obtained from The Gambia government and Medical Research Council ethics committee, reference number R016005. A demographic-obstetric questionnaire (Additional file 1) and the Support and Control in Birth (SCIB) scale (Additional file 2) were used to obtain participants’ information. The structured demographic-obstetric questionnaire was developed by the researcher based on evidence. That is, the variables that were included in the questionnaire such as age, education, place of delivery, marital status, parity, number of antenatal attendance and birth plan were selected based on similar studies [17–22]. Participants in this study were classified as either married or single. The married participant was classified as being in monogamous or polygamous families, and those not married were single, cohabitating, or widowed. Age of participants ranges from 18 to 35 years, participants ages were grouped as 24 years and below and 25 years and above. This age cut-off was based on a previous study by Aitken and colleagues [23]. Educated participants were those with primary education or above, and those uneducated have no formal education. The parity of participants’ ranges from 1 to 4, primiparous were participants who have given birth for the first time and multiparous were those having given birth two or more times. Birth planning is one of the components of antenatal care in The Gambia and in this study, a participant who had a birth plan is one who was educated on a birth preparedness plan and complication readiness in one or more antenatal visits during pregnancy. Participants ethnicities in this study are those found in The Gambia [14]. The Support and Control in Birth (SCIB) scale was developed by Ford et al. [22]. It is a 33-item scale with three subscales, namely; internal control, external control, and support. Internal control subscale assessed participants’ ability to control oneself during childbirth including events such as pain, emotion, behavior, physical functioning and thoughts through their own efforts. The external control subscale assessed participants’ control over events being controlled by external forces such as pain relief (comfort measures or analgesic), information, environment, decisions and procedures, and birth outcome. The support subscale assessed coaching, coping techniques, staff attitude, empathy, understanding and reassurance, encouragement, listening to women’s wishes, informational support, and physical support for pain relief. The SCIB scale is a 5-point Likert scale with responses ranging from completely agree to completely disagree, the middle number (3) representing neither agree nor disagree. The 5-point response scale ranges from 1 to 5, with high scores indicating more support or control, low scores indicating less support or control, and a score of 3 indicating an average support or control. Negative items in the scale were reversed scored. The scale has an overall Cronbach’s alpha coefficient of 0.95, internal subscale (0.86), external subscale (0.93) and the support subscale (0.93) [22]. It was tested by Ford et al. (2009) and the psychometric properties were compared well with other published scale of the same field, notably, the Labour Agentry Scale [22]. Similarly, the scale was used by Inci, Gokce, and Tanhan (2015), to develop and validate a Turkish version of the SCIB scale, which was concluded to be reliable and valid with an internal consistency coefficient of 0.86 [24]. All the variables explained in the subscales are incorporated in the health system of the Gambia as per WHO standard. However, as a result of the difference in demography and culture, the SCIB scale was adapted and it was pretested to ensure consistency. The Cronbach’s alpha for the total scale was 0.78, internal control subscale was 0.78, external control subscale was 0.75 and support subscale was 0.81. The Cronbach’s alpha in this study is lower compared to a study conducted in the United Kingdom, to measure maternal perception of support and control during childbirth [22]. The inter-items correlation indicated an increase in the Cronbach’s Alpha if items such as “I was overcome by the pain” and “I gained control by working with my body” in the internal control subscale and “I could get up and move around as much as I wanted” in the external control subscale, were deleted. There was no irrelevant item in the support subscale. Cultural beliefs and demography of participants may be responsible for the difference in the Cronbach’s Alpha of the two studies. In each health facility, participants admitted more than 3 h post- delivery in the postnatal ward for observation, and who met the eligibility criteria and signed the consent form, were invited to participate. As a result of the low literacy rate among women in The Gambia, the questionnaires were administered to the eligible participants that were in the ward at the time of data collection and are willing to participate using the face-to-face interview. SPSS statistical software version 23.0 was used to analyze the data. Frequency distributions, mean and standard deviation were used to analyze participants’ demographic-obstetric characteristics and perceptions of support and control during childbirth. As a result of the non-normal data, non-parametric tests such as Mann-Whitney U test, Kruskal-Wallis H test and Spearman’s rho correlation were used to compare difference in participants’ demographic-obstetric characteristics and perceptions of support and control during childbirth, and relationship between perceptions of support and control during childbirth. Linear multiple regression was used to analyze participants’ demographic-obstetric characteristics predicting perceptions of support and control during childbirth.