Assessing The Impact Of Preference For Vaginal Birth On Neonatal Mortality Rate In Nigeria

Running head: VAGINAL BIRTH AND NEONATAL MORTALITY 1

Assessing the Impact of Preference for Vaginal Birth on Neonatal Mortality Rate in Nigeria

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VAGINAL BIRTH AND NEONATAL MORTALITY 2

Table of Contents

Table of Contents ............................................................................................................................ 2

List of Figures and Tables............................................................................................................... 5

Abstract ........................................................................................................................................... 6

Chapter One: Introduction .............................................................................................................. 7

1.1. Background of the Study .................................................................................................. 7

1.2. Statement of the Problem ................................................................................................. 9

1.3. Rationale of the Study .................................................................................................... 10

1.4. Study Objectives ............................................................................................................ 10

1.5. Research Questions ........................................................................................................ 11

1.6. Significance of the Study ............................................................................................... 11

1.7. Study Assumptions and Delimitations ........................................................................... 12

1.8. Working Definition of Key Terms ................................................................................. 13

Chapter Two: Literature Review .................................................................................................. 13

2.1. Overview of the Chapter .................................................................................................... 13

2.2. Theoretical/Conceptual Framework ................................................................................... 14

2.2.1 Theoretical Framework ................................................................................................ 14

2.2.2. Conceptual Framework ............................................................................................... 17

2.3. Factors Influencing Preference for Vaginal Delivery ........................................................ 18

2.4. Risks Factors and Challenges in Vaginal Delivery............................................................ 19

2.5. Factors Influencing Preference for Caesarian Delivery ..................................................... 21

2.6. Mandatory Factors Necessitating Caesarian Section ......................................................... 22

2.7. Relationship between Delivery Mode and Infant Mortality Rates .................................... 23

VAGINAL BIRTH AND NEONATAL MORTALITY 3

2.8. Measures for Reducing Infant Mortality Rates at Delivery Level ..................................... 25

2.9. Summary of the Literature Review and the Research Gap ................................................ 26

Chapter Three: Methodology ........................................................................................................ 27

3.1. Introduction of the Chapter ................................................................................................ 27

3.2. Research Design................................................................................................................. 27

3.3. Research Philosophy .......................................................................................................... 28

3.4. Population and Recruitment ............................................................................................... 29

3.4.1 Study Setting ................................................................................................................ 29

3.4.2. Study Population ......................................................................................................... 30

3.4.3 Sample Size .................................................................................................................. 31

3.4.4. Sampling Technique ................................................................................................... 31

3.5. Study Instruments/Tools .................................................................................................... 32

3.6. Data Collection Procedure ................................................................................................. 33

3.7. Data Analysis Approaches ................................................................................................. 34

3.8. Ethical Considerations ....................................................................................................... 34

Chapter Four: Findings ................................................................................................................. 35

4.1. Overview of the Study Demographic Findings ................................................................. 35

4.2. The Factors Influencing the Preference for Vaginal Delivery in Nigeria .......................... 41

4.3. The Factors Influencing Effectiveness of Vaginal Delivery in Nigeria ............................ 46

4.4. How Vaginal Delivery Preference Influence Neonatal Mortality Rates in Nigeria .......... 47

Chapter Five: Discussion .............................................................................................................. 49

5.1. The Factors Influencing the Preference for Vaginal Delivery in Nigeria .......................... 49

5.3. The Factors Influencing Effectiveness of Vaginal Delivery in Nigeria ............................ 51

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5.4. How Vaginal Delivery Preference Influence Neonatal Mortality Rates in Nigeria .......... 53

5.5. Study Limitations ............................................................................................................... 54

5.6. Study Implications ............................................................................................................. 55

Chapter Six: Conclusion and Recommendations .......................................................................... 55

6.1 Conclusion .......................................................................................................................... 55

6.2. Recommendations .............................................................................................................. 56

References ..................................................................................................................................... 57

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List of Figures and Tables

Figure I: Diagram Illustration of Theory of Reason Action ____________________________ 15

Figure II: Diagram Illustrating Theory of Choice ___________________________________ 16

Figure III: Conceptual Framework _______________________________________________ 17

Figure IV: Google Map Locating Imo State University Teaching Hospital ________________ 30

Figure 4a: Age Distribution ____________________________________________________ 36

Figure 4b: Level of Education __________________________________________________ 37

Figure 4c: Marital Status _______________________________________________________ 38

Figure 4d: Respondents State in Nigeria __________________________________________ 38

Figure 4e: Respondents’ Occupation _____________________________________________ 39

Figure 4f: Gravida series _______________________________________________________ 40

Figure 4g: Respondents Preference for Vaginal Delivery _____________________________ 41

Figure 4h: Vaginal Birth Riskier than CS in Neonatal Mortality ________________________ 42

Figure 4i: Respondents Ruling out CS to Deliver Vaginally ___________________________ 43

Figure 4k: Factors Influencing Vaginal Delivery ____________________________________ 44

Figure 4L: Bivariate Correlation of Demographic Factors and Preference for SVD _________ 45

Table 1: Emerging Themes and Support on Factor Hindering Selection of SVD ___________ 46

Figure 4m: Number of Neonatal Death per Pregnancy Series __________________________ 47

Figure 4n: Delivery Mode ______________________________________________________ 48

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Abstract

Purpose: The study purposed to evaluate the impact of preference of vaginal birth on neonatal

mortality in Nigeria.

Background: Nigeria ranks second worldwide among countries with high neonatal mortality

rates. While other countries are making tremendous efforts towards addressing this challenge,

Nigeria seems to be at standstill. Most (74%) of the deliveries in Nigeria are conducted

vaginally; thus, there is need to assess the link between mode of delivery and neonatal deaths.

Methods: This was a cross-sectional study conducted in one of the state hospitals in Nigeria

involving 300 mothers aged between 18 – 40 years. The study assembled qualitative and

quantitative data using a structured questionnaire. Major factors contributing to preference for

vaginal delivery included past deliveries (38%, n = 114), knowledge of the birth options (30.7%,

n = 92) and family members (22.3%, n = 76), cultural beliefs (5%) and religion (4%).

Results: All the 300 mothers included completed their questionnaires, which were analyzed

using SPSS software and thematic analysis for quantitative and qualitative data respectively.

94% of the mothers preferred vaginal delivery.

Conclusion: The study concludes that there are factors impeding on effective vaginal delivery

contributing to neonatal mortality in Nigeria. It is these factors such as home deliveries,

difficulty accessing hospitals on time, query competence of midwife, and maternal preparedness,

and not vaginal birth per se that risks increased rates of neonatal mortality rates. Future studies

should focus on how these factors affect quality of vaginal births.

Keywords: Caesarian Delivery, Infant, Neonatal mortality, Neonate, Sub-Saharan Region,

Vaginal Birth

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Chapter One: Introduction

1.1. Background of the Study

Preventing and reducing preventable deaths has remained a matter of public health

concern for many years across the globe. The World Health Organization (WHO) and the United

Nations (UN) agree on the vitality to contain the worrying mortality rates among children with

the concern being well illustrated by the establishment of Millennium Development Goals,

number 4, which sought to have countries reduce the under-five mortality rate by 66% before

2015 (WHO, 2017). One of the objectives under this goal was to check on neonatal mortality

rates. The renewed global strategy – Sustainable Development Goals, a move by the UN, also

seeks to control neonatal deaths by setting a target of as low as 12 per 1000 neonates (WHO,

2015). According to Lawn et al., 2012, neonatal deaths, which refers to mortality of child within

first 28 days of life, accounts for roughly 40% of the under-five mortality cases globally. The

rates increase to 60% for deaths occurring within the first year of life (Ezeh et al. 2014). Between

2000 and 2010, the rate of neonatal death worldwide reduced by 2.1% compared to 2.9%

reduction witnessed with under-five deaths (Akinyemi, Bamgboye & Ayeni, 2015). The fact

remains that the highest contributor of the under-five deaths was neonatal deaths, which

increased by 7% to 44% from 1990 through 2013 (Akinyemi, Bamgboye & Ayeni, 2015).

Despite these rates of neonatal deaths reducing in some countries and regions, not all

areas are witnessing significant improvement. According to a statistics over 90% of these

neonatal deaths occur in low-and-middle income countries (Ezeh et al. 2014). African countries

fall in this category, with the Sub-Saharan region accounting for over 39% of all neonatal deaths

recorded in the world annually (Akinyemi, Bamgboye & Ayeni, 2015). The Sub-Saharan African

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region host 16 countries that top the list of countries leading in neonatal deaths as well as the

region recording the slowest decline in neonatal mortality rates at 2.7% (Dahiru, 2015).

Nigeria is one of the countries in the Sub-Saharan African countries. Globally, Nigeria

contributed to 13% of the global child mortality burden recorded in 2013 (Dahiru, 2015). The

country, Nigeria, is ranked second in terms of those leading with neonatal deaths after India

(Ezeh et al. 2014). Statistics indicate that every year, Nigeria losses close to 250000 neonates,

which may mean over 700 babies die before they are 28 days old (Ezeh et al. 2014). The rates of

neonatal mortality in Nigeria have dropped deplorable slow compared to other countries in the

Sub-Saharan countries, which increase the concerns for identifying the main contributing factors.

The rates dropped from 49 deaths in 1000 in 1990 to 39 in 2011 to 37 in 2013 to 34.3 in 2015

(Akinyemi, Bamgboye & Ayeni, 2015). The Nigerian government has stepped up measures to

address the issue of neonatal deaths, but there is still much that needs to be done in realizing a

significant decline in neonatal mortality rates.

The worrying rates of neonatal death have attracted significant interests among scholars

and interested agencies to seeking to unearth the main factors contributing to these rates, not only

in Nigeria but also in other countries. Among the factors that influence the rate of neonatal

mortality rates to include the social economic status of the mother, proximity to health care

centers, quality of antenatal care, nutritional health, maternal age, prematurity, and maternal

illness (Dahiru, 2015; Ezeh, 2017). These factors can be targeted to improve the survival rates

for children born in Nigeria. Child related factors contributing to the high rates of neonatal

deaths include neonatal tetanus, asphyxia, prematurity, septicemia and pneumonia (Akinyemi,

Bamgboye & Ayeni, 2015). Apart from these factors, there are many more factors which can

VAGINAL BIRTH AND NEONATAL MORTALITY 9

influence the rate of neonatal deaths. This study seeks to explore the role preference for mode of

delivery may have on the rates of neonatal deaths.

1.2.Statement of the Problem

According to a study by Ezechi, Loto, Ndububa et al., 2009, the mode of child delivery,

caesarean section, vaginal delivery, or vacuum delivery - can influence the survival rates of the

child. Data indicate that in Nigeria, most mothers deliver vaginally, spontaneous vaginal

delivery, which accounts for over 74% of all births (Daniel & Singh, 2016). However, the rates

do change in the urban areas, which are nearer to private hospitals, available physicians, and

relatively better economic status compared to those living in the rural areas (Bako, GEidam,

Sanusi, Mairiga & Isa, 2016). Statistics on neonatal deaths indicate that most of the reported

neonatal deaths are mostly from the rural areas. This understanding may lead to deducing that the

spontaneous vaginal delivery, not the caesarean section is more likely to result in increased risk

of neonatal death. A study by Dahiru, 2015, suggests that the rural areas in Nigeria are under

staffed with health staffs, they have few health centers, inhabitants are poor, the level of

education is low, and malnutrition issues are prominent compared to urban settlers. These factors

are supported by the literature to be key contributors influencing neonatal mortality rates. In

another study, caesarean section is argued to be more likely to cause maternal and child

morbidity compared to vaginal delivery (Daniel & Singh, 2016). Both modes of child deliveries

have their shortcomings and merits, and it is mostly the agreement between the patient and the

health staffs to decide which is the best approach considering maternal and child outcomes. The

purpose of this study is to explore the relationship between vaginal delivery and caesarean

section delivery on neonatal mortality rates.

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1.3. Rationale of the Study

The world and Nigeria for that matter incur heavy economic, social, and health

consequences following the increasing rates of neonatal deaths. There is every need for

coalescing multi-sectorial and professional efforts towards addressing neonatal deaths. To do

that, the factors contributing to the high rates of neonatal deaths must be identified for enabling

effective and feasible approaches to be implemented. The decision of the child delivery mode,

whether vaginally or caesarean section, is hypothesized to have a significant impact on the

outcome of the neonate's survival. Understanding the influence the mode of delivery has on

neonate survival can help inform the mothers and the health care providers on the best suitable

delivery mode they should go for at individual level based on client’s status and characteristics.

In addition, the factors related to delivery mode, which may contribute to neonatal deaths once

addressed can help towards reducing the rates of neonatal mortality rates in Nigeria. A

preventive approach will help the stakeholders reduce the associated costs and burden arising

from neonatal mortalities.

1.4. Study Objectives

The primary objective of this study was to assess the impact of preference for vaginal

birth on neonatal mortality rate in Nigeria. To achieve this broad objective, three specific

objectives crafted from the main primary objectives were established, which include;

a. To determine the factors influencing the preference for vaginal delivery in Nigeria

b. To determine the factors influencing effectiveness of vaginal delivery in Nigeria

c. To assess how vaginal delivery preference influence neonatal mortality rates in Nigeria

VAGINAL BIRTH AND NEONATAL MORTALITY 11

1.5. Research Questions

The research questions offer more guidance to the researcher by setting the research

breadth delimitations (Creswell 2013). The main research question for this study aims at

determining the implications of preference for vaginal delivery on neonatal mortality rates. The

specific questions include

a. What are the main factors influencing the preference for vaginal delivery in Nigeria?

b. What are the key factors influencing the effectiveness of vaginal delivery in Nigeria?

c. How does the vaginal delivery preference influence neonatal mortality rates in Nigeria?

1.6. Significance of the Study

According to Creswell, 2013, researches aim at addressing an identified gap or concern

with main objectives being to assert an existing policy or practice; offer criticism to current

practice, policy or belief; support new direction towards a practice or policy; or simply update

the existing literature. In meeting these goals, the researchers not only communicate their

perspectives but also get to grow intellectually in the process of completing the research.

Therefore, at the academic level, this study is quite significant since it is critical for successful

completion of the doctorate course the researcher is undertaking. From the policy point of view,

the study can play a significant role informing on the best approaches when it comes to advising

mothers on their choice of mode of delivery. The study may also be critical towards eliciting

further research interest in the area of preference for vaginal delivery over a caesarian section or

vice versa, and in matters to do with neonatal mortality. Such further or future studies are critical

in fine-tuning the existing policies and practices to help deliver the very best quality care

VAGINAL BIRTH AND NEONATAL MORTALITY 12

possible. Furthermore, this study may also be used to give directions on the current patients and

public perception regarding vaginal delivery and neonatal death. Such insights are profoundly

relevant in advancing the level of care to meet the expectations of the patient population. Lastly,

apart from the stated significances, this study will build on the existing literature regarding the

area of this study’s interests as well as add more knowledge on the matter to the researcher and

targeted audiences.

1.7. Study Assumptions and Delimitations

Simon, 2011, defines study assumptions as factors out of control of the researcher, but

very critical in enhancing the relevance of the study. Without the study assumptions, the research

is more likely to be irrelevant and unreliable. One of the assumptions for this study is that there

will be an adequate number of mothers willing to participate in this study. Secondly, the

participants are expected to offer honest and sincere responses to the highlighted questions for

purposes of gathering reliable and valid primary data. It is also assumed that the study will not be

influenced by ground changing phenomenon or events, which may upset the reality of the matter

under evaluation. Finally, the research assumes that the study will be completed as planned and

offer relevant deductions as per the findings.

Delimitations are the boundaries setting the scope of the study, which are mainly set by

the study objectives, study questions, study sample, and study setting. Unlike assumptions,

delimitations are in the researcher control (Leedy & Ormrod, 2010). For this study, the main

delimitations are that the study will major of preference for vaginal delivery, in Nigeria with

much focus on Imo region, and will target women who have delivered or gravid at the time of

the study.

VAGINAL BIRTH AND NEONATAL MORTALITY 13

1.8. Working Definition of Key Terms

a. Neonate: the definition for a neonate is not different from that given by Ezeh, 2017,

which refers to a neonate as a newborn aged below 28 days.

b. Neonatal mortality: neonatal mortality refers to the death of live births before they

reach 28 days of life (Ezeh, 2017).

c. Early neonatal mortality: Dahiru, 2015, describes the death of newborns within the

first 6 days of life. This definition will be adopted for purpose of this study.

d. Vaginal delivery/normal delivery in this study is equivalent to spontaneous vaginal

delivery, which describes the delivery of the baby via the birth canal successfully

without the use of vacuum evacuation or surgeries to extract the baby.

e. Delivery outcomes describe the indicators for both the mother and the baby in

respect to expectations child birth.

Chapter Two: Literature Review

2.1. Overview of the Chapter

This chapter seeks to consolidate evidence from the existing literature on the preference

of vaginal birth on neonatal mortality. By doing this, the researcher will manage to get to

familiarize with what other scholars have focused on regarding the area under investigation, and

identify the existing gap in the literature (Creswell, 2013). It is this gap that offers a solid

justification as to why this study is critical at the current moment. In so doing, the literature

review provides an up-to-date synthesis of the previous studies with their strengths and

weaknesses (Simon, 2011). This synthesis also inspires the researcher to identify the most

VAGINAL BIRTH AND NEONATAL MORTALITY 14

appropriate topic, themes, variables, and study method to be employed for the current study.

Indeed, this chapter was quite relevant in implicitly justifying the choice of the topic,

methodology, and study as a whole. In achieving the above-stated objectives of the literature

review chapter, the researcher organized the sections thematically to ensure key themes

regarding the study area were adequately covered. The section concludes with a summary of the

review and identification of the existing gap in the literature.

2.2. Theoretical/Conceptual Framework

2.2.1 Theoretical Framework

Theoretical and conceptual frameworks help put the study into perspective by guiding the

study process. The framework also enhances the understudying of the research and its

importance in the context of the application. Using the theoretical framework and the conceptual

framework – which is the diagrammatic representation of how the main variables interact or

relate – enables the audience to draw rationale, predictions, and comprehend the perspective and

direction of the study (Green, 2014). The research can be able to offer guidance by

systematically identifying logical and precise relationships among study variables (Green, 2014).

For this study, the theoretical framework is based on two main theories; the Theory of Reason

Action (TRA) and the Theory of Choice (TC). The first theory, TRA, was established by

developed by Fishbein Martin in collaboration with Icek Ajzen in the 1980s (Reyna, 2008). The

theory holds that behavior or decision is influenced mainly by attitude and norms. Furthermore, a

number of factors influence the attitude on behavior, thereby, dictating on the course of action.

Norms help regulate the attitude while attitude help reinforces norms. In persuading an

individual to make a decision or adopt a behavior, both the norms and the attitude must be

VAGINAL BIRTH AND NEONATAL MORTALITY 15

considered (Head & Noar, 2014). The diagrammatic representation of this theory is as illustrated

in Figure I below.

Figure I: Diagram Illustration of Theory of Reason Action

Source: Fishbein 2008.

The theory of choice is takes the decision making higher, especially when it comes to

making preferences in a situation where several options are available (McFadden, 2001). On top

of the subjective attitude an individual may have regarding an option, the theory of choice holds

that past influences and experiences in form of memories play a role to dictate the preferred

choice. The individual also ponders on information drawn from perceptions and beliefs mainly

influenced by the social norms towards the available options (McFadden, 2001; p.356). A

diagrammatic representation of this theory is as illustrated in Figure II below.

Beliefs about outcomes

of vaginal birth

Evaluation of the

outcomes

Normative beliefs about

the behavior

Motivation to comply

Subjective norms

Attitude towards

vaginal birth

Preferred Option

(Vaginal Birth)

VAGINAL BIRTH AND NEONATAL MORTALITY 16

Figure II: Diagram Illustrating Theory of Choice

Source: McFadden, 2001; p. 356.

The two theories are critical given that mothers may be needed to make a decision on

whether to deliver normally or opt for an elective caesarean section. Both options have their

merits and demerits as discussed in the subsequent section. In the first theory, the mothers’

attitude together with norms such as what the medical staff recommends will be significant in

their preference for vaginal birth over other choices. Using the theory of choice, the preference

will also be influenced by past experiences for those who have given birth before by either

vaginal birth or caesarean section. For the primigravida mothers, their preference is more likely

to be influenced by what they have heard, learned, or witnessed from others.

Experience

Information

Stated Preference

Attitude Scales

External influencers

e.g. time, money,

accessibility

Choice (Revealed

preference – vaginal

birth)

Attitudes

Stated Preferences

Preferences

Motivation/affect

Memory

Process

Perception/beliefs

VAGINAL BIRTH AND NEONATAL MORTALITY 17

2.2.2. Conceptual Framework

Drawing from the two theories and the topic of this study, the conceptual framework

guiding this study is as illustrated in figure III.

Figure III: Conceptual Framework

Source: Author

Mother Perspectives

Positive attitude, supportive

social norms, supportive

experience, and positive

beliefs

Negative of this result in

preference for another

option

Social Beliefs

Myths, hearsay,

cultural believes,

religious influence,

Preference for Vaginal Birth

Medical Advice

Supporting vaginal birth,

optional, or against it with

medical reasons

Maternal Outcomes

Considered

Rate of recovery, risk of

morbidity, risk of

mortality, access to the

baby, bonding concerns,

fear of the process

Baby Outcomes

Considered

Risks of harm, risk of

death, risk of

morbidity, ease of

starting to breastfeed,

Other Factors

Cost involved,

accessibility, staffing,

timing

VAGINAL BIRTH AND NEONATAL MORTALITY 18

2.3. Factors Influencing Preference for Vaginal Delivery

The term preference in health care and in this study describes the relative desirability of

health course based on the associated health-related outcome, process, or treatment choice

(Dirksen et al., 2013). In a cross sectional study by Loke, Davies & Li, 2015, that involved 319

women aged between 18-40 years, the factors influencing the preferences of delivery approach

were categorized into demographic factors, personal expectations factors, previous birth

experiences, medical advice, and foreseeable outcome for both mother and child. Using the

health belief model, the study discussed perceived susceptibility, severity, benefits, and barriers

as the pillars under which the decision to prefer one mode of delivery over the other was

founded. According to a descriptive study involving 840 women conducted by Yilmaz, Bal, Beji

& Uludag, 2013, the majority of the points highlighted as supporting the preference for vaginal

delivery inclined to misleads and fears. The examples the study identified being healthy, swift

postpartum recovery, being a natural process, enable early breastfeeding, no fear of surgery, and

safer for baby (Yilmaz, Bal, Beji & Uludag, 2013).

Rahmati-Najarkolaei et al. 2014, conducted a descriptive study involving 226 women

aimed at assessing the factors influencing delivery selection in Tehran. In their study, vaginal

delivery was preferred by 44.7% of the sample with the rest going for caesarean section delivery.

A number of reasons promoting a preference for vaginal delivery were highlighted including

safer approach, knowledge on benefits of vaginal birth, positive spiritual effects, fear of CS,

improved vaginal births reducing pain, recommendation by physicians, and association to better

child development. These findings were also evidenced in Shi et al, 2016, study conducted in

China and involved 977 women who responded to questionnaire assessing the factor influencing

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mode of birth. The highest percentage 53.8% preferred CS while vaginal delivery was favored by

just 46.2%. The reasons given for opting for vaginal delivery included fast recovery, natural

process, healthier baby, ease of breastfeeding, no scar, and less costly.

In another study evaluating the preference of birth delivery modes, Walana et al., 2017,

conducted a cross sectional study involving 499 women. In this study, 85% of those involved

preferred spontaneous vaginal delivery. The main reason behind this choice as stated in the study

included naturally safe, fewer complications, quick recovery, and following previous

experiences. These findings seem to contradict the preference rates reported in Shi et al, 2016

and Rahmati-Najarkolaei et al. 2014, where the preference for CS was higher than that of vaginal

delivery. In yet another study, Zamani-Alavijeh, 2017, assess a tool developed to help women

make informed and reason-based decision on the preferred mode of delivery. This study involved

342 low-risk pregnant women, and the findings supported the argument that mothers deserve to

consider more than just the hearsay and society beliefs; but rather ponder on the more factual

reasoning in determining their preferred mode of delivery.

2.4. Risks Factors and Challenges in Vaginal Delivery

A number of studies have assessed the risk factors and challenges associated with vaginal

delivery. On top of the risk as to why women would not prefer vaginal birth is the pain

experienced during child birth (Yilmaz, Bal, Beji & Uludag, 2013; Loke, Davies & Li, 2015).

The pain seemed to be a driving force for most women choosing CS, and according to Shi et al,

2016, it instills fear among the women. This perception of the excruciating pain is mainly fueled

by beliefs, fear, and experience created in the society by those who have witnessed or undertaken

vaginal delivery (Rahmati-Najarkolaei et al. 2014). However, Walana et al., 2017, argue that this

VAGINAL BIRTH AND NEONATAL MORTALITY 20

pain creates minimal inconveniences compared to the healing and scar left after caesarean

section delivery.

The second risk in vaginal delivery is as discussed by Gurol-Urganci et al., 2013, is

perineal tears and lacerations. According to Gurol-Urganci et al., 2013, perineal tears increased

in percentage among a study population of 1.03 million women conducted between 2000 and

2012. Factors increasing the rate of perineal tears include big babies, shoulder dystocia, brow

presentation, poor monitoring of the baby, and mother’s age past 25 years. In preventing perineal

tears or lacerations associated with vaginal delivery, the midwife must support the perineal and

give episiotomy where necessary (Wu, et al. 2013). Third to fourth-degree tears are likely to

complicate the situation resulting in fistulas, fecal incontinence, or urinary incontinence (Wu, et

al. 2013). These complications further put off mothers from choosing SVD.

Postpartum hemorrhage caused by atonic uterus and tears and laceration during vaginal

birth is also put SVD at high risk especially for mothers with clotting disorders, multiple

pregnancies, or delivered outside health facilities (Wetta et al., 2013). In their retrospective

cohort study, Buzahglo et al. 2015, identified that 0.8% of the SVD complicated to postpartum

hemorrhage, with main risk factors including post-term pregnancy, hypertension, labor dystocia,

and severe perineal, vaginal, or cervical tears. Poor child labor management, especially when

done at home or in poorly equipped rural facilities increases the risk of postpartum hemorrhage.

Buzahglo et al. 2015, point out that PPH is among the leading causes of maternal death; thus,

women who may have such data/information are likely to disfavor SVD for CS.

With the increased uterine activity, increase the risk of open blood vessels, and the high

strenuous process of child delivery, there are high risks of thromboembolism, which may cause

VAGINAL BIRTH AND NEONATAL MORTALITY 21

pulmonary embolism, stroke, and heart attack (Virkus et al. 2014). With these risks among

others, the preference for SVD may be negatively affected. However, this does not mean that CS

is free of complications and risk, but as Rahmati-Najarkolaei et al. 2014, put it, SVD is more

exposed to unprofessional handling than CS which can only take place in a hospital environment.

2.5. Factors Influencing Preference for Caesarian Delivery

Mainly, the disadvantages that make mother not to prefer vaginal delivery are the

supporting points as to why they prefer caesarean section delivery. In a study by Rahmati-

Najarkolaei et al., 2014, the leading motivation for those choosing CS delivery was the fear of

the pain and side effects associated with vaginal delivery accounting for 56.37%. Other stated

reasons in this study included the inability to deliver vaginally, medical advice against SVD,

knowledge of CS, previous CS delivery experience, and family decision. Shi et al., 2016, also

assessed the factors influencing the choice of delivery mode. In this study, most of the

participants (53.8%) preferred CS delivery over SVD on accounts of poor confidence in SVD

outcomes, medical reasons disqualifying possibilities of SVD, associated it with fewer risks,

associated CS with less pain, capability of setting specific time of birth, and less likely to affect

sexual life after birth.

Loke, Davies, and Li 2015 identified only 22.9% of the 319 women assessed preferred

CS over SVD. Caesarean section delivery was reported in this study to be more prone to risks,

severity, and with barriers such as cost, qualified personnel, and access to such facilities

complicating the process. The study argues that CS is commonly observed with the elite

populations delivering in the private centers. Walana et al., 2017, also investigated the factors

influencing delivery mode and only 3% of the 499 women involved preferred to have an elective

VAGINAL BIRTH AND NEONATAL MORTALITY 22

caesarean section. Factors identified to motivate the decision to go for CS included less painful

on delivery, much safer for the child, decency, and due to medical reasons. The findings from

these studies do not give a distinctive direction as to what percentage of the population agrees

with going for CS or SVD. However, one thing is quite clear that there is a significant population

of women who consider CS to be more preferred than SVD. The reasons arising from the studies

on the key factors reinforcing mothers to go for CS are fear for the pain experience with SVD,

medical reasons, sense of CS being safer to the child, and knowledge of CS following previous

deliveries.

2.6. Mandatory Factors Necessitating Caesarian Section

Despite the fact that mothers may prefer vaginal delivery, there are instances where

medical reasons do rule out the possibility of successful vaginal delivery; thus, an elective or

emergency CS is preferred (Gupta & Garg, 2017). A study by Mylonas and Friese, 2015,

assessed the indicators and risk for an elective caesarean section amid evidence that rates of

elective CS are on the rise. The study revealed that by 1991, caesarian section deliveries in

Germany accounted for 15.3% of all births which increased to 31.7% by 2012. Of the total CS

deliveries in 2012, only 10% had a medical indication. Mylonas and Friese, 2015, argue that

although elective CS is not prohibited, mothers should be open to medical advice on what is the

best option. The main medical reasons highlighted in Mylonas and Friese, 2015, study for CS

were categorized into absolute indications and relative indications. The absolute indications are

those which give 100% nullification for vaginal delivery. They include pelvic disproportion,

chorioamnionitis, pelvic deformation, eclampsia, HELLP syndrome, fetal asphyxia, cord

prolapse, complete placenta previa, and uterine rupture. The relative indicators, which are not a

VAGINAL BIRTH AND NEONATAL MORTALITY 23

certainty for CS include one previous CS, poor progress, maternal HIV positive, poor progress,

and maternal exhaustion.

Hamadneh et al., 2017, asserted the necessity to ensure good timing of elective CS since

early timing before maturity of the baby may result in respiratory distress, asphyxia, and low

birth weight. Late CS increase risks of jaundice, postdates and increased risks of maternal

complications, especially those motivating the idea for CS (Hamadneh et al., 2017). Therefore,

the health care professionals should ensure that there is good timing to reduce both neonatal and

maternal complications, which may end up increasing the risks of neonatal mortality rates. In an

observational study by Sarma, Boro, & Acharjee, 2016, identified that 27.60% of all deliveries in

the study site were CS. Main medical indicators that resulted in these CS included cephalopelvic

disproportion, eclampsia, placenta previa, breech position, cord prolapse, and previous CS. Liu et

al., 2014, identified the leading cause of CS was maternal request in a cross-sectional study

conducted in China. This reason was followed by fetal distress, previous scare, and

malpresentation. Understanding these reasons may help in helping the mothers make the right

decision when it comes to deciding what delivery mode to select.

2.7. Relationship between Delivery Mode and Infant Mortality Rates

Under this subtitle, the researcher seeks to present evidence or justify the lack of it

regarding the influence of delivery mode on neonatal mortality rates. In a study by MacDorman

et al. 2008, that assessed the risks of neonatal mortality for mothers with no risk or indications

preventing SVD. The study assessed births between 1999 and 2002, which included over 8.026

million births and 17, 412 infants deaths. This study indicated that caesarean deliveries had a

higher rate of adjusted neonatal mortalities by 2.4 times that of SVD in mothers with no birth

VAGINAL BIRTH AND NEONATAL MORTALITY 24

complications. From these findings planned vaginal delivery is much safer in regard to neonatal

mortality compared to CS, which cement the idea to consider the mode of delivery in

determining the neonatal outcome.

Volpe 2011, also sought to determine the existence of a relationship between mode of

delivery and mortalities to infants or mothers. Volpe, 2011, used data collected for between 200

– 2009 from 193 countries. The study reported that countries with struggling rate of CS

deliveries, that is those with CS rate below 15% recorded significantly higher rates of maternal

and neonatal deaths compared to countries with CS rates accounting for over 15% of total births.

The argument, in this case, is that those with high rates of CS are less likely to make the decision

for CS when matters have already complicated as likely to be the case for those countries with

CS accounting for less than 15% of total births. Delayed decision to determine on whether to

undertake a CS is likely to affect negatively the outcome of the delivery process since the

emergency and urgency nature reduces adequate preparation. Molina et al., 2015, also conducted

a study almost similar to Volpe study, only that the data used was for years between 2005 and

2012 for 194 WHO member states. Similar results were observed with higher rates of CS being

inversely correlated with neonatal deaths or maternal deaths.

Ghahiri & Khosravi, 2015, compared caesarean and vaginal deliveries of aspects of

maternal and neonatal mortality rates. This was a comparative cohort study involving 300 cases

of CS and 300 cases of SVD. The study reported 7% cases of neonatal death in SVD and no

neonatal mortality case for the CS category. The conclusion made was that CS can be used,

especially in emergency cases to reduce the risk and rate of neonatal deaths. However, these

findings contradict those reported by Ray, Bhatta & Keriakos, 2011, who following their review

VAGINAL BIRTH AND NEONATAL MORTALITY 25

and analysis of 22 studies argued that despite the notable increase in CS cases, CS cannot be

indicated as a strategy to reduce neonatal mortality. However, they supported the decision to

advise mothers to undergo CS based on obstetrics emergencies. Tura, Fantahun & Worku, 2013,

assessed the role the delivery facility plays in determining neonatal mortality in a systematic

review involving 19 articles. Mothers delivering in health facilities witnessed a 29% reduction in

neonatal mortality compared to those who delivered at home. This observation from Tura et al,

2013, study is critical to the current study given that rural areas are more prone to home

deliveries in low-and-middle income countries.

2.8. Measures for Reducing Infant Mortality Rates at Delivery Level

One of the reported strategies for reducing neonatal mortalities at delivery level include

helping mothers make an informed decision on delivery mode (Walana et al., 2017). This

ensures that their decision is made based on medical insights, which would reduce choosing a

method of delivery that may result in complications during the delivery process. The second

strategy is reported by Tura, Fantahun & Worku, 2013, which advocated for a significant

reduction in the number of home deliveries. Home deliveries are mostly vaginal deliveries, and

in most cases occur in rural areas due to the difficulties of accessing health facilities and

influence from traditional social beliefs on child birth. Most of these deliveries are not attended

by health professionals, which increase the risks of complications to both the mother and the

neonate. The third strategy involves ensuring early and appropriate decisions on the mode

feasible mode of delivery (Buzaglo et al., 2015). Delayed decisions are more likely to complicate

the process due to poor planning. Mothers should be assessed adequately and helped to make the

decision on delivery mode early enough to promote the effectiveness of the delivery process

VAGINAL BIRTH AND NEONATAL MORTALITY 26

(Hamadneh et al., 2017). The fourth strategy is to ensure the mother receives adequate care and

monitoring before and during delivery to ensure that possible complications to the mother or the

fetus are intercepted and addressed early enough (Ezeh 2014). The fifth strategy as proposed by

Lawn et al., 2012, is to ensure the baby receives individualized care immediately after delivery to

ensure all arising problems are intervened on time; hence, reducing complications.

2.9. Summary of the Literature Review and the Research Gap

In summary, the literature is rich in details regarding the link between factors influencing

neonatal mortality rates. The factors influencing the preference for the delivery approaches are

mainly based on medical advice, social influence, knowledge and experience, accessibility of the

health care facility and family influences. These factors influence the final decision of the

mother, with main factors demotivating mothers to choose vaginal delivery being fear of pain

and medical reasons. With respect to delivery and neonatal mortality, much attention has been

given to CS with no convincing evidence that can be used to deduce the impact of vaginal

delivery on neonatal mortality. Also, the evidence and data linking the association between

delivery mode and neonatal mortality is not conclusive enough given the notable disparities

some arguing CS and not SVD is associated with high risk of neonatal deaths while others

contradicting this argument. Therefore, the literature presents with a gap on the exact

relationship between preferences for SVD on outcomes such as neonatal mortality rates. This gap

further vindicates the rationale for conducting this study, which seeks to clarify and address the

noted gap.

VAGINAL BIRTH AND NEONATAL MORTALITY 27

Chapter Three: Methodology

3.1. Introduction of the Chapter

This section presents the discussion regarding the methods to be adopted in completing

this study. According to Creswell, 2013, the method section is vital in a research since it offers

the platform for assessing the reliability, appropriateness, trustworthiness, and usability of the

research report. The audiences are more likely to judge a study based on the methodological

approach adopted and its appropriateness to the study topic. The areas of concern with the study

methodology that are discussed here are research design, study setting, study population,

sampling, instruments, data analysis and presentation, ethical considerations, and limitations.

Adequate details and supportive evidence from the literature will be given to account for the

researcher’s decision as to why the selections were made amid other options in each of the areas

identified above. Such supportive details are critical, according to Kallet, 2014, for purposes of

justifying the choices of the methods used in completing the study to ensure the audience follows

the study process without much difficulty.

3.2. Research Design

Research design, as part of the study methodology, describes the overall plan employed

by the researcher to delineate the connection between conceptual research problems with

empirical research (Creswell 2013). Under this category, the target is to communicate to the

audience the type of data, how it was collected, and steps taken in analyzing the data. In the

research design, Mitchell & Jolley, 2012, emphasize that the purpose of inquiry e.g. exploration,

description, explanation, prediction, or historical account should come out clearly.

VAGINAL BIRTH AND NEONATAL MORTALITY 28

This study adopted an explorative cross-sectional study that sought to include both

qualitative and quantitative data drawn from primary and secondary data sources. A cross

sectional study examines the relationship between variables, specifically the cause-effect

outcomes, using data at a single point in time (Rindfleisch et al., 2008). A cross sectional study

was preferred over other options such as cohort, case study, experimental, or randomized

controlled study based on a number of reasons. First, cross sectional studies are less time

consuming given that they do not involve following the subjects over a prolonged period of time

(Rindfleisch et al., 2008). Secondly, cross sectional studies are relatively inexpensive given the

little time involved and the less procedural work involved. Thirdly, cross sectional studies

enhance the possibility of assessing many variables and their interaction at a point of time. The

study design fits this study given that the main aim of this study is to assess the impact of

preference for vaginal birth on neonatal mortality rate. Creswell 2013, argue that cross sectional

studies are relevant in making sense on phenomenon or relationship that may require current

time data.

3.3. Research Philosophy

Research philosophies, according to Saunders, Lewis & Thornhill, 2009, describe a

system of beliefs and assumptions regarding the emergence and development of knowledge in

research. Understanding the research philosophy helps the audience to predict and align the study

design with the research objectives. Common research philosophy paradigms include

positivisms, interpretivism, pragmatism, and realism, all which have varying perspectives

regarding study approaches. For the purpose of this study, the most applicable philosophy is

pragmatism. According to Sefotho, 2015, pragmatism philosophy holds that no single point of

VAGINAL BIRTH AND NEONATAL MORTALITY 29

view can be holistic in interpreting an entire picture or reality. Different approaches do exist, and

those whose concepts are relevant in supporting action. The philosophy is more of a bridge

between positivism and interpretivism on a continuum explaining the nature and source of

knowledge (Saunders, Lewis & Thornhill, 2009). In research based on pragmatism philosophy,

the both deductive and inductive research approaches are merged in objective and subjective

evidence (Mkansi & Acheampong 2012). Pragmatism informs this study given that both

qualitative and quantitative data will be much relevant for the study.

3.4. Population and Recruitment

3.4.1 Study Setting

The study seeks to gain more insight regarding the relationship or lack of it between

preference for vaginal delivery and neonatal mortality. This study is, therefore, best suited in a

hospital setting, specifically antenatal clinic, maternity clinics, and postnatal clinic/ward settings.

The study will be conducted in Imo State University Teaching Hospital, located in Orlu town in

Imo state in Nigeria. The hospital was selected given the high flow of patients in the facility and

the fact that it serves a wide range of the community from both the rural and the urban areas.

Therefore, the setting offers a platform where the many demographic factors in Nigerian women

population will be depicted in entirety. Furthermore, the institution is an accredited facility for

research work; thus, it will offer the researcher easy time interacting with the institution’s

administration. Figure IV gives the Google map location of Imo State University Teaching

Hospital.

VAGINAL BIRTH AND NEONATAL MORTALITY 30

Figure IV: Google Map Locating Imo State University Teaching Hospital

Source: Google Maps

3.4.2. Study Population

Study population, according to Creswell, 2013, describes the accessible population that

meets the attributes of those that the researcher seeks to explore. This population is a

representation of the target population, which refers to the general population within which the

researcher can generalize the study findings (Mitchell & Jolley 2012). Guided by the description

VAGINAL BIRTH AND NEONATAL MORTALITY 31

of the target population, the target population for this study is women within the reproductive

period aged between 18 – 40 years. The study population will be those women within the age of

18 and 40 years seeking maternal child health care at the stages of antenatal, perinatal, or

postnatal periods at Imo State University Teaching Hospital, in Nigeria.

3.4.3 Sample Size

The sample size refers to a representative portion of the study population (Omair 2014)

The sample size entails the subjects that the researcher will engage in collecting primary data

through questionnaire, interviews, observation, or focus group discussion (Singh & Masuku

2014). For this study, the sample size was qualified by attributes such as being gravid or recently

delivered, preference for vaginal delivery, aged between 18 and 40 years, and willing to take part

in the study. Those who met these criteria were excluded if they were known chronic condition

patients, those with critical illnesses, and those may have posed a conflict of interest probably

due to being in another study. The researcher used a sample size of 300 respondents selected

from the sample frame among mothers visiting the respective hospital units within the two weeks

that the data collection for the study was conducted.

3.4.4. Sampling Technique

Given the short duration of the time, the mothers would spend in the hospital during their

hospital visit, the research was convinced convenient sampling technique was the best approach.

This sampling method entails enrolling the subjects into the study based on how well the

respondents fit to meet the study criteria and convenience to researcher accessibility (Singh &

Masuku 2014). It should be noted that mothers visiting Imo State University Teaching Hospitals

VAGINAL BIRTH AND NEONATAL MORTALITY 32

may come from hundreds of kilometers; thus, only those willing to spare some time for the study

were found convenient to ensure the data gathering process was not compromised by time factor

for both the researcher and the participants involved. According to Creative Research Systems,

2012, the sampling technique should be appropriate to both the study topic and the sample size

targeted. Convenient sampling was considered for this study due to advantages such as being

easy to implement, less costly, fast to arrive at the sample size, and the fact that the researcher

can control confounding variables (Singh & Masuku 2014). However, Creswell, 2013, observes

that convenient sampling may be open to bias, which may injure credibility of a study. This

aspect of bias was controlled by having an external researcher, colleague; evaluate the suitability

of the respondents selected. Where there were disagreements between the two recruiters, the

consensus was used to arrive at a decision.

3.5. Study Instruments/Tools

Study tools/instruments refer to the accessories used by the researcher in gathering the

primary data from the respondents (Creswell, 2013). Common study tools at researchers’

disposal include survey tool (questionnaire), interview guide, focus group guide, or observation

chart among others (Taylor, Bogdan & DeVault, 2015). For this cross-sectional study aiming at

collecting both qualitative and quantitative primary data, a structured survey tool was used. The

questionnaire had both closed ended and open ended questions to ensure data gathered was

adequate to respond to the study questions. The survey tool was administered face-to-face, which

was preferred since it allows the room for making clarifications with the respondents.

Questionnaires enhance the ability to collect relevant data in large volume within the

controlled scoped. This ensures that the data analysis process and the interpretation are much

VAGINAL BIRTH AND NEONATAL MORTALITY 33

more relevant to the study topic and with fewer complications. Questionnaires also reduce the

room for confounding variables by restricting the area of questioning, unlike interview or focus

group discussion which may suffer uncontrolled limits for the response. Questionnaires are not

affected by the ability of the researcher to interview given that the questions have to be

interpreted and answered o the best of the respondents’ knowledge. However, some of the

challenges that must be considered when using the questionnaires include the fact that they are

applicable to literate population, can be affected by content and context validity, may be

expensive, and may not depict the non-verbal emphasis as in the case of interviews and focus

group discussion.

3.6. Data Collection Procedure

The questionnaire was drafted with insight from the literature based on other such related

studies. The researcher also had the questionnaire vetted for reliability and validity by peer

reviewers. Furthermore, a pretest study using the questionnaires was done in a neighboring

hospital to ensure that the tool was valid and reliable. These three measures were geared towards

promoting the feasibility, effectiveness, validity, reliability, and relevancy of the study tool to the

study topic and research questions as advocated for by (Mitchell & Jolley 2012; Creswell, 2013).

After identifying the relevant respondents, the researcher would explain the study topic and

purpose, then request the subject to voluntarily take part in the study by providing data through

completing the questionnaire. Those willing were required to append their signature to a consent

form prepared for this study. The questionnaire was simplified to ensure the respondent would

take approximately 15 minutes to complete. Ones completed, the questionnaire was stored safely

VAGINAL BIRTH AND NEONATAL MORTALITY 34

by the researcher to await the data analysis process. Respondents were requested to respond as

completely as possible to all questions with utmost sincerity.

3.7. Data Analysis Approaches

The data collected using the questionnaire was analyzed using Statistical Package for

Social Sciences (SPSS v. 21). The software was preferred owing to justifiable evidence and

positive reviews regarding the effectiveness of the software to analyze quantitative data (Ozgur,

Kleckner & Li 2015). The qualitative data were analyzed thematically. The analyzed data were

then presented in form of charts, graphs, tables, and narratives where possible with the primary

goal of enhancing readability and comprehensibility of the findings.

3.8. Ethical Considerations

Like most other disciplines, the field of research has guiding ethics, which must be

observed to ensure the credibility of the research process and results is not compromised (Fouka

& Mantzorou, 2011). According to Resnik, 2015, ethical considerations in research germinate

from the basic ethical principles, namely; justice, autonomy, beneficence, and maleficence.

These principle guide researcher to ensure the subject is protected from any harm that may result

from participating in the research process. First, the researcher ensured that the study was

approved by the research ethics board overseeing research done within the jurisdiction of the

researcher. Secondly, the researcher sought permission from the study setting (Imo State

Hospital) administration to be allowed to undertake the study in the institution. Thirdly, the

researcher ensured that respondents did agree voluntarily to participate in the study by signing

the consent form. There was no form of coercion, intimidation, or manipulation to participants,

VAGINAL BIRTH AND NEONATAL MORTALITY 35

but they agreed to take part in the study under their own free volition. To strengthen participants

safety and enhance privacy, the participants were requested not to use any personal names on

questionnaires; thus, enforcing anonymity as advocated by Resnik, 2015. The data collected was

stored and safeguarded under the care of the researcher reducing the risk of exposing the data to

scrupulous individuals with malice intentions. The respondents were also assured that the data

was to be used for purposes of the study, and not in any other way. These ethical considerations

reinforce study trustworthiness and usability by the audience and other scholars.

Chapter Four: Findings

4.1. Overview of the Study Demographic Findings

All the 300 mothers served with the questionnaire completed the questionnaires; thus, all

the respondents were incorporated in the analysis section. Most of the respondents of the study

were aged 18 – 25 years (37.3%, n = 112) followed closely by those aged between 26 and 32

years (34.0%, n = 102) and the rest were above 33 years old. Age was considered by the

researcher as a critical variable, which may influence the decision on the mode of delivery of

choice for the mother.

VAGINAL BIRTH AND NEONATAL MORTALITY 36

Figure 4a: Age Distribution

Literacy is also a critical influence on decision making given that the ability to discern

information varies across educational levels.

VAGINAL BIRTH AND NEONATAL MORTALITY 37

Figure 4b: Level of Education

For this purpose, the researcher evaluated the level of education for all the supporters with the

highest percentage (35.3%, n = 106) having secondary education as the highest academic

qualification followed by those with primary education (28.0%, n = 84), undergraduate category

(19.7%, n = 59), diploma/certificate (13.7%, n = 41), and the lowest category being those with

postgraduate qualification (3.3%, n = 10).

VAGINAL BIRTH AND NEONATAL MORTALITY 38

Figure 4c: Marital Status

In regard to marital status, married category colonized the respondents population

accounting for 84.0% (n = 252) followed by the single/divorced population at 11.7% (n = 35),

and the least being the widowed category at 4.3% (n = 13).

Figure 4d: Respondents State in Nigeria

VAGINAL BIRTH AND NEONATAL MORTALITY 39

In addition, most of the respondents were from Imo state (64.7%, n = 194), River state

(17.3%, n = 52), Abia (7.3%, n = 22), Anambra (4%, n = 12) and others (6.7%, n = 20). This

would help determine whether the location where the respondents came from had an influence on

respondents’ decision.

Figure 4e: Respondents’ Occupation

In terms of occupation, peasant farmers accounted for 55.7% (n = 167), those employed

in private sector following a distance at 17.0% (n = 51) while self-employed accounted for 15%

(n = 46) and government employee being 10.3 % (n = 31).

VAGINAL BIRTH AND NEONATAL MORTALITY 40

Figure 4f: Gravida series

To enhance the possibility of determining the impact of a number of children on delivery

mode preference, the researcher assessed gravida series (the number of the current pregnancy).

Most of the respondents (56.7%, n = 170) were recruited at their 2

or 3

pregnancy, followed

by those in their first pregnancy (19.3%, n = 58), those in their fourth, fifth, or sixth pregnancy

(15.3%, n = 46), while seventh, eighth, and ninth pregnancies accounted for 5.7% (n = 17), and

only 3% (n = 9) were in their 10

plus pregnancy while being recruited in the study.

VAGINAL BIRTH AND NEONATAL MORTALITY 41

4.2. The Factors Influencing the Preference for Vaginal Delivery in Nigeria

A whopping 94.3% (n = 283) of the participants preferred vaginal delivery while 4.3% (n

= 13) preferring CS and the remaining 1.3% (n = 4) arguing it didn’t matter the delivery mode as

long as the outcomes were favorable. These findings are presented in figure 4g below. When

asked whether vaginal birth is riskier compared to CS 85% (n = 255) said no, further supporting

the argument for their preference for vaginal delivery with 10.3% ( n = 31) arguing that vaginal

birth is riskier to CS and 4.7% were not sure which was riskier in terms of resulting in neonatal

death (see figure 4h).

Figure 4g: Respondents Preference for Vaginal Delivery

VAGINAL BIRTH AND NEONATAL MORTALITY 42

Figure 4h: Vaginal Birth Riskier than CS in Neonatal Mortality

Further assessment identified that out of the 120 patients recommended for CS in the first

pregnancy, 12 (10%) rejected the recommendation meaning the opted and delivered vaginally.

In the second pregnancy, 123 mothers were recommended to undergo CS among those

interviewed, but 34 (27.64%) declined the recommendation and delivered vaginally. The those

who rejected the call to go for CS in their third pregnancy out of the recommended number of

142 were 39 (27.46%). These findings, which are also presented in figure 4i, are critical towards

determining the influencing the decision to prefer vaginal delivery over CS.

VAGINAL BIRTH AND NEONATAL MORTALITY 43

Figure 4i: Respondents Ruling out CS to Deliver Vaginally

CS Medically Recommended First Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

180

60.0

CS recommendation

followed

108

36.0

96.0

CS recommendation

rejected

4.0

100.0

Total

300

100.0

CS Medically Recommended Third Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

158

52.7

CS recommendation

followed

103

34.3

87.0

CS recommendation

rejected

13.0

100.0

Total

300

100.0

Asked about the main factors influencing their preference for vaginal delivery, the top of

the list were; experience from past deliveries (38%, n = 114), knowledge of the birth options

(30.7%, n = 92) and family members (22.3%, n = 76). Cultural beliefs (5%) and religion (4%)

accounted the list percentages. Cost involved, access to facility, and number of children intended

CS Medically Recommended Second Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

177

59.0

CS recommendation

followed

29.7

88.7

CS recommendation

rejected

11.3

100.0

Total

300

100.0

VAGINAL BIRTH AND NEONATAL MORTALITY 44

were also identified are crucial influencers of Medical decision was considered to be one of the

main factors given that for those recommended to undergo CS, from the immediate previous

section, over 75% of them in the first, second, and third pregnancies agree to go ahead to have

CS delivery.

Figure 4k: Factors Influencing Vaginal Delivery

To determine whether the demographic factors of age, the level of education, marital

status, and gravida series have an impact on preference for vaginal delivery, a bivariate

correlation test was undertaken. The findings are as illustrated in Figure 4L below. Age was

identified to have a weak positive correlation with statistical significance (CL = 0.01; r = 0.311;

p = 0.000), which denotes that increase in age, improved the preference for SVD. A moderate

positive correlation with statistical significance also existed between level of education and the

preference for vaginal delivery (CL=0.01; r = 0.456; p = 0.000). Marital status presented the

VAGINAL BIRTH AND NEONATAL MORTALITY 45

demographic with strongest correlation to influencing preferences for vaginal delivery (CL=0.01;

r = 0.519, p = 000). The number of pregnancies (gravida series) at the time of contact with the

respondent has a very weak negative correlation with no statistical significance in regard to it

relation with a preference for vaginal delivery (CL = 0.01; r = - 0.042; p = 0.471). This

contradicted with the main reason argued out to be the major influence of vaginal delivery being

past delivery experiences.

Figure 4L: Bivariate Correlation of Demographic Factors and Preference for SVD

Correlations

Age

Highest level of

education

Marital

status

Gravida

series

Preference for vaginal_

delivery

age

Pearson

Correlation

.906

.484

.517

.311

Sig. (2-tailed)

.000

300

Highest level

of education

Pearson

Correlation

.906

.568

.517

.456

Sig. (2-tailed)

.000

300

Marital

status

Pearson

Correlation

.484

.568

.362

.519

Sig. (2-tailed)

.000

300

Gravida

series

Pearson

Correlation

.517

.362

-.042

Sig. (2-tailed)

.000

.471

300

Preference

for vaginal

delivery

Pearson

Correlation

.311

.456

.519

-.042

Sig. (2-tailed)

.000

.471

300

**. Correlation is significant at the 0.01 level (2-tailed).

VAGINAL BIRTH AND NEONATAL MORTALITY 46

4.3. The Factors Influencing Effectiveness of Vaginal Delivery in Nigeria

The study sought to investigate the factors that respondents believed to be influencing the

effectiveness of vaginal delivery. In a multiple choice question, it was a unanimous agreement

that staff competence, facility status/preparedness, adherence to antenatal clinic appointment, the

urgency of reporting to the hospital at the onset of labor, and maternal cooperation were key to

determining SVD outcome. Other factors also highlighted in an open-ended question on major

issues influencing quality and safety of SVD included; nutrition, family support, early

intervention to pregnancy and birth complications, and adequate health education. In an open

ended question intended to capture qualitative data, mothers were asked to list the main factors

that would provoke them to consider CS over SVD. The emerging themes are as illustrated in the

table below.

Table 1: Emerging Themes and Support on Factor Hindering Selection of SVD

Theme

Supportive Evidence

a. Pain

“I hear it is very painful”

“I saw the mother gnawing in severe pain, and I fear that”

“My first experience was horrible, pain like never before”

“It was the worse pain I ever get to experience”

b. Incompetent

midwife

“some of the midwives may not be perfect”

“CS is guaranteed to be operated by doctor”

“I will not be tempted to deliver at home”

c. Sexual life after

birth

“I fear after delivery my marriage may worsen due to poor sexual”

“my vaginal may loosen putting my man off”

“There is risk of husband becoming unfaithful because of changes in

my reproductive organ, you know what I mean”

VAGINAL BIRTH AND NEONATAL MORTALITY 47

4.4. How Vaginal Delivery Preference Influence Neonatal Mortality Rates in Nigeria

This section sought to answer one of the specific research questions, which is at the heart

of the study. An analysis based on the responded cases on neonatal deaths in the first, second,

and third pregnancies for those interviewed. The findings are as illustrated in figure 4m below. In

those in those who had delivered previously, indicated that 7% (n = 10) had neonatal deaths,

27.64% (n = 32) in the second pregnancy and 27.46% (n = 38) in third pregnancy. From the data

in figure 4n, those who delivered through CS in their first pregnancy were 96, in second

pregnancy were 55, and in third pregnancy were 64. Going by these values, a deduction can be

made that neonatal deaths were lowest when high number of mothers involved delivered by CS.

Figure 4m: Number of Neonatal Death per Pregnancy Series

VAGINAL BIRTH AND NEONATAL MORTALITY 48

Figure 4n: Delivery Mode

CS Medically Recommended First Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

180

60.0

CS recommendation

followed

108

36.0

96.0

CS recommendation

rejected

4.0

100.0

Total

300

100.0

CS Medically Recommended Third Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

158

52.7

CS recommendation

followed

103

34.3

87.0

CS recommendation

rejected

13.0

100.0

Total

300

100.0

In the first year, 96 mothers delivered through CS and the reported neonatal deaths were

10. In the second pregnancy, 55 delivered via CS and neonatal deaths were 32 while in third

pregnancy 68 mothers delivered through CS with neonatal death amounting to 38. However, this

interpretation may give the true relationship given that complicated cases, actual vaginal births,

CS Medically Recommended Second Pregnancy

Frequency

Percent

Valid Percent

Cumulative

Percent

Valid

CS not medically a must

177

59.0

CS recommendation

followed

29.7

88.7

CS recommendation

rejected

11.3

100.0

Total

300

100.0

VAGINAL BIRTH AND NEONATAL MORTALITY 49

causes of neonatal deaths, and area (home, clinics or big hospital) where the delivery was

conducted are not included.

Chapter Five: Discussion

The study was completed successfully. The majority of the women indicated in the

sample indicated that they preferred vaginal delivery, a case also evidenced in the studies by Shi

et al., 2016; Walana et al., 2017; Loke, Davies & Li, 2015. These findings show a close

connection or relation with studies conducted in other places such as China and Asia, but

contrast with one study conducted in Rahmati-Najarkolaei et al. 2014, which indicated higher

preference of CS than SVD. Given the diversity of the origin, age, and occupation sectors, these

factors cannot be said to have skewed the findings; thus, the results can be generalized to

represent the nature of the Nigeria women. For purposes of readability, comprehension, and

flow, the discussion is organized under the specific research questions with limitations and

implications coming as the last two sections.

5.1. The Factors Influencing the Preference for Vaginal Delivery in Nigeria

The study managed to address the issue of factors influencing the preference for vaginal

delivery in Nigeria. Most of the findings made from the primary data concurred with a number of

findings reported in the literature. In broad, the findings made from the primary data indicate that

those factors influencing preference for vaginal delivery can be categorized into maternal factors,

medical factors, facility factors, and sociocultural factors. On maternal factors, the most

evidenced included the attitude towards the delivery mode, knowledge of delivery modes, and

fear based on experience, witness, or hearsay. These factors were also identified in studies by

VAGINAL BIRTH AND NEONATAL MORTALITY 50

Loke, Davies & Li, 2015; Yilmaz, Bal, Beji & Uludag, 2013; Shi et al, 2016, although they were

not categorized into a single ground. The most reported among these factors in the literature is

fear and pains associated with vaginal delivery and CS delivery.

The medical factors which influence for the preference for delivery mode include factors

such as attitude health professionals used in advising mothers regarding the birth method,

medical conditions/problem limiting the use of one or more delivery modes, and availability of

medical professionals, and advice from medical professionals. In relation to the existing

literature, Rahmati-Najarkolaei et al., 2014, reported that two of the reasons towards the

selection of CS as a preferred mode of delivery were medical advices and having a medical

condition that nullified the possibility of SVD delivery. Similar observations were noted by

Walana et al., 2017, with a significant number of those seeking CS doing so due to having

medical problems. Facility factors entail those associated with the point of delivery. These

include accessibility, affordability, availability of staff, and how satisfied the patient feels. For

instance, the rural areas have low preference for CS deliveries, according to a study by Loke,

Davies, and Li 2015, due to lack of availability of such facilities in these regions.

Sociocultural factors such as beliefs, patients’ society perception, family influence, the

cultured understanding of the delivery methods, and religion influence (Buzahglo et al. 2015).

From the primary data, the mothers included in the study identified factors such as religion,

society, and family influences are critical determinants of the outcome of their preferred mode of

delivery. In Nigeria where the culture of the community is still key determinant of the people

practices and interpretation of life events, the preference for the delivery method is more likely to

suffer such influence (Faremi et al., 2014). Although this study did not manage to identify those

VAGINAL BIRTH AND NEONATAL MORTALITY 51

living in the rural and urban, it is general knowledge that traditional beliefs are held dearly by

those in the rural areas than urban areas (Ezeh, 2017). In an overall, the factors noted with

Nigerian women, which influence their choice of the delivery method are in great deal related to

those identified in the literature review. However, lack of certainty on the availability of CS, and

the impact of accessibility to hospitals seemed to be strong indicators of the increased preference

for vaginal delivery.

5.3. The Factors Influencing Effectiveness of Vaginal Delivery in Nigeria

This study noted that the effectiveness of vaginal birth is influenced by a number of

factors arising from the many players involved in the delivery process. From the primary

evidence gathered from the mothers, health care staffs hold a key role in enhancing and ensuring

the mothers delivering vaginally do so successfully. The health care providers’ role in ensuring

successful and effective vaginal delivery is not limited to the delivery process, but as early as

during the antenatal visits. Wetta et al., 2013, argue that during the early assessment of the

pregnant mothers, the health professionals can identify problems, challenges, and imminent

complications with the mother, hence advising them accordingly. Such health education

influences the mothers’ attitude towards the choice of delivery mode and prepares them

psychologically to face the reality; thus, reducing last minute surprises that heighten anxiety and

impairs informed decision making.

Wu, et al. 2013, further states that the health professionals should ensure the mother

understand the delivery process for purposes of promoting cooperation and reducing delivery

complications. This argument is further emphasized by Hamadneh et al., 2017, who argue that

poor understanding of the delivery process result in mothers not viable for vaginal delivery

VAGINAL BIRTH AND NEONATAL MORTALITY 52

complicating and delivering at home, before arriving hospitals, or arriving with complication

having already set in. From the primary data, mothers argued that health education on available

health methods, what they entail, preparations needed, how to reduce complications, and after

birth care does influence the preferred method and increase the effectiveness of the delivery

process. With early and effective monitoring and interventions during pregnancy period, delivery

process, and postnatal period, the child birth outcomes for both the mother and the baby are

expected to improve (Sarma, Boro, & Acharjee, 2016). Such evaluation form health

professionals nullify cases where mothers with absolute indicators for CS do not make a mistake

of delivering vaginally, which would increase the risks of complications and mortalities for both

the mother and the baby (Mylonas and Friese, 2015).

Other than the impact of the health professionals, who seemed to carry the major

responsibility for promoting effective vaginal delivery, mothers too have a critical role. First,

they are bound to observe the health messages, education, and advice from the health

professionals. It is one thing to educate mothers comprehensively on pregnancy and delivery

process/care, and another thing to have the messages adhered to (Volpe, 2011). For instance, the

study identified that a significant number of women rejected the medical recommendation for

delivering through CS, and instead went ahead to deliver vaginally, which could have been a

major contributor of neonatal mortalities. Although failure could have been due to other factors,

such as accessibility and affordability of the service, blatant dismissal of professional health

advice should be discouraged strongly for the sakes of the mother and child health. Furthermore,

it is the mothers’ responsibility to take ensure they seek qualified information from health

professionals regarding any problems or information they receive, which may affect their

decision making in choice for delivery method (Tura, Fantahun & Worku, 2013).

VAGINAL BIRTH AND NEONATAL MORTALITY 53

Accessibility of health facilities in terms of cost and proximity are also key factors

influencing the effectiveness of vaginal birth in Nigeria. One of the factors identified by the

participants is influencing their decision to prefer vaginal birth over CS was the cost of CS

services. Zamani-Alavijeh, 2017, argued that where people cannot afford the health services,

they are likely to resort to seeking health from traditional birth attendants, which in most cases

increases the risk of poor outcomes or referral o health facility when the damage is beyond may

be challenging to contain. Similarly, lack of ease of access to health facilities rules outs the

possibility of health facility deliveries. According to Tura, Fantahun & Worku, 2013, delivering

in health facilities reduces the risks and improves the outcomes for both the mother and the baby.

5.4. How Vaginal Delivery Preference Influence Neonatal Mortality Rates in Nigeria

The child delivery method, CS of SVD, preferred by the mother may have a considerable

impact on the outcomes of the baby. The study identifies that factors such as the timing of

delivery, midwife competency, place of delivery, the status of the mother, and the status of the

child before delivery are critical factors influencing the outcome of vaginal delivery. Neonatal

mortality may be increased in cases where the mother delivers vaginally at home or before

arriving in the hospitals due to possible complications such as maternal postpartum hemorrhage,

birth asphyxia, prolonged labor, cord prolapse, head trauma, aspiratory pneumonia, and

respiratory distress for the baby. These outcomes are much more likely to result in neonatal

death, especially when the delivery was conducted in a facility or home where resuscitation

facilities are unavailable (Tura, Fantahun & Worku, 2013). Therefore, it should be the interests

of all stakeholders to advocate and campaign to have facility deliveries in Nigeria, which would

cut down the risk of neonatal mortalities.

VAGINAL BIRTH AND NEONATAL MORTALITY 54

From the literature review, studies indicate that neonatal mortality was more associated

with caesarean section in countries with CS rates below 15% (Volpe, 2011; Molina et al., 2015).

In Nigeria, between 12 – 26% of the deliveries are CS deliveries with disparities being

contributed by living in the urban or the rural setting with the latter recording the low CS rates.

The primary data for this study indicate that although there is no direct connection between

vaginal delivery, indicated that a high number of people who defied medical recommendation for

CS increased the rates of neonatal deaths. Some of the main factors that could be leading to

increased risks and rates of neonatal mortality in births recorded in rural areas in Nigeria could

be due to difficulties in accessing health facilities that increase home deliveries or late arrival in

the hospitals, and poverty factors. Buzaglo et al., 2015, also noted that the rural areas have low

literacy levels; thus, more likely to be held hostage by traditional beliefs and culture, which may

impact negatively on effective delivery of care.

5.5. Study Limitations

One of the key limitations of this study was the inability to resources constraints. With

adequate resources, the researcher would have considered doing a more intense assessment on

the subjects’ conditions such as visiting their home to assess other factors that may have

influenced their preference for vaginal birth and risk for neonatal deaths. Secondly, the study

also encountered time constraints, which reduced the exposure needed to follow the mothers for

a better understanding of factor in play linking preference for vaginal delivery and neonatal

deaths. Thirdly, lack of an already established survey tool in the area of interest for this study

resulted in the researcher developing own study tool; thus, there is no benchmark on the

reliability of the study other than the pretest study done conducted prior to this study. Despite

VAGINAL BIRTH AND NEONATAL MORTALITY 55

this limitations, the study strengths include the fact that the literature was rich with factors

influencing preference of birth method and those influencing neonatal death rates.

5.6. Study Implications

This study would go a long way influencing the health education delivered to the mother

for purposes of improving their informed decision making regarding preference for vaginal

delivery. The study argues that much focus should be geared towards ensuring the mothers

understand their choices and their roles in making the delivery process a success. Health care

providers and the involved agencies/stakeholders in child delivery should also take measure to

reduce barriers and challenges reducing the effectiveness of each of the delivery methods.

Chapter Six: Conclusion and Recommendations

6.1 Conclusion

In conclusion, the study deduces that preference for vaginal delivery is not entirely a

causative factor to neonatal deaths. Instead, the factors influencing the effectiveness of vaginal

delivery and external factors are more likely to have a massive impact on neonatal deaths. In

Nigeria, preference for vaginal birth is high and so does the neonatal deaths. However, CS

cannot be recommended to be a solution to this problem given that access to the facility, the cost

of care, poverty levels, literacy levels, and family influences still have considerable impacts on

neonatal outcomes. The some of the rural areas are remote, and most of the mothers in these

areas deliver vaginally due since they cannot access afford or access CS services. The main

factors hypothesized by this study to be a contributor to high neonatal mortality rates in Nigeria

is vaginal deliveries conducted at home, and not those in hospitals, given that home deliveries

VAGINAL BIRTH AND NEONATAL MORTALITY 56

are likely to be conducted by non-professionals in circumstances where birth complications and

challenges cannot be addressed on point. In fact, CS deliveries in the hands of incompetent

handlers or in a facility with inadequate capability are riskier to vaginal delivery. Therefore,

factors affecting the effectiveness of vaginal birth, and not vaginal birth, do have significant

impacts on a vaginal delivery.

6.2. Recommendations

Based on the findings made in this study, a number of recommendations are proposed

herein. The first recommendation is that an extensive retrogressive cohort study should be

considered by the future researcher to bring out the main factors that link vaginal delivery with

neonatal deaths. Such as study would fill in the gap in the literature and bring out the deductions

made in this study by identifying the exert reasons as to why Nigeria has high neonatal deaths.

Secondly, the study recommends for intensive antenatal health education session targeting the

rural people to ensure that mother understands the necessity of hospital delivery. Thirdly,

midwives should be competent enough and have them release in a mobile clinic in remote areas

to reduce home deliveries and ensure professional delivery care reaches those mother in the rural

areas without hospital facilities. Lastly, the general population should be targeted with health

education on pregnancy and delivery, especially girls in school to enhance the quality of decision

making.

VAGINAL BIRTH AND NEONATAL MORTALITY 57

References

Bako, B., Geidam, A.D., Sanusi, I.M., Mairiga, A.G. & Isa, B. (2014). Vaginal birth or repeat

caesarean section: women’s preferred mode of delivery after a primary caesarean section

in Maiduguri, Nigeria. International Journal of Medicine and Medical Sciences, 6(11);

230-235

Buzaglo, N., Harlev, A., Sergienko, R. Sheiner, E. (2015). Risk factors for early postpartum

hemorrhage (PPH) in the first vaginal delivery, and obstetrical outcomes in subsequent

pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine, 28(8); 932 – 937

Creative Research Systems (2012). Determining the sample size. Creative Research Systems

Available at < https://www.surveysystem.com/sscalc.htm>

Creswell, J.W. (2013). Research design: qualitative, quantitative, and mixed methods

approaches (4th ed.). Thousand Oak, CA; SAGE Publications, Inc.

Dahiru, T. (2015). Determinants of early neonatal mortality in Nigeria: results from 2013 Nigeria

demographic health survey. Journal of Pediatrics and Neonatal Care, 2(5); 1 – 10

Daniel, C.N. & Singh, S. (2016). Caesarean delivery: an experience from a tertiary institution in

north western Nigeria. Nigerian Journal of Clinical Practice, 19(1); 18 – 24

Dirksen, C.D., Utens, C.M., Joore, M.A. et al. (2013). Integrating evidence on patient

preferences in healthcare policy decisions: protocol of the patient-VIP study.

Implementation Science, 8(64). doi:10.1186/1748-5908-8-64.

VAGINAL BIRTH AND NEONATAL MORTALITY 58

Ezechi, O.C., Loto, O.M., Ndububa, V.I. et al. (2009). Caesarean section and perinatal mortality

in south western Nigeria. Nepal Journal of Obstetrics and Gynecology, 4(1); 46 – 48.

Ezeh, O.K. (2017). Trends and population-attributable risk estimates for predictors of early

neonatal mortality in Nigeria, 2003 -2013: a cross-sectional analysis. BMJ Open, 7(5); 1 -

12. doi:10.1136/bmjopen-2016-013350

Ezeh, O.K., Agho, K.E., Dibley, M.J., Hall, J. & Page, A.N. (2014). Determinant of neonatal

mortality in Nigeria: evidence from the 2008 demographic and health survey. BMC

Public Health. 14(521). DOI: 10.1186/1471-2458-14-521

Fishbein, M. (2008). A reason action approach to health promotion. Medical Decision Making,

28(6); 834-844

Fouka, G. & Mantzorou, M. (2011). What are the major ethical issues in conducting research?

is there a conflict between the research ethics and the nature of nursing?” Health

Science Journal, 5(1); 1 -12.

Ghahiri, A. & Khosravi, M. (2015). Maternal and neonatal morbidity and mortality rate in

caesarean section and vaginal delivery. Advanced Biomedical Research, 4(193).

doi: 10.4103/2277-9175.166154

Green, H.E. (2014). Use of theoretical and conceptual frameworks in qualitative research. Nurse

Researcher, 21(6); 34-38. doi: 10.7748/nr.21.6.34.e1252.

VAGINAL BIRTH AND NEONATAL MORTALITY 59

Gupta, M. & Garg, V. (2017). The rate and indications of caesarean section in a tertiary care

hospital at Jaipur, India. International Journal of Reproduction, Contraception,

Obstetrics and Gynecology. 6(5); 1786 -1793

Hamadneh, J., Alchalabi, H., Hamadneh, S. et al. (2017). Association between timing of elective

caesarean delivery and adverse outcomes among women with at least two previous

caesareans. International Journal of Gynecology & Obstetrics, 137(1); 51 – 56.

Head, K.J. & Noar, S.M. (2014). Facilitating progress in health behavior theory development and

modification: the reasoned action approach as a case study. Health Psychology Review,

8(1); 34-52

Kallet, R.H. (2014). How to writer the methods section of a research paper. Respiratory

Care,49(10); 1229 – 1232.

Lawn, J.E., Kinney, M.V., Black, R.E. et al. (2012). Newborn survival: a multi-country analysis

of a decade of change. Health Policy Plan.27(3); iii6 – 28. doi: 10.1093/heapol/czs053.

Liu, Y., Li, G., Chen, Y., Wang, X. et al. (2014). A descriptive analysis of the indications for

caesarean section in mainland China. BMC Pregnancy Childbirth, 12(14); 410 – 419

Loke, A.Y., Davies, L. & Li, S.F. (2015). Factors influencing the decision that women make on

their mode of delivery: the health belief model. BMC Health Services Research, 15(274);

doi: 10.1186/s12913-015-0931-z

VAGINAL BIRTH AND NEONATAL MORTALITY 60

MacDorman, M.F., Declercq, E., Menacker, F. & Malloy, M.H. (2008). Neonatal mortality for

primary caesarean and vaginal births to low-risk women: application of an intention-to-

treat model. Birth, 35(1); 3 – 8.

McFadden, D. (2001). Economic choices. The American Economic Review. 91(3); pp.351-378

Mitchell, M.L. & Jolley, J.M. (2012). Research design explained. Boston, MA; Cengage

Learning

Mkansi, M. & Acheampong, E.A. (2012). Research philosophy debates and classifications:

students’ dilemma. The Electronic Journal of Business Research Methods, 10(2); 132-

140

Molina, G., Weiser, T.G., Lipsitz, S.R. et al. (2015). Relationship between caesarean delivery

rate and maternal and neonatal mortality. Journal of American Medical Association,

314(21); 2263 – 2270

Mylonas, I. & Friese, K. (2015). Indications for and risks of elective cesarean section. Deutsches

Arzteblatt International, 112(30); 489 – 495.

Omair, A. (2014). Sample size estimation and sampling techniques for selecting a representative

sample. Journal of Health Specialties, 2(4); 142 - 147

Ozgur, C., Kleckner, M. & Li, Y. (2015). Selection of statistical software for solving big data

problems. Sage Journals, 5(2), DOI: 10.1177/2158244015584379

VAGINAL BIRTH AND NEONATAL MORTALITY 61

Rahmati-Nakarkolaei, F., Eshraghi, T., Dopeykar, N. & Mehdizadeh, P. (2014). Influencing

factors to delivery selection in pregnant women: a case study in Tehran. Journal of

Health Policy and Sustainable Health, 1(3). 85 – 88.

Ray, S., Bhatta, C. & Keriakos, R. (2011). Review of the recent literature on the mode of

delivery for singleton vertex preterm babies. Journal of Pregnancies. Article ID 186560

http://dx.doi.org/10.1155/2011/186560

Resnik, D.B. (2015). What is ethics in research & why is it important? National Institute of

Environmental Health Sciences, Available at < https://www.niehs.nih.gov/research

/resources/bioethics/whatis/>

Reyna, V. F. (2008). Theories of medical decision making and health: an evidence-based

approach. Medical Decision Making : An International Journal of the Society for

Medical Decision Making, 28(6), 829–833. http://doi.org/10.1177/0272989X08327069

Rindfleisch, A., Malter, A.J., Ganesan, S. & Moorman, C. (2008). Cross-sectional versus

longitudinal survey research: concepts, findings, and guidelines. Journal of Marketing

Research. 45(3); 261 – 279.

Sarma, P., Boro, C. & Acharjee, P.S. (2016). An analysis of indications of caesarean sections at

Tezpur medical college and hospital, Tezpur (a government hospital). International

Journal of Reproduction, Contraception, Obstetrics and Gynecology. 5(5); 1364 - 1367

Saunders, M., Lewis, P. & Thornhill, A. (2009). Understanding research philosophies and

approaches. Research Methods for Business Studies, 4(2); 106-135

VAGINAL BIRTH AND NEONATAL MORTALITY 62

Sefotho, M.M. (2015). A researcher’s dilemma: philosophy in crafting dissertations and theses.

Journal of Social Sciences, 42(1,2); 23 -36.

Shi, Y., Jiang, Y., Zeng, Q., Yuan, Y., Yin, H., Chang, C. & Pang, R. (2016). Influencing factors

associated with the mode of birth among childbearing women in Hunan province: a

cross-sectional study in China. BMC Pregnancy and Childbirth, 16(108).

DOI: 10.1186/s12884-016-0897-9

Simon, M. K. (2011). Dissertation and scholarly research: Recipes for success (2011 Ed.).

Seattle, WA, Dissertation Success, LLC.

Singh, A.S. & Masuku, M. (2014). Sampling techniques & determination of sample size in

applied statistics research: an overview. International Journal of Economics,

Commerce and Management, 2(11); 01 -22

Taylor, S.J., Bogdan, R. & DeVault, M. (2015). Introduction to qualitative research methods: a

guidebook and resource. Hoboken, NJ; John Wiley & Sons

Tura, G., Fantahun, M. & Worku, A. (2013). The effect of health facility delivery on neonatal

mortality: Systematic review and meta-analysis. BMC Pregnancy and Childbirth, 13(18).

Virkus, R.A., Lokkegaard, E., Lidegaard, O. et al. (2014). Risk factors for venous

thromboembolism in 1.3 million pregnancies: a nationwide prospective cohort. PLOS

One, 9(5): e96495

VAGINAL BIRTH AND NEONATAL MORTALITY 63

Volpe, F.M. (2011). Correlation of cesarean rates to maternal and infant mortality rates: an

ecologic study of official international data. Pan American Journal of Public Health,

29(5); 303 – 308

Walana, W., Acquah, S.E., Vicar, E.K. et al. (2017). Preference of birth delivery modes among

women attending antenatal and postnatal clinics in the Tamale Metropolis of Ghana.

Journal of Pregnancy and Child Health, 4(1). doi:10.4172/2376-127X.1000297

Wetta, L.A., Szychowski, J.M., Seals, S. et al. (2013). Risk factors for uterine atony/postpartum

hemorrhage requiring treatment after vaginal delivery. American Journal of Obstetrics

and Gynecology, 209(1); 51e1 – 51e6

World Health Organization (2015). UN sustainable development summit 2015: sustainable

development goals. World Health Organization. Retrieved from

<http://www.who.int/mediacentre/events/meetings/2015/un-sustainable-development-

summit/en/>

World Health Organization. (2017). Millennium development goals: reduce child mortality.

World Health Organization. Retrieved from

<http://www.who.int/topics/millennium_development_goals/child_mortality/en/>

Wu, L.C., Malhotra, R., Carson, J, Lie, Tan. & Ostbye, T. (2013). Risk factors and midwife-

reported reasons for episiotomy in women undergoing normal vaginal delivery. Archives

of Gynecology and Obstetrics, 288(6); 1249 – 1256

VAGINAL BIRTH AND NEONATAL MORTALITY 64

Yilmaz, S.D., Bal, M.D., Beji, N.K. & Uludag, S. (2013). Women’s preferences of method of

delivery and influencing factors. Iranian Red Crescent Medical Journal. 15(8); 683 –

689.

Zamani-Alavijeh, F., Shahry, P., Kalhori, M. & Araban, M. (2017). Pregnant women’s

preferences for mode of delivery questionnaire: psychometric properties. Journal of

Education and Health Promotion, 6(20); doi: 10.4103/2277-9531.204738

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