*Corresponding Author:
Mr. Abigail Uchenna Emelonye
Department of Nursing Science, University of Eastern Finland, P. O. Box 1627, FIN - 70211 Kuopio, Finland.
E-mail: [email protected]

Abstract

A male companion at antenatal care is unusual and spousal participation during labor and delivery in Nigeria is poor. This can be attributed to amongst other things the beliefs that labor is exclusively a women affair. Although there are few studies about male involvement in maternity care in Nigeria, no review has been conducted regarding spousal participation in labor and delivery. Therefore, majority of women desire their spouses as birth companions and attest to having emotional comfort and support when their spouses participate in their labor and delivery, the status and acceptability of spousal participation in labor and delivery in Nigeria is quite low due in part to socio‑cultural drawbacks. This narrative review looks at existing research literatures identified through electronic sources such as Google Scholar, PubMed and EBSCO published in English between 1995 and 2013. The aim of this narrative review is to extract from these literatures the level of participation of Nigerian spouses in labor and delivery. Keys words used for the search include spouse, labor, delivery, Nigeria, maternal; childbirth and only English papers were included. Although presently weak, the spousal participation in labor and delivery in Nigeria should be encouraged and promoted as a deliberate health‑care policy through the creation of an enabling environment and dissemination of information highlighting the pivotal role that spouses could play in labor and delivery.

Keywords

Delivery, Labor, Nigeria, Participation, Spousal

Introduction

Globally, women in labor and delivery undergo enduring experiences of painful discomfort, fear, anxiety and tensions. In a bid to ameliorate these experiences, several studies have been conducted to establish the relationship between companionship by either medical personnel or spouses. These studies have shown that practices of professional support caregivers in labor known as “doula” when available and employed effectively to support women in labor produce an ameliorative effect on parturient pain.[1] For purposes of this review, labor support is interpreted as a continuous non-medical care of a parturient woman. It includes physical comforting such as touching, massaging, bathing and emotional support such as companion, reassurance, encouragement, etc., These supports are either done by the medical personnel, family members, spouse or a hired hand (doula).[2]

In different parts of the world, more especially in developed countries such as UK and Denmark, spousal participation is common practice during labor and delivery with about 95% attendance.[3] Studies conducted in these developed countries shows that women who had continuous spousal labor support are reassured, comforted and emotionally encouraged to overcome pain associated with labor and delivery.[3,4] Furthermore, a similar review has shown that women with continuous support by spouses also experience shorter labors, reduced need for oxytocin, anesthesia, analgesia, instrumental deliveries and decreased by 50% their chances of being admitted to a cesarean section.[4]

Contrarily, in low income countries like Nigeria, which is known to be a patriarchal male dominated society where pregnancy and child birth is regarded as exclusively women’s affairs, spousal participation in labor and delivery remains acutely low.[5] Men traditionally do not accompany their wives for antenatal care and are mostly absent in the labor room during delivery, leaving their support roles to relatives and midwives.[5] Thus, a question that readily comes to mind is what percentage of Nigerian spouses participate in labor and delivery? In an effort to resolve this question and bearing in mind that the extent of participation of spouses in labor and delivery in Nigeria in debatable, this narrative review will examine existing and accessible research literatures in relation to spousal participation in labor and delivery in Nigeria. Based on the findings of the examination, this narrative review will proffer possible recommendations that would encourage, promote and institutionalize the introduction of spousal participation in labor and delivery in Nigeria. The aim of this narrative review is to explore the extent of spouses participation in labor and delivery in Nigeria.

Summary of Maternal Mortality in Nigeria

Nigeria is a diverse society with a population size of about 170 million people. Demographic data shows 50.6% were males and 49.4% were females make up this overwhelming population size.[6] The birth rate in Nigeria is estimated at 39.23 births/1000 people annually which equate the rapid growth of the population. According to World Health Organization’s statistics, more than half a million women die annually as a result of complications of pregnancy and childbirth characterized by pain and other delivery related complications.[7] A disproportionately high burden of these deaths is borne by developing countries particularly Nigeria where the maternal mortality and morbidity rates have remained one of the highest globally. Data shows a daunting maternal mortality ratio of 1500/100,000 births in Nigeria accounting for nearly 15% of the global estimates of maternal mortality.[8]

Furthermore, the death risk faced during pregnancy or childbirth by Nigerian women is greater than that of women in half of other African countries put together.[8] With antenatal care coverage and institutional delivery estimated at 47% and 33% respectively, there is an average of 6 births/woman in Nigeria.[9] This situation is aggravated due to inadequate management of pregnancy and labor, which does not only inflict psychological and physical hardship on parturient women; but essentially bugs the health-care system with huge financial burden.[10]

Methods of literature search

The information for this review was sourced online from Google search, PubMed and EBSCO websites. Key words used for the search include, Spouse, labor, delivery, Nigeria, maternal and childbirth. After the several input of key words, 400 articles were generated from the search. Selection criteria such as literatures in English language, literatures relevant to the topic and published between 1997 and 2013 were used in the abstract selection of 30 articles. These 30 articles underwent further shifting process vis-a-vis the topic of this narrative review and resulted in the final identification and selection of the 10 articles used for the review.

Results of literature search

The final 10 literatures for the review consist of five studies based on the quantitative methodology, three studies employing the qualitative methodology, one study with mixed methodology and one that adopted a systemic review. Four of the studies were carried out in a hospital setting out of which two are randomized control trials [Table 1].

Author Sample size/res. Study/design Challenged assessed
Umeora et al., 2011[1] n=149 menHospital (urban) Cross sectional prospective surveyQuantitative study Level of spousal companionshipduring labor
Somers-Smith, 1999[3] n=8 couples post-partumHomes (urban) Ethnographic approachQualitative study Support from male partners duringpregnancy
Hodnett et al., 2007[4] n=16 trials (13,391 women)(randomized and non-randomizedtrials) Systematic review Continuous support for womenduring child birth
Iliyasu et al., 2010[5] n=400 menHomes (urban/semi-urban/rural) Descriptive and cross-sectional surveyQualitative and quantitative study Men’s role in maternity care
Brown et al., 2001[11] n=37 primiparasn=9 multiparasHomes (rural/urban) Retrospective descriptive surveyQuantitative study Non-pharmacological method inlabor pain relief
Kainz et al., 2010[12] n=67 first time mothersHome (urban/semi-urban/rural) Hermeneutic approachQualitative study Mother’s experience of partner’spresence during childbirth
Olayemi et al., 2009[13] n=462 pregnant womenHospital (urban/semi-urban/rural) Descriptive and cross-sectional surveyQuantitative study The level of participation of Nigerianmen in pregnancy and birth
Morhason et al., 2009[14] n=585 pregnant womenHospital (urban) Cross-sectional surveyRandomized control trialQuantitative study Psychosocial support on laboroutcome
Morhason et al., 2008[15] n=224 pregnant womenHospital (urban) Cross-sectional surveyRandomized control trialQuantitative study Attitude and preferences aboutsocial support during childbirth
Hardin et al., 2010[16] n=17 post-partum womenHome (urban) QualitativeDescriptive study Positive characteristics ofunmedicated birth

Table 1: Overview of literatures

Overview of existing literature

In Africa, particularly Nigeria, the volume of research literatures relating to spousal participation in labor and research findings as to how the practice ameliorates labor and delivery pain is very limited. As such, it is pertinent to underline the fact that since this area of study is very much under researched particularly in Nigeria, the scope of this article is restricted by the minimal number of relevant literatures available and accessible.

The review of research literatures reveals results supporting the effectiveness of a variety of non-pharmacological methods in managing labor and childbirth.[1,11,12] One of such non-pharmacological method is spousal support which is applied during labor and delivery to positively influence the experiences of mothers during childbirth.[11,12] In a study that investigated the impact of caregiver support for women during childbirth, Hodnett et al. reported that continuous support provided for a laboring woman resulted to reduction in use of medication for pain relief, forceps during delivery and less incidence of caesarean section.[4] Another study assessing the experience of wives who had unmedicated birth illustrated that a good percentage of women have positive birth experience if supported by the presence and participation of their husbands.[13] The effect of support is more remarkable if a purely support role is adopted by using a spouse rather than using a caregiver that is also providing medical care.

A randomized control trial was conducted at the University College Hospital Ibadan exploring the effect of psychological support during labor.[14] A total number of 585 women with anticipated vaginal delivery were recruited and randomized into an experimental group with companionship in addition to routine care throughout labor and another control group with only routine care. Findings show that women in the control group (n = 292) with only routine care and without companionship were about five times more likely to deliver by cesarean section, had significantly longer duration of the active phase and higher pain scores. This findings contrast with those in the experimental group (n = 293) who had a more satisfying labor experience.

Furthermore, a 2008 survey report by Morhason et al. on 224 pregnant respondents aged range of 18-44 years that received antenatal support at a Nigerian hospital in Ibadan demonstrated an overwhelming percentage of pregnant women who prefer to have a companion during childbirth to provide social support.[15] Although a vast majority of respondents (86%) indicated their husbands as preferred labor companion, the remaining <20% choose their mothers or showed a preference for a sibling, friend or someone else.

Another study focusing on the attitude and preferences of pregnant respondents about social support during labor and childbirth found that the pivotal role men play providing support during labor improves delivery outcome for both the mother and her newborn. They are also considered to be critical partners for improvement of maternal health-care in Nigeria.[5]

Even though, most of the Nigerian women desire the companionship of their husbands during delivery, certain factors hinder the actualization of this desire. In the context of urban health facilities in South East Nigeria, high gender disparities and discrimination prevalent in the five Eastern states have negatively impacted on the husband’s active involvement and support during pregnancy and childbirth.[1] Education has also been shown in some studies as a determining factor reporting high participation of educated spouses of above 50% accompanying their spouses to the antenatal clinic and delivery room than uneducated men.[1,5,13] According to Olayemi et al.,[13] it was common practice that nearly all husbands (97.4%) encouraged their wives and pay for antenatal service bills, however only 63.9% were actually present at the delivery. Even though the study shows that more than 50% of men participated in the delivery process, their participation was linked strongly to their educational background. On the other hand, most uneducated men in Nigeria think that their presence are not necessary during delivery, but rather restricted to only the duty of providing financial support for their spouses.[5] Further probe on why spouses were absent during birth, showed a response of 92 participants with no particular reasons for their absence and 57 believing that their presence was not needed. It is common place here to see parturient women accompanied by aged women or an under aged female relatives.

Other factors such as Ignorance, poverty, cultural and religious practices were shown to be reasons for low spousal participation (18.7%) during delivery in a cross-sectional study conducted in a semi urban part of Northern Nigeria on 389 men. Further, men that have a monogamous family and higher socio-economic status significantly attend more to labor compared to husbands of less social and economic status. This is a common finding shared by studies used in this article. In Nigeria where culture and religion governs the practices of the society, there is a strong cultural belief in several parts of the country that spousal presence worsens labor pain and prolongs labor.[9] Furthermore, attitude of spouses toward husband’s participation in maternal care is strongly opposed to the physical presence of husbands in the labor room during delivery due to the strong cultural and religious effects of Islamic law applicable in the predominant Muslim population in Northern Nigeria.[5] This is a sharp contrast from the Christian dominated Southern Nigeria where there is a good percentage of spouses inclined to spousal participation in antenatal and post-natal care.[1,13,14]

Pursuing this further, practices and policies of most health-care facilities are also identified as factors that impede full spousal participation in maternal care. Husbands are prohibited from entering delivery rooms because the rooms accommodate multiple parturient at the same time. Despite the problem of poor infrastructure, the ill-knowledge, attitudes and practices of midwives and other health personnel promote an unwritten maternity culture that would discourage male spouses or partner’s presence in the delivery room. Further, the study concluded that low education, cultural and religious beliefs are factors that contribute to the negative influence of low spousal participation in delivery Nigeria.[5]

Discussion

Firstly, the literatures above demonstrate very poor participation of male spouses in labor and delivery processes of their children especially in the Northern Nigeria (32%).[5] Likewise, in the Southern parts of the country where majority of studies on spousal participation in delivery have been conducted, the situation is slightly better with some studies reporting about 63% participation.[1,13-15] Notwithstanding, this result is still poor as it reported that only men who are educated with high social status make up this percentage. In general, childbirth is perceived to be exclusive women affair in which case men are rather at the background providing all the financial support and making decisions regarding the choice of maternity care. Since spouses play this important role in the family and irrespective of the fact that this important aspect of physical and psychological support in the delivery process is grossly overlooked, it is only rational to encourage them to support their wives during labor in the health-care facility. As it has been demonstrated in several studies[1,9,14] that women overwhelmingly prefer their husbands as their support companion during childbirth vis-à-vis midwives or other relatives, it is unfortunate that women in Nigeria still go into labor and delivery without spousal support except for the assistance of ever busy midwives.[2] It should however be noted that in some instances, spouses are subtly dissuaded from participating in the labor by unfriendly hospital settings and staff or through unequivocal inscriptions on the labor ward door such as “you are not needed here.”[5] Although the World Health Organization recommends the practice whereby parturient women are allowed to have a birth companion of choice,[17] the reverse is obviously the practice in Nigeria.

Equally, there are enormous benefits from psychosocial support especially when spouses are involved in their wives labor and delivery. Such benefits include emotional comfort, improved family communication and bonding, pain relief without analgesia and positive birth experience. Even though these benefits accrue from the participation of spouses in labor and delivery, it has not yet found its place in the Nigerian maternal health-care system. There is no gainsaying the fact that educational, social, religious and cultural factors have been seen to influence the participation of spouses in labor and delivery. On the other hand, education is seen as a very significant factor in determining spousal participation in delivery as an evident in the finding that most men that accompany their wives to the hospital in Nigeria are literate and are well-informed about the birth processes. This contrasts with the findings that illiterate spouses that constitute the higher percentage of spouses in Nigeria do not accompany their wives but hold the belief that they only have financial obligation towards childbirth.[1,13] Nevertheless education regardless of level attained, religious and cultural beliefs are held in very high esteem in Nigeria and persistently remain the most influential factors inhibiting spousal participation in labor and delivery.

There are beliefs that spousal presence will delay the labor process, causing more harm than good.[9] Apparently this belief is a myth that has been handed down from generations. Guided by this myth and coupled with the perception of wives that the presence of their spouses is not necessary or needed during labor, husbands refrain from participating in childbirth. Akin to this, a study conducted in the Northern part of Nigeria showed that male respondent held on to their cultural and religious beliefs that they had no role in labor and delivery since their religion and culture forbids a male presence during childbirth and their wives also share the same beliefs and views.[5] Contrary to the recommendation of the World Health Organization to the effects that parturient woman should be encouraged to undergo labor and delivery with the support of a companion she trusts and can feel at ease with, the reverse is the case in Nigeria. This is regardless of its inherent advantage of reducing the use of analgesia and capacitating the parturient to gain control of her situation.[16] While noting the positive maternal experiences of wives in developed countries due to spousal support and participation during labor and delivery, the poor state of the practice in Nigeria demands immediate further research.

Conclusion

Conceding that factors such as low level of education, poverty, culture, religious beliefs, health workers negative attitudes have all contributed to poor spousal participation in labor and delivery in Nigeria, there is still a veritable opportunity for hospital and maternity policies and practices to be revised to take into consideration the importance of spousal participation in labor and delivery. This change in policy, practice, attitude and knowledge of all health-care stakeholders could be effected through research findings. Further randomized research studies are needed to investigate the perception, attitude and knowledge of health-care providers in granting complete participation to spouses of women during their birthing process.

Although presently weak, the spousal participation in labor and delivery in Nigeria should be encouraged and promoted as a deliberate health-care policy through creation of enabling environment and dissemination of information highlighting the pivotal role that spouses could play in labor and delivery.

A major limitation of this article is that it is a narrative and not a systematic review. As such, the method used in selection of literatures is highly subjective and also the language area is limited to English publication only.

Acknowledgment

We acknowledge the support of Uchenna Emelonye (United Nations) and Alex Aregbesola (University of Eastern Finland). This project is self-funded.

Source of Support: Nil.

Conflict of Interest: None declared.

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