Childbirth In a Medical Environment: Attitudes and Practices of Urban Women in the Municipality of Yopougon/ Côte D’ivoire / West Africa
Touré Ecra A1, Konan Blé R1, Edi M1, Koffi Koffi A2, and Konan P3
1Yopougon Attié General Hospital
2Urban community health center of Wassakara
3Abobo General Hospital, Côte d’Ivoire
Submission: January 23, 2023; Published: January 30, 2023
*Corresponding author: A Touré-Ecra, Yopougon Attié General Hospital, Côte d’Ivoire
How to cite this article: A Touré-Ecra. Childbirth In a Medical Environment: Attitudes and Practices of Urban Women in the Municipality of Yopougon/ Côte D’ivoire / West Africa. J Gynecol Women’s Health 2023: 24(4): 556144. DOI: 10.19080/JGWH.2023.24.556144
Summary
Introduction: Developing countries are characterized by a high maternal mortality rate. This situation is multifactorial, and many of these factors figure prominently, pregnancy monitoring but also childbirth management. The author describes in this work the characteristics of 4081 parturients who carried out all the labor without any medical supervision.
Results: 14% of women giving birth had had a job without medical supervision. the study population has an average age of 30 years with 12% of teenagers. the number of previous deliveries was 1 and they had had an average of 4 prenatal consultations.
Conclusion: Even if access to a medical center can sometimes be difficult, the practices of the parturients and especially their relatives can help to explain this lack of medical supervision.
Keywords: Labor- medical supervision-developing countries
Introduction
We cannot reflect on women’s health problems without addressing adressing pregnancy and childbirth issues, especially in developing countries. In Africa, motherhood plays a key role in society. Unfortunately, these regions of the globe are also characterized by the highest mortality rates. Maternal mortality is defined as the death of a woman during her pregnancy, during childbirth or in the 6 weeks following it from a cause related to her pregnancy or aggravated by pregnancy.
Côte d’Ivoire, a country in West Africa, although it has seen a considerable drop in its maternal mortality rate (from 614 deaths per 100,000 live births over the last decade to 314 in 2021) from due to the implementation of health programs by the ministry and learned societies responsible for maternal health, the fact remains that mortality remains high. The first cause of this maternal mortality remains postpartum hemorrhage in almost all countries, even in developed countries.
An aggravating factor of this mortality is the cultural conception of childbirth: the woman must not only give birth in pain, but especially by vaginal delivery which consecrates the femininity of the woman. Caesarean section, therefore, is still perceived as a weakness, an insufficiency of femininity. In addition, the numerical overload of labor rooms with insufficient staff makes the hospital unattractive for parturients.
The Yopougon maternity hospital was closed to the public for two years for the purpose of refurbishing the premises. It has reopened since April 2022. It is a neighborhood maternity hospital which is very popular with the inhabitants of the neighborhood, and also because of its renovation, it is a clean and pleasant place for the populations. The crowd is high with an average of 25 deliveries per day.
We wanted to evaluate the attitude of parturients towards medicalized childbirth in this context of “technical renewal” in one of the largest municipalities of Côte d’Ivoire.
Methodology
The study involved 4,081 deliveries recorded at the maternity ward of Yopougon General Hospital from May 1 to November 30, 2022, i.e. a period of 7 months.
Were included in the study all the parturients who arrived at complete dilation of the cervix or in the expulsive phase i.e at the last stage of the labour.
Non-inclusion criteria:
a) Home deliveries
b) Labor performed under medical supervision in the delivery room
Exclusion criteria:
a) Patients whose data have not been found (Figure 1-5).
Discussion
Epidemiology
A high birth rate: The maternity of Yopougon Attie was closed to the public for two years due to rehabilitation. It was a neighborhood maternity where most of the locals were born. When it opened, it became a second level hospital according to the health scale of Côte d’Ivoire. Because of its location in the largest municipality of Abidjan, its novelty and its history with the populations, it is popular. In seven months, there were 4,166 deliveries, an average of 595 deliveries per month and 20 per day.
Côte d’Ivoire is a developing country, therefore with a high birth rate: the gross birth rate in 2022 in Côte d’Ivoire is 33.5% according to the World Data Atlas; the gross birth rate is the number of live births during the year, per 1000 inhabitants; it is estimated in the middle of the year. This fertility rate is 4.3 children per woman according to data from the last general census of the population conducted in 2021.
Between 1990 and 2014, the global rate of assisted deliveries was estimated between 59 and 71%; this contributed to reduce maternal mortality by 45% for the same period (2015 Report, MDGs). Despite this progress, maternal mortality remains high in sub-Saharan Africa and one in two women does not give birth in a hospital, particularly in the Sahel [1].
Age and Parity
Ivorian population remains very young because, according to population census data, 75.6% are under 35 years old. The average age of our study population is 30 years, with a maximum of 47 years (figure 3). This late age at birth is the consequence of the conception of fertility in Africa. Childbirth is rewarding, and it is often menopause that marks the end of motherhood. Teenage pregnancies are a real public health problem in Côte d’Ivoire. For the 2012-2013 school year alone, there were 5,076 early pregnancies. These pregnancies constitute a real social drama insofar as they are the frequent cause of dropping out of school, of rejection by the family [2].
These teenagers represent 12% of our sample with extremes ages at 14 et 47 years old (figure 3). This labour out of hospital in these cases is either the consequence of a pregnancy which has been hidden from the parents (these often arrive at gynecological emergencies for pelvialgia and they will be told at the hospital about their daughter pregnancy), or the consequence of an subestimation of the duration of labor by the family. About a third of our study population is nulliparous; one can imagine that the patients did not recognize the labor pains in time and were surprised by the progress of the labor. But considering the sociocultural environment of the primipara in Africa, it’s almost certain that primipara are supervised from the end of the pregnancy by their mother or more experienced women. Ignorance of the labour pains is therefore unlikely. It is therefore necessary to mention an error in the estimation of labor progress among these primiparas; indeed, the primipara is known to have a long labor even in the secular environment. While these hypotheses can be advanced for labor conditions in adolescents and nulliparous women, they cannot be valid for adult women (88%) and for those who have given birth at least once (70%) (figure 5). It is therefore judicious to evoke the perception of childbirth in maternity by the populations: the concept of obstetrical violence which is an emerging concept [3].
The time spent in the delivery room deemed too long, away from the family, in these moments when family warmth is essential, a situation that also fits into the concept of obstetrical violence; from the above , one can understand that parturients looks for ways and means to shorten the time spent in the maternity ward, and sometimes , they even avoid hospital [3] The highest proportion of the country’s urban population lives in Abidjan, yet culture still has a very strong influence on people’s behavior. This is how they will use oxytocics from the traditional pharmacopoeia, which will have the effect of hastening labor.
More than half of our study population has at least three children; but the mode which designates the most frequent parity is primiparous; we can therefore relate primiparous to nulliparous who may have a long labor or who do not have much experience in recognizing uterine contractions. It’s important to mention the case of 27% (161/ 588) of these patients who were evacuated from peripherals medical centers; Once the need to evacuate has been explained to the family, in practice, certain factors will delay the patient’s access to her final place of delivery:
a. traffic jams
b. lack of ambulance availability
c. last turn at home to try traditional medication
d. This delay can justify that patients reach the hospital when the cervix is fully dilated.
Prenatal and Delivery Care
Patients are however informed of the evolution of the pregnancy and the warnings symptoms [4]. In a study carried out in Côte d’Ivoire in 2009, there were 17% home births [5]. Among these patients, 38.5% had made a deliberate choice of their place of delivery; however, it should be noted that among these patients, 10% had given birth in a public transportation towards the maternity. 94% of patients had gone to the maternity after delivery, which shows the interest of mothers for the well-being of the newborn; but the need to establish administrative documents also explains that even those who have made the deliberate choice to give birth at home go to the maternity after delivery in order to obtain those documents.
A study is interesting insofar as it was conducted in the same municipality of Abidjan. The majority of our patients had between 3 and 6 prenatal visits. This number is below the 2016 WHO recommendations which recommends 8 prenatal visits during pregnancy to lower the maternal mortality rate. The average of prenatal visits was 3.9 with a mode of 3 (figure 4); whereas in the study conducted by Bénié, the average was 2.89 for a standard at the time of 4 prenatal visits according to the WHO.
In our department for the study period, 77 births (2%) took place at home (Figure 2). It is certainly an obvious positive evolution of practices compared to 2009, but the renovation of the maternity as described earlier can explain this enthusiasm for giving birth in the maternity. If we add the patients whose labor took place entirely outside a health service to the patients who gave birth at home, we have 16% of the patients who had an unassisted labor, 84% having had a childbirth in hospital. This rate is stable given the figures for Bénié, which had 83% of deliveries in the maternity ward.
This constancy of rates has both institutional and social causes: obstetrical violence, which are attitudes and practices considered to undermine the psychological well-being of women during pregnancy and labor.
[6]. This type of violence is perceived by women in all countries, whether they are from the North or the South, whatever the intellectual and social level.
Conclusion
Death is a drama that still revolves around a happy event which is the birth of a child. The millennium goals are to reduce the mortality rate, especially in developing countries where this health indicator represents a health emergency. The obstetrical violence to which pregnant women feel subjected alters the quality of the patient-doctor relationship particularly in Africa where the doctors are powerful. The cultural perception of pregnancy and childbirth still encourages many pregnant women to seek secondline medical care. In this context, it will be difficult to reduce maternal mortality without an in-depth analysis of this obstetrical violence.
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