Perception of pregnant women towards midwives : attitude and practice during child delivery in health institutions in Ogbomoso , South-West , Nigeria

Background: This study aims to ascertain pregnant women’s perceptions of the attitudes and practice of midwives during labour in a mission teaching hospital and a state hospital in ogbomoso, Southwest nigeria, and to determine whether or not a relationship exists between patients’ perceptions of midwives practice during delivery and the occurrence of neonatal deaths. MeThodS: The survey was conducted by administering the questionnaire adapted from caring Behaviour Inventory (cBI) to a random sample of five hundred and seventy nine respondent mothers who gave birth in either a Mission teaching hospital or a state hospital in ogbomoso, Southwest nigeria. This standardised questionnaire collects demographic data and patient perceptions of nursing attitudes and practice, ranking patients’ responses to a series of statements about the midwives on a four point Likert scale. data was analysed using Pearson product moment correlation analyses and multiple regression analyses. reSuLTS: our study revealed that there was a positive response on the attitude and practise of midwives during delivery by the respondents. Secondly, there was a positive impression on the influence of the attitude and practice of midwives during delivery by the respondents. concLuSIonS: There was no evidence of a relationship between patients’ perceptions of midwives practice during delivery and the occurrence of neonatal deaths.

P ERCEPTION Of PREGNANT w Om EN TOwAR dS m I dwIVES ...

InTroducTIon
A midwife is defined as a 'person who obtained a midwifery certificate from the Nursing and Midwifery Council of Nigeria (NMCN) after attending an approved school of Midwifery in Nigeria and spending the stipulated amount of years in training recommended by the NMCN'.The midwife must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the post-partum period, to competently conduct deliveries independently and to care for the newborn infant.This care includes preventive measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help.She has an important task in health counselling and education, not only for the patients, but also within the family and the community.The work should involve antenatal education and preparation for parenthood and should extend to certain areas of gynaecology, family planning and child care.She may practise in hospitals, health units, under domiciliary conditions or in any other service [1].The roles of midwives are also described as lifesavers, educators, advisers, promoters of clean and safe deliveries, mobilisers, traditionalists and team members [2].
Every mother experiences this pain albeit in varying degrees irrespective of their educational, ethnic, social or financial background.This pain is associated with the physiological termination of pregnancy at term, to bring about motherhood [3].Leap [1] said that the pain of labour is a pertinent topic for discussion and women have highlighted a perception that the attitudes of midwives have a profound effect on their experience of giving birth.She further explained the theory and purpose of pain as a trigger of neurohormonal cascades.When pain stops, women are able to find a place of safety to give birth and to mark the occasion.Pain summons support; pain helps develops altruistic behaviour towards babies.Pain heightens joy as in the transition to triumphant motherhood.The expression of pain gives clues to progress in labour.During painful labour, women show signs of anxiety.Labour pain can be identified by its severity.The task that the mother performs in labour is rigorous and as such women in labour need care and support of health professionals.
Midwives are the health professionals that play the central role in the care of pregnant mothers in the home, health institutions and community.The purpose of Maternity care is to allow the midwives take foremost role in the relief pain and caring for the clients.Knowledge of midwifery is an important key to the concept of 'child delivery'.The midwives are expected to have a positive attitude towards pregnant women during delivery and also use their knowledge on pain management to reduce or relief pain.It is also believed that the midwives can relief anxiety by their knowledge in psychology because some of these mothers' threshold to pain is very low.Women in labour tend to overestimate their ability to cope with pain.In the practice of safe delivery therefore, the midwife is expected to be courteous, patient and attend to client's/patient's need immediately when taking delivery.McCrea, Wright and Murphy-Black [4] examined the influence of midwives' approaches on the care given to women for pain relief during labour and their findings revealed that the midwives approach had a positive influence on the women's experience of labour pain.
Many women lose their lives in the process of childbirth every year, about half a million of women die in sub Saharan Africa from pregnancy related causes and maternal mortality rate (MMR) is between 166 and 1,549 per 100,000 birth [5].More than 70% of maternal deaths in Nigeria are due to five major complications: haemorrhage, infection, unsafe abortion, hypertensive disease of pregnancy and obstructed labour [6].Poverty is also a major cause of maternal deaths in Nigeria.Also worthy of note, is the ancient method of practicing medicine in Nigeria markedly which is different from what currently obtains in modern medicine mostly due to the uncaring attitude of many health care providers in the context of maternal care [7].At the safe motherhood Initiative conference 1987 in Kenya, participating countries agreed to decrease MMR by 50% yet this remains high yet the rate remains high in Nigeria.Poor utilization of quality health services contribute to maternal mortality rate which may be attributed to the attitude and practice of the skilled workers especially the nurses and midwives.The majority of child births occur at home or hospital in developing countries, although most of the home deliveries are done  Women need to be encouraged during child delivery.Despite the increasing activities of the nurses and midwives to improve the quality of care, it was observed that mothers still complain of midwives' attitude and practice [8].It seems the midwives do not take into cognisance the views of the mothers for effective care and the provision of a client centered service is important where women can express their opinion.Potani [9] stated that Callister Mutherica, the first lady of Malawi was persuading the pregnant women to deliver in public health facilities at a National Nurses and Midwives Advocacy Campaign meeting in Lilongwe.She also pleaded with nurses and midwives in Malawi to practice professionally, ethically, with empathy towards pregnant women.It is believed that some nurses are scarring the pregnant women by their attitude and practice.Omoruyi [6] lamented on the relationship between the density of health workers and maternal mortality rates in Nigeria.She further stated that more than one-third of births in Nigeria are attended by doctors, trained nurses and midwives and, in spite of the fact that the level of assistance a woman receives during delivery can reduce maternal deaths and related complications but, the attitude of many nurses/midwives towards pregnant women and those in labour is poor; some of them act inappropriately to the woman in labour which raises the question of what the duties of a nurse/ midwife are to a woman in labour.
Centre for maternal and children enquires (CEMACH) in May 27th 2005 mentioned that poor quality care delivery provided by health workers contributed to the increase in maternal mortality and morbidity rates in Nigeria.The quality care is a major public health concern and it has the potentials of improving the health of the mother and child.Furthermore, various models of quality assurance are developed to enhance improved health care delivery services [10] and the use of consumer perception of services also help to improve services rendered.There are many studies on the attitude, practice and knowledge of midwives towards pregnant women during delivery, but none has given information to show if the midwives current attitude and practice is still the same or there is a better progressive modification.The result of this study will reveal the current attitude and practice of midwives and further assist the health care facilities to plan new strategies on how to improve services rendered not only by midwives but all health workers.
It was suggested that in order to reduce maternal deaths in Nigeria, there is need for ethical orientation emphasizing the need to show care to vulnerable patients (for example, pregnant women) irrespective of their socioeconomic status.This will enhance quality care and foster good relationships between healthcare providers and their patients.This study is to ascertain the perception of the pregnant women on the attitude and practice of the midwives during delivery.objectives 1.To determine the practice of the midwives towards pregnant women during labour.2. To identify the attitude of the midwives towards the pregnant women during delivery.3. To assess the perception of pregnant mothers during delivery.

research hypothesis
1.There is no significant relationship between attitude and practice of midwives towards pregnant women during delivery.2. There is no significant influence of attitude and practice of midwives towards the perception of pregnant women during delivery.

MeThodS
Study Design: Descriptive survey Research Settings: Mission hospital and Government hospital Ogbomoso.
The Mission hospital is a 182 bed hospital founded 1907.The hospital was accredited by NMCN for the training of Nurses and Midwives.The total nurses working there are ninety seven.It has facilities such as medical, surgical, paediatric and maternity wards, eye clinic, dental clinic, intensive care unit, outpatient department, theatre, accident and emergency unit etc. Laboratory services such as X-ray, ultra sonography, medical microbiology lab etc.Government hospital is a 60 bed hospital founded in 1957 by the then Premier of Western region.The number of nurses working in this hospital is fifty five.It has facilities such as medical, surgical, paediatric and maternity wards, theatre, ophthalmic, dental, outpatient department physiotherapy department.Laboratory services such as X-ray, medical microbiology lab, etc.It serves Ogbomoso and its environs.
Target Population under Study: All pregnant women who are clients from Mission hospital and Government hospital in Ogbomoso.Primi -gravida client and sick pregnant women were exempted from the study.The respondents must have reading and writing abilities in either Yoruba or English languages.They must be 28-42 weeks pregnant.The total population is 579.300 clients from Government hospital and 279 clients from Mission Teaching hospital voluntarily participated in the study.
Sampling Technique: The sampling method was simple randomization.Clients were randomly selected from antenatal clinic, labour and postpartum ward from both hospitals.
Instrument: The instrument for collecting the data required for this study was adapted from a standardized instrument-Caring Behaviour Inventory (CBI).The content of the questionnaire were divided into three sections namely: demographic data, attitude, practice and perception.Twenty statement items were used to measure attitude, eleven to measure practice and seven to measure perception.For each statement, respondents are asked to state their experience on the attitude, practice and perception of midwives using a four point Likert scale rating, ranging from 1 (strongly disagree) to 4 (strongly agree).This means that except for the demographic information that was categorical, the three independent variables were measured continuously (score).The adapted questionnaire was pilot tested in areas other than the study areas.The reliability test was carried out using the Cronbach's/ Alpha procedure to ascertain the internal consistency of the instrument and it yielded an r-value ranging from 0.67 to 0.86.
Procedure for data collection: On the receipt of approval from the hospital ethical committees of the Mission Teaching Hospital and Government hospital Ogbomoso, a descriptive survey questionnaire was distributed to all interested participants.A consent form and a cover letter were attached to each questionnaire.The questionnaire was first prepared in English language and also translated into the native Yoruba language.Participants who gave their consents to participate in the study received elaborated explanation on the purpose of the study and the type of questions and how to answer by trained facilitators.Furthermore, to enhance honest and frank responses privacy ensured.Participants were instructed to complete the questionnaire through the help of the research assistance.The study took a period of six months (February to July 2011).
The returned questionnaire was coded and a statistical package for social sciences (SPSS) was used to analyze the coded response.Results were presented in percentages.Tables were designed using Pearson product moment correlation and multiple regression analysis.
Ethical Considerations: The right of the subjects privacy was maintained.This includes the issues on restriction and anonymity, also confidentiality.

reSuLTS
Sample distribution of respondents and how variables were measured are presented in table 1.
The total respondents for this study are five hundred and seventy nine pregnant women from both Mission and Government hospitals participated in the study.Findings showed that respondents' age was between 17-45 years old.35% were civil servants, 50% traders and 15% housewives.45% had tertiary education, 50% lower education (secondary and primary schools) and 5% adult education.
Hypothesis one: There is no significant relationship between attitude and practice of midwives towards pregnant women during delivery.Pearson product moment correlation was used to analyse this hypothesis at 0.05 level of significance, the result is presented in table 2.
The table shows a r-value (0.557**) which is positive but moderate value.It follows then that there exists a moderate positive relationship between the two variables.The level of significance (.000) which is less than 0.05, indicates that the relationship is significant.Therefore there is significant relationship

attitude and practice of midwives towards pregnant women during delivery.
Hypothesis two: There is no significant influence of attitude and practice of midwives towards the perception of pregnant women during delivery.Multiple regression analysis was used to test the hypothesis at 0.05 level of significance.
The result in table 3 shows that the combination of all the predictor variables (attitude of midwives and practice of midwives) are jointly related to the predicted variable (pregnant women perception of midwives), the correlation is positive and moderate (R = .229).More importantly, they accounted for 8.6% of the variance in pregnant women perception of midwives.
Furthermore table 4 ANOVA revealed that there is a strong joint contribution of the predictor variables (attitude of midwives and practice of midwives) to pregnant women perception during delivery F (2, 576) = 28.233,p <0.05.Based on the result, it was deduced that attitude of midwives and practice of midwives when used together significantly contributes to pregnant women perception towards midwives.Table 5 reveals the relative contribution of two predictor variables (attitude of midwives and practice of midwives) toward pregnant women in south west Nigeria as it is given by beta weight.The β value indicates the contribution of each of the two predictor variables to the criterion variable (perception of pregnant women toward midwives).The higher the β value, the greater the contribution of the predictor variable.This implies that attitude of midwives and practices of midwives when used alone are important factors to predict pregnant women perception towards midwives.This means that the attitude and practice of midwives goes a long way to influence pregnant women perception about them and promote mutual relationship between the mid-wife and the pregnant women and this may result to successful child(ren) delivery.

dIScuSSIon
Our study establishes a significant relationship between attitude and practice of midwives towards pregnant women during delivery.This means that the midwives attitude towards pregnant women in labour is positive and the skills used for child delivery enhance positive outcome.This disagree with Onasoga Opiah, Osaji and Iwolisi [11], whose findings stated that 60% of the respondents said that the midwives were not with pregnant women all through the labour and majority of the respondents rated the attitude of the midwives as being poor.The respondents described the attitude of the midwives that attended to them in Labour as uncaring, but our study result supported the study of Harvey et al [12] on evaluation of satisfaction with midwifery care and findings revealed that women in the midwife group reported significantly greater satisfaction and a more positive attitude toward their childbirth experience than women in the doctor group in Arbour Birth Center, Calgary, Alberta, Canada.
In this study, we investigated the pregnant women's perception on the attitude and practice of midwives during delivery.The data showed that there is significant influence of attitude and practice of midwives towards the perception of pregnant women during delivery.This signified that the attitude and practice of midwives gave a positive impression on the pregnant women's perception.This is in line with the study of Geranmayeh, Hadian, Rezaepur, Akhondzadeh and Haghani [13].They concluded that education caused a significant effect on knowledge, attitude and practice of midwives in using different labour pain relieving approaches as well as a positive attitude towards these approaches.
Findings of this study showed that the practice of midwives toward pregnant women during delivery has no relationship with the occurrence of neonatal death.This study is in agreement with Brink, who believed that quality care has the potentials of improving the pregnant women perception, also health of the mother and child.Furthermore, the attitude and practice of midwives goes a long way to influence pregnant women perception about them and promote mutual relationship between the mid-wife and the pregnant women and this may result to successful child(ren) delivery.

concLuSIon
This study revealed that midwives' attitude and practice elicit positive effect on women in labour, which gave a positive impression on the pregnant women's perception.Supportive relationship and high quality care will empower
in the absence of skilled professionals.
Epidemiology Biostatistics and Public Health -2014, Volume 11, Number 2 P ERCEPTION Of PREGNANT w Om EN TOwAR dS m I dwIVES ...
Epidemiology Biostatistics and Public Health -2014, Volume 11, Number 2 P ERCEPTION Of PREGNANT w Om EN TOwAR dS m I dwIVES ... between

table 1
Sample diStribution of reSpondentS and how variableS were meaSured P ERCEPTION Of PREGNANT w Om EN TOwAR dS m I dwIVES ...