الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Egypt showed liberal escalation in CD rate (51.8%) as a part of the global progressive rise above the WHO recommended threshold for CS (15%) with no evidence of benefit for the mother or neonate.
When CS rise was studied it revealed a multi-faceted problem. Primarily, the pregnant women’s decision-making process based on her knowledge and information gained from surrounding family and friends previous experiences. This helped fear of childbirth, labor pains and safety to evolve; imprinting women’s perception of benefits and risks for each mode of delivery. Subsequently, the misperceptions helped the emergence CDMR; that was incriminated for CS rise.
Secondly, the obstetrician / physician was recognized as having an influence in choosing CD either based on an emerging medical indication or rationalized by the obstetrician’s personal preferences or tendencies. Although obstetricians acknowledged the women’s right to demand a CD and considered it part of the patient autonomy and rights, some physicians could seek increased financial profit, scheduling convenience for the operating time and place and the fewer surgical complications provided by CD.
Despite the importance of the issue there is limited knowledge and research on women perceptions and how they make decisions regarding the mode of delivery in Egypt and the Middle East in general.
The aim of this study was to identify pregnant women’s perceived risks of vaginal and cesarean deliveries before and after delivery versus literature-reported risks to detect accuracy of perceptions, in addition to assessing maternal satisfaction with the mode of delivery.
Study design: A cross sectional study and a follow up study.
Study setting:Family Health Units and Centers in each of the 8 health districts in Alexandria governoratewere represented by one center/ unit with the highest birth rate.
Study population: Three hundredpregnant women attending the aforementioned settings for antenatal care (ANC) visits at 37-40 weeks of pregnancy.
Inclusion criteria:Pregnant women during 37th – 40th week of gestation, nulliparous, with singleton pregnancy and cephalic presentation, low risk, regular attendance, and planning to deliver in Alexandria.
Sampling: The minimal required sample size was estimated to be 277 pregnant women based on detecting change in perceptions of abdominal adhesions before and after delivery (minimum change) = 3 point- width effect size for change = 0.15.The sample was rounded to 300eligible pregnant women to avoid loss to follow up effect. Using the proportional allocation method, the estimated sample sizewas distributed based on the number of births in the catchment area of the unit or center.
Data collection:Women were asked to complete the questionnaire through an interview. The interview was conducted using 2 structured interviewing questionnaires. They were re-interviewed after 1 week of delivery during a postnatal visit.
The two questionnaires (before and after delivery) were used in the present study (Appendix I and II), covering the following areas:
I. The first interviewing questionnaire (Before delivery):
1. Personal and demographic data.
2. Reproductive profile data.
3. Preference and decision of delivery.
4. Multidimensional Health Locus of Control.
5. Perceived risks of health outcomes of VD and CD before experiencing child birth.
II. The second interviewing questionnaire (After delivery):
1. Parturition data.
2. Perceived risks of health outcomes of VD and CD after experiencing child birth.
3. Actual delivery outcomes.
4. Maternal satisfaction.
The main results of this study could be summarized as follows:
1. The present study revealed a high CD rate of 60%. from the total CD women, “Maternally requested” CD constituted a small portion (10%), while CDsdecided by “Obstetrician with no clear reported indication” constituted 40%of the total CD.
2. Vaginal delivery was the most commonly preferred and decided mode before delivery. Rapid recovery (74.3%), and fear of anesthesia and operation rooms (65%) were the most frequently reported benefits. However, 59.2% switched their decision from VD and actually delivered by CS due to an emerging indication that was mainly reported as cephalopelvic disproportion (31.1%).
3. The highly reported perceived benefits of CS were avoiding labor pains (98.1%), avoiding episiotomy (77.8%) and being experienced by many of the women’s acquaintances without complications (59.3%).
4. The obstetricians/physicians were reported as the main influence for the pregnant mother as a source of information for pregnancy and delivery (82.3%), main source of encouragement for a certain mode of delivery (obstetricians were described as always encouraging CD by 40.7% and VD by 29%), as well as, the final decision maker at actual time of delivery (79%).
5. According to the Multidimensional Health Locus of Control (MHLC-C) used, the women’s dependency on their doctor/physician was the highest stated category by both groups (VD 88.8% and CD 91.4%).
6. Before delivery, high and very high-risk perceptions were associated with CD in: chronic abdominal pain (36.3%), wound infection (21%), limitation of daily activities (21%), negative impact on mental health (12.4%), abdominal adhesion (11.3%) and negative impact on breastfeeding (11.3%), while perineal pain was the only outcome perceived as a high or very high risk with VD (35%).
7. After delivery, risks perceived as “high or very high” increased significantly after delivery as chronic abdominal pain (66.1%), negative impact on mental health (54.4%) limitation of daily activities with CS (45.5%) and wound infection (45.0%). On the other hand, long term perineal pain (33.3%) and urinary incontinence (27.6%) were the risks that increased with VD.
8. Compared to literature reported risks, VD mothers accurately perceived dyspareunia (79.1%) and urinary incontinence (39.2 %) while they overestimated the risk of long term perineal pain (69.1%) and underestimated the risks of abdominal adhesions and the negative impact of breastfeeding (66.6% and 86.7% respectively).
9. CD mothers accurately perceived dyspareunia (65%) while they overestimated the risk of wound infection (65.6%) and chronic abdominal pain (82.2%) and underestimated the risks of abdominal adhesions and negative impact of breastfeeding (51.1% and 81.7% respectively).
10. Nearly two thirds of the sample had no maternal complications in both VD and CD (65.0% and 68.3% respectively). Neonates delivered vaginally were significantly free of complications compared with those delivered by CD (74.2% versus 58.3%). Moreover, neonatal jaundice was significantly higher in CD neonates (32.8%) compared to VD neonates (13.3%).
11. The VD mothers showed significantly higher general satisfaction with the mode of delivery than CD ones (88.4% and 73.3% respectively).
Based on these results the following is recommended:
1. The expectant mothers should make an “informed decision” based on the appropriate scientific information received from their physician.
2. Pre-delivery counselling of the different modes of delivery, their indications, steps and possible medical concerns of maternal and infant safety should be discussed followed by constructing a birth plan relying on the correct information received.
3. Obstetrician/Physician has the responsibility to evaluate the maternal medical condition and recommend a suitable mode of delivery. However, in absence of medical indications, physician autonomy entails giving the right to refuse to perform a CS when believed to be unnecessary and associated with risks as any surgical procedure.
4. Encouraging the presence of high standard trained “doulas” assisting in the vaginal birth process, supporting in the different stages of labor and keeping the obstetrician informed may help lowering the CS rates and increasing women’s satisfaction with their birth experience.
5. Raising the awareness through dissemination of reliable information through the media (television and internet) and planning a community based health educational programs and services concerned with pregnancy and delivery.
6. Implementation of labor management and CDMR guidelines in the main governmental hospitals, shouldbe assessed and followed by the obstetrics staff, in addition to active encouragement of a vaginal birth after cesarean (VBAC).
7. The use of electronic records and monitoring of rates and indications of CD in both governmental hospitals and family health centers.