Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-19T12:14:42.541Z Has data issue: false hasContentIssue false
  • English
  • Français

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan

Published online by Cambridge University Press:  08 October 2019

Zubia Mumtaz Open the ORCID record for Zubia Mumtaz [Opens in a new window] ,
Afshan Bhatti  and
Sarah Salway
Zubia Mumtaz*
Affiliation:
School of Public Health, University of Alberta, Edmonton, Canada
Afshan Bhatti
Affiliation:
Real Medicine Foundation Pakistan, Islamabad, Pakistan
Sarah Salway
Affiliation:
School of Health and Related Research, University of Sheffield, Sheffield, UK
*
*Corresponding author. Email: zubia.mumtaz@ualberta.ca
Get access Rights & Permissions [Opens in a new window]

Abstract

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan – Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient–provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

Keywords

Mistrust of C-sectionsUnnecessary C-sectionsUnder- and over-receipt of C-sections
Type
Research Article
Information
Journal of Biosocial Science , Volume 52 , Issue 4 , July 2020 , pp. 491 - 503
Copyright
© Cambridge University Press 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Angeja, AC, Washington, A, Vargas, JE, Gomez, R, Rojas, I and Caughey, AB (2006) Chilean women’s preferences regarding mode of delivery: which do they prefer and why? BJOG: An International Journal of Obstetrics & Gynaecology 113(11), 1253–1258.CrossRefGoogle Scholar
Atlas.ti Scientific Software Development GmbH (n.d.) ATLAS.ti: Atlasti Qualitative Data Analysis. URL: http://www.atlasti.com/product.html (accessed 30 July 2012).Google Scholar
Aziken, M, Omo-Aghoja, L and Okonofua, F (2007) Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta obstetricia et gynecologica Scandinavica 86(1), 42–47.CrossRefGoogle ScholarPubMed
Barros, AJ, Santos, IS, Matijasevich, A, Domingues, MR, Silveira, M, Barros, FC and Victora, CG (2011) Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off. Revista de saude publica 45(4), 635–643.CrossRefGoogle Scholar
Betrán, AP, Merialdi, M, Lauer, JA, Bing-Shun, W, Thomas, J, Van Look, P and Wagner, M. (2007) Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 21(2), 98–113.CrossRefGoogle ScholarPubMed
Borghi, JO, Ensor, T, Somanathan, A, Lissner, C, Mills, A and Lancet Maternal Survival Series Steering Group (2006) Mobilising financial resources for maternal health. The Lancet, 368(9545) 1457–1465.10.1016/S0140-6736(06)69383-5CrossRefGoogle ScholarPubMed
Campbell, M and Gregor, F (2002) Mapping Social Relations: A Primer in Doing Institutional Ethnography. University of Toronto Press.Google Scholar
Castro, A (1999) Commentary: increase in caesarean sections may reflect medical control not women’s choice. British Medical Journal 319(7222), 1401–1402.Google Scholar
Cecilia De Mello, E S (1994) C-sections as ideal births: the cultural constructions of beneficence and patients’ rights in Brazil. Cambridge Quarterly of Healthcare Ethics 3(3), 358–366.Google Scholar
Chatterjee, S and Laxminarayan, R (2013) Costs of surgical procedures in Indian hospitals. British Medical Journal Open 3(6), e002844.Google ScholarPubMed
Chigbu, CO and Iloabachie, GC (2007) The burden of caesarean section refusal in a developing country setting. BJOG: An International Journal of Obstetrics & Gynaecology 114(10), 1261–1265.CrossRefGoogle Scholar
CSS Forum (n.d.) All Pakistan Ranking of Districts by Literacy Rates and Illiterates. CSS Forum: Civil Service of Pakistan. Online at www.cssforum.com.pk/css-compulsory-subjects/pakistan-affairs/8805-literacy-rate-pakistan-district-wise.html (accessed 7 September 2018).Google Scholar
Dahlke, JD, Mendez-Figueroa, H, Rouse, DJ, Berghella, V, Baxter, JK and Chauhan, SP (2013) Evidence-based surgery for caesarean delivery: an updated systematic review. American Journal of Obstetrics and Gynecology 209(4), 294–306.CrossRefGoogle Scholar
Damschroder, LJ, Aron, DC, Keith, RE, Kirsh, SR, Alexander, JA and Lowery, JC (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 4(1), 50.CrossRefGoogle ScholarPubMed
Dekker, L, Houtzager, T, Kilume, O, Horogo, J, van Roosmalen, J and Nyamtema, AS (2018) Caesarean section audit to improve quality of care in a rural referral hospital in Tanzania. BMC Pregnancy and Childbirth 18(1), 164.CrossRefGoogle Scholar
Essendi, H, Mills, S and Fotso, JC (2011) Barriers to formal emergency obstetric care services’ utilization. Journal of Urban Health 88(2), 356–369.CrossRefGoogle ScholarPubMed
Fenwick, J, Gamble, J and Mawson, J (2003) Women’s experiences of Caesarean section and vaginal birth after Caesarian: A Birthrites initiative. International Journal of Nursing Practice 9(1), 10–17.CrossRefGoogle ScholarPubMed
FIGO (2019) New Guidelines for Caesarean Births. International Federation of Gynecology and Obstetrics, London, UK. URL: https://www.figo.org/news/new-guidelines-caesarean-births-0012240 (accessed 31 May 2019).Google Scholar
Gonen, R, Tamir, A and Degani, S (2002) Obstetricians’ opinions regarding patient choice in cesarean delivery. Obstetrics & Gynecology 99(4), 577–580.Google ScholarPubMed
Hammersley, M (1998) Reading Ethnographic Research: A Critical Guide. Longman, London and New York.Google Scholar
Islam, M and Yoshida, S (2009) Women are still deprived of access to lifesaving essential and emergency obstetric care. International Journal of Gynecology & Obstetrics 106(2), 120–124.CrossRefGoogle ScholarPubMed
Kabakyenga, JK, Östergren, PO, Emmelin, M, Kyomuhendo, P and Odberg Pettersson, K (2011) The pathway of obstructed labour as perceived by communities in south-western Uganda: a grounded theory study. Global Health Action 4(1), 8529.CrossRefGoogle ScholarPubMed
Kalish, RB, McCullough, L, Gupta, M, Thaler, HT and Chervenak, FA (2002) Intrapartum elective cesarean delivery: a previously unrecognized clinical entity. Obstetrics & Gynecology 103(6), 1137–1141.CrossRefGoogle Scholar
Koken, G, Cosar, E, Sahin, FK, Arioz, DT, Duman, Z and Aral, I (2007) Attitudes towards mode of delivery and cesarean on demand in Turkey. International Journal of Gynecology & Obstetrics 99(3), 233–235.CrossRefGoogle ScholarPubMed
Langer, A and Villar, J (2002) Promoting evidence based practice in maternal care: would keep the knife away. British Medical Journal 324(7343), 928.CrossRefGoogle Scholar
Liu, S, Liston, RM, Joseph, KS, Heaman, M, Sauve, R and Kramer, MS (2007) Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian Medical Association Journal 176(4), 455–460.CrossRefGoogle ScholarPubMed
Mayan, MJ (2009) Essentials of Qualitative Inquiry. Left Coast Press, Walnut Creek, US.Google Scholar
McGrath, P, Phillips, E and Vaughan, G (2010) Speaking out! Qualitative insights on the experience of mothers who wanted a vaginal birth after a birth by cesarean section. Patient 3(1), 25–32.CrossRefGoogle Scholar
Miller, S, Abalos, E, Chamillard, M, Ciapponi, A, Colaci, D, Comandé, D and Manuelli, V (2016) Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet 388(10056), 2176–2192.CrossRefGoogle ScholarPubMed
Molina, G, Weiser, TG, Lipsitz, SR, Esquivel, MM, Uribe-Leitz, T, Azad, T and Haynes, AB (2015) Relationship between cesarean delivery rate and maternal and neonatal mortality. Journal of the American Medical Association 314(21), 2263–2270.CrossRefGoogle ScholarPubMed
Mumtaz, Z, Levay, A, Jhangri, GS and Bhatti, A (2015) Coverage of private sector community midwife services in rural Punjab, Pakistan: development and demand. Health Research Policy and Systems 13(1), S51.CrossRefGoogle Scholar
Mumtaz, Z, Salway, S, Bhatti, A, Shanner, L, Zaman, S and Laing, L (2014) Improving maternal health in Pakistan: towards a deeper understanding of the social determinants of poor women’s access to maternal health services. American Journal of Public Health 104(S1), S17–S24.CrossRefGoogle Scholar
National Institute of Population Studies (2008) Pakistan DHS, 2006–07: Final Report. URL: https://dhsprogram.com/publications/publication-fr200-dhs-final-reports.cfm (accessed 7 July 2018).Google Scholar
National Institute of Population Studies (2014) Pakistan DHS, 2012–13: Final Report. URL: https://dhsprogram.com/publications/publication-fr290-dhs-final-reports.cfm (accessed 12 July 2018).Google Scholar
O’Dougherty, M (2013) Plot and irony in childbirth narratives of middle-class Brazilian women. Medical Anthropology Quarterly, 27(1), 43–62.CrossRefGoogle ScholarPubMed
Paxton, A, Bailey, P, Lobis, S and Fry, D (2006) Global patterns in availability of emergency obstetric care. International Journal of Gynaecology & Obstetrics 93(3), 300–307.CrossRefGoogle ScholarPubMed
Ronsmans, C, Holtz, S and Stanton, C (2006) Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet 368(9546), 1516–1523.CrossRefGoogle ScholarPubMed
Shoaib, T, Memon, S, Javed, I, Pario, S and Bhutta, SZ (2012) Decision-making and involvement of women with previous C-section in choosing their mode of delivery. Journal of the Pakistan Medical Association 62(10), 1038–1041.Google ScholarPubMed
Sivananthajothy, P and Mumtaz, Z (2018) Who makes the call? A critical interpretive synthesis of the literature on caesarean section decision-making. Master’s thesis, University of Alberta, Edmonton, Canada.Google Scholar
Stuckler, D and Basu, S (2009) The International Monetary Fund’s effects on global health: before and after the 2008 financial crisis. International Journal of Health Services 39(4), 771–781.CrossRefGoogle ScholarPubMed
Tuckett, AG (2005) Part II: rigour in qualitative research: complexities and solutions. Nurse Researcher 13(1), 29–42.CrossRefGoogle ScholarPubMed
Ugwu, NU and de Kok, B (2015) Socio-cultural factors, gender roles and religious ideologies contributing to Caesarian-section refusal in Nigeria. Reproductive Health 12(1), 70.CrossRefGoogle ScholarPubMed
Villar, J, Carroli, G and Gülmezoglu, AM (2001) The gap between evidence and practice in maternal healthcare. International Journal of Gynecology & Obstetrics 75(S1).CrossRefGoogle Scholar
Wax, JR, Cartin, A, Pinette, MG and Blackstone, J (2004) Patient choice cesarean: an evidence-based review. Obstetrical & Gynecological Survey 59(8), 601–616.CrossRefGoogle Scholar
World Bank (n.d.) Pakistan Demographic and Health Survey 1990–1991. URL: http://microdata.worldbank.org/index.php/catalog/1467 (accessed 20 April 2018).Google Scholar
World Health Organization (1985) Appropriate technology for birth. The Lancet 2, 436–437.Google Scholar
World Health Organization (2015) WHO Statement on Caesarean Section Rates. No. WHO/RHR/15.02. World Health Organization, Geneva.Google Scholar
World Health Organization (n.d.) Reproductive Health Library. URL: http://www.who.int/reproductivehealth/en/Google Scholar