Faculty of Higher education

Research proposal

Perception of Factors affecting post-partum

women on deciding cesarean section in
Red Crescent Society Hospital
Prepared by:

Rawan Abu Dayyah

Supervisor:

Dr.

2017

1
Table of content

Abstract ……………………………………………….. I
Introduction ……………………………………………….1
Background ………………………………………………2
Problem of statement…………………………….. 6
Significant of study ………………………………6
Aim of Research ………………………………7
Research Questions ……………………………… 7
Hypothesis ………………………………………...8
Literature Review ………………………………………15
Method and procedure ………………………………21
Study design ………………………………21
Sampling ………………………………………22
Study Population ………………………………22
Population and Sample: ………………………22
Site and Setting: ………………………………23
Data Collection and Instrument ………………24
Data Analysis ………………………………24
Ethical Consideration ………………………25
Reference ………………………………………………28
Time Table ………………………………………………29

2
Abstract:

In recent years, an increasing rate of cesarean section has concurred with increased
incidence rate in Palestine. Therefore, the aimed of this study were to explore
Perception of Factors affecting post-partum women on deciding cesarean section in
Red Crescent Society Hospital

This study will be quantitative and descriptive correlation in nature, the study will
include postpartum women from Red Crescent Society Hospital Jerusalem, data will
collected by questionnaire.

3
Introduction:

Cesarean section is usually performed when a vaginal delivery would put

the baby’s or mother’s life or health at risk, although in recent times it has
also been performed upon request for a childbirth that could otherwise
have been natural (Becher & Stokke, 2013). Similarly, according to
American College of Obstetricians and Gynecologists [ACOG] (2013),
cesarean section was the delivery of a baby through incisions made in the
mother’s abdomen and uterus. So, cesarean section divided into two types
that are emergency and elective.
The selection of the cesarean method without medical reason by the
pregnant mother was called elective cesarean section (Cunningham et al.,
2010). Some women explained their positive attitude by the belief that
cesarean delivery was safe for the infant and less painful than vaginal
birth. Fear of vaginal delivery and issues relating to physical
consequences associated with vaginal delivery have also been reported.
Moreover, having a planned cesarean may be preferred for reasons of
convenience (Gallagher et al., 2012) by partner, relative and culture (Tai,
2013).
Statement of problem.
In recent years, the Cesarean Section (CS) rate has increased in different
parts of the world, both in developed countries and in developing
countries (Zhao & Chen, 2013). In Palestine cesarean section deliveries
risen from 6.0% in 1996 to 14.8% in 2006, (PCBS, 2007) However,
World Health Organization [WHO] (1985) considered a rate as low as
15% as an acceptable rate for performing cesarean section. The rate is
considered as an index of healthcare coverage in different nations
(Yazdizadeh et al., 2011). The elective cesarean section is influenced by
feelings from family members and causes psychology pressure to medical

4
doctors. Women believe that vaginal delivery increases bad consequence
of childbirth and lead them to prefer cesarean section. Also Increases in
cesarean sections worldwide have been well documented over the past 2
decades (Munro, et al., 2009). evidence in Europe showed that the
average rate of CS deliveries was 19%, also Many researchers have
shown that the consequences CS to mother includes hemorrhage,
anesthetic complications (Liu et al., 2007), potentially morbid procedures
showing high rate of overall infectious morbidity (Keen, 2004), potential
surgical complications, and risks to future pregnancies, such as abnormal
placenta and uterine rupture (Lee & D’Alton, 2008), hysterectomy, and
anemia in pregnancy (Ecker, 2013). Influencing to infant as increased to
risk of neonatal respiratory morbidity (Ecker, 2013). Betrán et al. (2007)
reported data from the United Kingdom Confidential Enquiry into
Maternal Deaths was increased cesarean section rates may be an indicator
for excess maternal mortality in developed countries as an elective
cesarean section with no emergency presents was 2.84 times greater
chance of maternal death than a vaginal birth. Moreover, women’s
feelings and thoughts that vaginal birth may give more pain than cesarean
section and more traumas (Gallagher et al., 2012) and elective cesarean
section was associated with fear of childbirth including fear of labor pain
(Chong & Mongeli, 2015).
Significant of study
The study will investigate the factors that affecting post partum women
on deciding cesarean section in Red Crescent Society Hospital, when
theis factor are knowable, the policy maker, staff and other can work on it
by increase educational program and decrease believe in such issues in
whole this will lead to decrease the demand for cesarean section on
maternal request and decrease complication . also this study will be basic
for other research in this topic in Palestine, because upon to our

5
knowledge this the first study in Palestine, and the study information will
be reference for changing behavior programs about CS.
 The results of this study wil in nursing education, including
information regarding the specific attitudes and beliefs that
pregnant women hold that may be addressed as part of
interpersonal communication between nurses, pregnant women and
their families.
 The results of this study will use as a framework to develop
prenatal education programs. Providing accurate information on
the risks and benefits of elective cesarean section and reduce the
prevalence of elective cesarean section
 Results from this study can help nurses and midwives to develop
intervention researches to enhance attitude of pregnant women and
to change perception from them as well as family members related
to intend of elective cesarean section.

Aim and objectives : (/)

The general aim of the study will be
To determine the Perception of Factors affecting post-partum women on
deciding cesarean section in Red Crescent Society Hospital.
objectives:
1. To identify women perception about CS in relation with her current
status.
2. To explore knowledge and attitude of participants towards cesarean
section on maternal request.
3. To investigate reasons stated for cesarean section on maternal
request.
4. To explore relationship between socio-demographic variabels and
factor that women to choose CS.
6
Research question: (/)
Is their significant relationship between number of parity and CS request?
Is their significant relationship between age and CS request?
Is their significant relationship between fear and CS request?
Is their significant relationship between attitude and perception with CS
request?

Conceptual framework of study

This study will base on Theory of Planned Behavior (TPB) and literature
review. TPB was created by Ajzen (1988); this model has been developed
from Theory Reasoned of Action (TRA) by Fishbein and Ajzen (1975).
According to the TPB, the most important determinant of person’s
behavior is intention to behavior. The individual's intentions to perform a
behavior are combined of attitude toward performing the behavior,
subjective norms and perceive behavioral control (Ajzen, 1991).
The central concept of the theory of planned behavior is the individual’s
intention to perform a given behavior. Ajzen (1988) purported that the
stronger a person’s intention to perform a behavior, the more likely he/
she would be to carry out that behavior. Intention is determined by three
kinds of considerations: firstly, attitude towards the behavior refers to a
person overall evaluation of the behavior, meaning, it is beliefs about
consequences of the behavior and the corresponding positive or negative
feelings performing a behavior and judgments about each of these
features of the behavior (Ajzen, 1991). Secondly, subjective norms are an
individual’s perceptions of general social pressure to perform or not to
perform the behavior. It focuses on the individual’s beliefs regarding
what significant others think about the behaviors (Ajzen, 1991). If an
individual perceives that significant others approve or disapprove of the
behavior, they are more or less likely to intend to perform it (Armitage &

7
Conner, 2001). Finally, perceived behavioral control is the individual’s
beliefs about whether a specific behavior is easy or difficult for her to
perform (Ajzen, 1991).
However, this study focuses only on relationship between attitude,
subjective norms and intention behavior of pregnant women, because
they are highlights phenomenon in Quang Ngai province, Vietnam. In
this study will be explored relationship between behavioral intention and
actual behavior. For example, firstly, she has a planned pregnancy and
preferred a cesarean section can estimate relationship by many people
said that cesarean section has more benefits and less complications or
they believes also. Secondly, assessment women’s feeling toward
cesarean section is positive or negative feeling of individual about
intention performing behavior. Finally, subjective norms toward cesarean
section that are relations from her husband and social culture plays an
important role during a woman’s pregnancy, such as, choice to the good
time, day and even year.

8
 Theoretical framework of the study

Women related factors

Previous history of depression or

anxiety
Family history of depression or
anxiety
History of trauma
Outcome
HistoryObstetric
of abortion or stillbirth
factors
Prevalence of elective History of complication
CS Primigravida
Number of children
Gestational age
Gender of fetus
Change in physical function and
appearance
Pregnancy related symptoms
like morning sickness
Plan for pregnancy

Cesarean
section

Psychological factors
Partner support
Physical symptoms Community support
Psychological symptoms
Feeling of current pregnancy
Role function
Self confidence
Fetus and maternal complication
Fears of labor and
complications

Demographic factors
Age
Income
Occupation
Wight

9
Conceptual definitions
Emergency cesarean section is performed in an obstetric emergency,
where complications of pregnancy onset suddenly during the process of
labor, and immediate action is required to prevent the deaths of mother,
infant or both (Finger, 2010) It is included indications medical about the
cesarean section. According to Becher and Stokke (2013) review of
literature from previous researchers, the most12 common indications for
cesarean section were described into two groups: (a) maternal indications
including prolonged/ obstructed labor, preeclampsia, PIH-pregnancy
induced hypertension, placenta praevia and abruption placenta, infection,
previous cesarean delivery, and pelvic anatomy, and (b) fetal indications
including fetal distress, cord prolapse, presentation of the baby such as
breech presentation, transverse presentation, compound presentation,
large babies, and multiple babies.
Elective cesarean section is scheduled in advance rather than performed
because of an unscheduled emergency. Elective cesarean sections may be
performed on the basis of an obstetrical or medical indication, or because
of a non-indicated maternal request (National Institutes of Health [NIH],
2006).
Attitude: a feeling or way of thinking that affects a person's behavior.
(Tai, 2013).
Perception: is the organization, identification, and interpretation of
sensory information in order to represent and understand the
environment. All perception involves signals in the nervous system,
which in turn result from physical or chemical stimulation of the sense
organs. (Goldstein, 2009)

10
Operational definition of terms
Elective cesarean section refers to pregnant women’s cognitive
preference and readiness to plan regarding to elective cesarean section. It
will measure by items of the intention of elective cesarean section from
English Version of the Childbirth Delivery Options Questionnaire
(ECDOQ) (Tai, 2013).
Attitude towards cesarean section refers to pregnant women’s
emotional consideration of elective cesarean section means that they want
for baby’s safety and herself, and assessment level of attitude is positive
or negative. It will measure by items of the attitude toward elective
cesarean section from English Version of the Childbirth Delivery Options
Questionnaire (ECDOQ) (Tai, 2013).
Perception toward cesarean section refers to the pregnant women’s
believes regarding what significant others feelings about the elective
cesarean section.
Fear of childbirth refers to feelings and thoughts of pregnant women
about facing childbirth including labor pain, giving birth and traumas. It
was measured by questionnaire based on the Wijma Delivery
Expectancy/ Experience Questionnaire (W-DEQ) version A (Wijma,
Wijma, & Zar, 1998).

Age Age: the length of time during This type of question answer by circle aro
which a being or thing has Correct one of options mentioned
existed; length of life or 16-21 years old
existence to the time spoken. OR 22-27 years old
28-33 years old
a period of human life, measured 34-39 years old
by years from birth, usually ≥ 40 years old

marked by a certain stage or

11
 degree of mental or physical
development and involving legal
responsibility and capacity
(dictionary, 2017)
Gravity The number of times a woman is This type of question answer by circle
or has been pregnant, regardless around
of the pregnancy outcome. A Correct one of options mentioned
current pregnancy, if any, is One
included in this count. Twin Two
pregnancy is counted as 1
Three
Four
More than four
Parity Parity, or "para" indicates the This type of question answer by circle
number of pregnancies around
reaching viable gestational Correct one of options mentioned
No one
age (including live births and
stillbirths). The number of 1-2 times
fetuses does not determine 3-4 times
the parity. Twin pregnancy 5 or more
carried to viable gestational
age is counted as 1.

Presence Supportive person: is a snuggly This type of question answer by circle

of word. Anything that supports around
supporti you, or embraces you and holds Correct one of options mentioned
Presence of supporting person
ve you up is supportive. It can be
No one
person physically supportive, like a Your mother
girdle that holds your belly in, or Your husband
Friend

12
 emotionally supportive like a Another (open to write others provide
loving family or solid network of support during current pregnancy )
friends. A parent paying for a
child's college bills is supportive
financially. Things can be
supportive, too — posts holding
up a building are supportive.
Being supportive is a good thing.
Infant Infant gender: The state of being This type of question answer by circle
gender male or female (typically used around
with reference to social and Correct one of options mentioned
Male
cultural differences rather than
biological ones) (oxford Female
dictionaries, 2017) Male and female (not for single fetus )
Don’t know

Assumptions:
1-The participant would be truthful in responding to the questionnaire.

2-Adequate research references related to Cesarean section on maternal

request

3-The targeted hospital, would be cooperative in terms of permitting the

researcher to question their client .

Limitations:

1- Lack of local researches related Cesarean section on maternal request:

the viewpoint of delivered women

2- Instability of the political situation in the country.

13
3-Limited time for the researcher to do the research.

CHAPTER II: Literature reviews

Following the purpose of this study, the literature on perception and

attitude of post partum women and factors influencing intention of
elective cesarean section will be reviewed.

14
Intention of elective cesarean section refers to women’s preference and
plan regarding to elective cesarean section (Tai, 2013). According to
Ajzen (1991), intentions to perform behaviors of different kinds could be
predicted with high accuracy from attitudes toward the behavior,
subjective norms, and perceived behavioral control; and these intentions,
together with perceptions of behavioral control, account for considerable
variance in actual behavior.

The rates of schedule cesarean section have increased slightly over the
last decade. In 2011, a schedule CS was represented 40% of all women
having a cesarean in England (National Health Service Maternity
Statistics, Hospital Episode Statistics, 2012).

A study conducted in Asia shows that 3.7% pregnant women opt and a
planned cesarean section (Chong & Mongelli, 2003). In addition, a
literature review between 2000 and 2005 indicated that women’s
preference for a cesarean section varied from 0.3 to 14 percent; however,
only three studies looked directly at this preference in the absence of
clinical indications (McCourt et al., 2007). Moreover, the proportion of
Thai pregnant women who prefer and have to an elective cesarean
delivery was 1.5-3 times higher than that from other countries. For
instance, in an Italian, a Scottish and a Swedish this proportion was 4%,
7%, and 8.2% respectively (Yamasmit et al., 2012).

In Thailand, Yamasmit and Chaithongwongwatthana (2012), described

that significant predictors for women’ preference for cesarean delivery,
that belief cesarean delivery could preserve sexual satisfaction that might
be ruined following vaginal delivery, belief that cesarean delivery was
safer for the mother, belief that cesarean delivery was safer for the baby,
and the idea that cesarean section on demand was a patient’s right. In

15
addition, another study showed that the majority of Trinidadian women
(46.2%) were found to have very little information from which to make
informed decisions about selecting CS as the preferred choice of delivery.
Their preference was significantly associated with the perception of
safety (maternal or fetal death), difficulty (complications to mother and
baby), and pain (Mungrue et al., 2010).

Similarly findings, according to Pevzner, Preslicka, Bush, and Chan

(2011) were continuously studied a total of 3,929 women and analyzed of
81.7% of participants that they believed vaginal delivery was a safer
alternative for the mother and 72.8% believed that it was safer for the
fetus. While only 6.1% of women thought that CDMR was a good idea,
most believed that women should have the right to choose their mode of
delivery and that the option should be offered to everyone were 85.9%
and 79.6%, respectively. In addition, out of two hundred and twenty six
women 91.5% preferred vaginal delivery against cesarean section, when
asked for their preferred mode of delivery. The reasons given for
preferring vaginal delivery to cesarean section were natural way to
deliver, safer way to deliver (Ajeet, et al., 2011).A nationwide cross-
sectional telephone survey was done of 505 Korean women. Of the
women who delivered by cesarean section, 10.6 percent stated that they
had requested a cesarean section (Lee, Khang, & Lee, 2004).

Thuyen et al., 2013 conduct study In Vietnam about factors of choosing

CS 19% pregnant women choose cesarean section, for many reasons.
Included 87% thought of the safety of the mother and baby, 57% fear of
pain, 54% influenced by relative preferred cesarean section, 43% thought
that child would become more intelligent, 29% want to choose the good
date and good time for a delivery, and 9% fear of vaginal injury due to
delivery.

16
Besides, Johansson et al. (2010), result of 1105 fathers-to-be in Northern
Sweden was 6.4% of fathers preferred a cesarean section associated with
a preference for cesarean section were a wish to plan the date of the
baby’s birth. Being able to plan the date of the baby’s birth was the
strongest factor related to cesarean section preference among first-time
fathers. Moreover, 7.7% of the women and 6.9% of the partners preferred
a cesarean section as mode of birth. Partners who preferred a cesarean
section as a mode of birth scored higher in wanting a birth that would
allow them to plan the date of birth and that a woman should be able to
decide about having a cesarean section herself (Hildingsson, 2014).

Similarly finding, the men said that knew date and time of birth, this a
positive advantage as this allow them with the opportunity to plan their
life around the arrival of a new baby, “knowing the day and time and
everything meant I could prepare at home, that was an advantage, I could
prepare the baby’s room to be nice” (Johansson, Hildingsson, & Fenwick,
2013). In addition, the commonest sources of information about CS
among those who had requested cesarean delivery were from friends or
relatives (Ajeet et al., 2011; Chong & Mongeli, 2003), media, and health
workers (Ajeet et al., 2011).

1-Longitudinal cohort study was done in a Mid Sweden county in 2011.

where 693 women participated to compare experiences and feelings
during pregnancy and childbirth in women who preferred caesarean
section during pregnancy and were delivered by a planned caesarean
section, and women who preferred to give birth vaginally and actually
had a spontaneous vaginal birth. Women who preferred and actually were
delivered by caesarean section experienced a fear of childbirth to a higher
degree as compared to women with a vaginal birth. Despite a fulfilled
request, women who had a caesarean section were not pleased with the

17
decision making process. In addition, women who had a caesarean
section on request were less satisfied with antenatal care and had a more
negative birth experience, which made them doubt whether they would
have more children.

2-In a prospective cohort study , healthy primiparas from two different

groups, ‘‘cesarean section on maternal request and controls planning a
vaginal delivery completed three self-assessment questionnaires in late
pregnancy, two days after delivery and 3 months after birth. Symptom
scores from the Edinburgh postnatal depression scale at three months
after birth were also investigated. Women requesting cesarean section
experienced their health ass less good and were more often planning for
one child only . They more often reported anxiety for lack of support
during labor ,for loss of control and concern for fetal injury/death . After
planned cesarean section women in this group reported a better birth
experience compared to women planning a vaginal birth They were
breastfeeding to a lesser extent three months after birth There were no
differences in signs of postpartum depression between the groups three
months after birth .

3- Demographic Factors Associated with High C-Section Rates .The most

important characteristic is maternal age. Older (more than 35 years)
nulliparous and multiparous women tend to deliver more by Caesarean
section. In studying contributing factors to Caesarean delivery rates some
investigators have had to control for maternal age in a bid to eliminate
confounders in their results.

4- A retrospective cohort study. Data were collected from original

obstetrical records in different hospitals of Sikkim in 2001 and 2011 to
investigate and compare the rate and indications for CS in the early 2000s

18
as compared to early 2010s. The results revealed that in the year 2001,
the rate of CS at Sikkim was 10.1% and in the year 2011 it rose to
19.4% .The main indications for an elective cesarean in 2001 were
previous CS (24.1%) and Cephalopelvic disproportions (16.5%). In the
year 2011 along with previous CS (31.3%) another dominant indication
for an elective cesarean was a maternal request (29%) for fear of
childbirth without any co-existing medical indication.

5- cross-sectional study was to evaluate the prevalence of CS and their

indications. Performed a retrospective chart review of the indications of
all CS performed at a tertiary care clinic in Switzerland in 2002 and 2008.
to identify rising rate of cesarean sections (CS), especially those on
maternal request, is an important obstetric care issue The number of CS
rose from 23.3% in 2002 to 27.5% in 2008. Of all deliveries, the rate of
CS on maternal request and, among these, especially those requested after
previous CS, increased significantly .The number of CS due to previous
traumatic birth experience nearly doubled. Maternal and fetal
complications were rare but not negligible in the subset

low-risk patients requesting CS. The study demonstrated a significant

increase in CS on maternal request, especially in case of previous CS.
The findings of this study support the need for specific counseling
strategies for women requesting delivery by CS.

Chapter three

Method and procedure

19
This chapter will include description of the methods and procedures
employed by the researcher regarding: determining the methodology,
study design, the population and the sample of the study, and also the
preparation of the tool of the study as well as its validity and reliability, in
addition to description of the procedure employed by the researcher in
executing the study and the statistical treatment used in data analysis.

3.2 Study design

This study is prospective quantitative and descriptive in nature, according

to Polit and Beck, (2004), the quantitative research is a collection and
analysis of numeric information that is typically conducted within the
traditional scientific method which is0020systematic and control. ( Burns
and Grove, 1997) described the descriptive design as a design that
provides information about the phenomenon through observation, and a
picture of situation as naturally happen, and there are used to identify
problems with current practice" (p. 250). Polit and Beck, (2012)
described objectives of descriptive research is the accurate description of
person, situation, or group, and frequency with which certain phenomena
or characteristics occur. They added they describe exploratory research as
a study that explores the dimensions of a phenomenon or develops
hypotheses about the relationships between phenomena. Exploratory
research investigates the full nature of the phenomenon and the manner in
which it is manifested, used to develop or refine research questions or to
test and refine data collection methods, (Polit et al, 2012)

Babbie, (2007) argues that any research design requires researchers to

clearly specify what they want to find out and the best way to do it. Bless
and Higson-Smith (1995) described research design as a specification of
the most adequate operations to be performed in order to test a specific

20
hypothesis under given conditions. The researcher understands the
research design as a structure that clearly specifies what the research
wants to find out and want to do.

The purpose of the study is to explore factors that affect women to choose
CS delivery mode among post-partum women

3.3 RESEARCH METHODS

3.3.1 Sampling

Sampling involves selecting a group of people, events, behaviors, or other

elements which to conduct a study. The sampling theory was developed
to determine mathematically the most effective way to acquire a sample
that would accurately reflect the population under study. Its concepts
include elements, populations, sampling criteria, representativeness,
sampling errors, randomization, sampling frames and sampling plans
(Burns & Grove 2005: 341).

The sampling frame used in this study is post-partum women. The sample
will Purposive sample

3.3.1.1 Study Population

The study population will comprise of women delevierd by elective CS in

RBCS Hospital. The study population was the entire set of individuals
having some common characteristics (Burns & Grove 2005).

The accessible population was the portion of the target population which
comprised of the individuals who conformed to the eligibility criteria and
were available for this particular study. Eligibility criteria is the criteria
that specified the population characteristics used by the researcher that

21
designated the specific attributes of the target population, and which
subjects were selected for participation in this study (Polit & Beck 2008).

3.4 Population and Sample:

The study population will consist of women deleverd by elective CS in

Jerusalem - west bank of Palestine. For the purpose of sample size
determination the convenience sample of 100 women will be choose.

a- Inclusion criteria:

1. Women delivered by Elective CS.

2. Able to give inform consent.

b- Exclusion Criteria:

1. women have history of mental illnesses or medical illnesses

Research procedure and plan of recruitment:

After determining study population, study sample, and developing of data

collection tools, the researcher will approach to clients . After data
collection, the researcher will code and analyze all gathered information
to achieve the set purpose of the study.

3.5 Site and Setting:

This study will conduct in PRCS hospital in Jerusalem distinct of the

Palestine in west bank.

The branch in Jerusalem is considered one of the first Palestinian

humanitarian institutions and projects. The PRCS branch in Jerusalem is
one of the landmarks of Jerusalem. It was established in 1951. The branch
offers social and humanitarian care for the needy and poor people and the

22
families of martyrs and detainees and establishes hospitals and
emergency centers.

One of the main important projects of the PRCS branch in Jerusalem is

the PRCS maternity and obstetrics hospital which was established in
1953 inside the walls of the Holy City. Due to the increasing need for the
services of this hospital, it was moved outside the walls and is currently
located at Mt. of Olives

The Palestine Red Crescent Society Maternity and Obstetrics Hospital:

* The hospital has 42 beds. It is considered one of the leading health

institutions in the field of maternity and obstetrics in Jerusalem. Rate of
delivery reached 250-300 birth cases every month, and rate of surgical
operations reached 80 operations every month. The hospital also includes
an intensive care unit for the newly born babies.

* The hospital has been granted the ISO 9001/2008 certification. And
Joint Commission International (JCI) – Accreditation Standards for
Hospitals 2013.

For the medical staff at the Red Crescent Hospital, there are about 270
employees, including 70 nurses, 34 ambulance workers, 35 doctors, the
rest are maintenance, administrators, kitchen staff, hygiene and
psychological and 7 neonatal specialist doctor.

In spite of the increasing achievements and the current conditions, the

RCSH faces several obstacles and challenges, most notably the
restrictions of the occupation and its various procedures. "The entry of
patients and employees holding the identity of the West Bank to
Jerusalem hospitals is complicated, From any checkpoint or crossing, and

23
there are permits that allow the holder to pass through only certain
checkpoints.

"The Israeli Ministry of Health imposes conditions on doctors and nurses

to obtain an Israeli license to work, as well as hospital authorization and
inspections by the Israeli Ministry of Health," .

There are many hospitals surrounding the RCSH which provide maternity
and women's services, including Al-Makassed Hospital, which includes
the Department of Obstetrics and Gynecology, the number of births per
month 150 cases. In addition to the San john hospital , which opened the
Obstetrics and Gynecology about two years , the number of births about
100-120 cases per month.

3.6 Construction of data collection Instrument

The study questionnaire will be design by the study investigator after

scanning related studies and literature, about is to find out the prevalence
rate of depression and anxiety among pregnant women and the related
associated factors during the period of study. The questionnaire Content
validity will ensure through an intensive literature review of article, and
by discussion with many specialists in this field.

The questionnaire will include items of the intention of elective cesarean

section from English Version of the Childbirth Delivery Options
Questionnaire (ECDOQ) (Tai, 2013).
3.7 Data Collection:

Participation in the study is voluntary and based on the people ability to

give an informed consent, all data and information’s gathered will be
strictly confidential and will not be accessed by any other without prior

24
permission from the participants, moreover, the participant has the right
to withdraw at any time if he cannot complete the questionnaire.

3.9 Data Analysis:

Statistics will compute using the statistical package for the social
Science / personal computer (SPSS / version 21), data analysis is include
descriptive statistics to describe the study sample via mean, median,
range, and frequency.

3.10 Pilot Study

A pilot study will be conducted to determine the reliability and the

validity of the questionnaire. The study was conducted for the period of
through The pilot study aimed to:

1. Estimate the time required for the data collection.

2. Determine the reliability of questionnaires.

3. Obtain the clarity and the content adequacy of the questionnaire.

4. Identify the barriers that may count during the data collection process..

3.11 Ethical Consideration

The study is not considered to cause any harm to the participant.

All participants have the right not to answer any part of the questionnaire
if they consider it will have an adverse effect on them.

Privacy and dignity will ensure in this study, Avoiding harm, right to
withdraw and informed consent

Efforts were made to ensure that participants did not suffer any harm.

25
They treated with honor and respect, the questionnaires were Carefully
phrased to avoid embarrassment or subjecting any participant to any form
of psychological trauma and very sensitive questions were avoided.

Validity:

Validity refers to the degree to which an instrument has an appropriate

sample of items for the construct being measured and adequately covers
the construct domain ( Polit & Beck 2004). The instrument will use in
this study will constructed by the study investigator and valied 2 scales
will be use after reading studies literature . Content validity refers to how
relevant the questions are to the subject under study.

Reliability:

According to Polit & Beck (2004), reliability of an instrument can be

equated to clarity, stability, consistency and accuracy of a measuring tool;
it is the major criterion for assessing its quality and adequacy. Reliability
of the questionnaire ensured by pilot study and measured by using
Coefficient alpha (or Cronbach's alpha), the normal range between (0.00
and 1.00) where the higher value reflect a higher internal consistency of
the questioner items (Polit & Beck, 2012). So you have to check the
reliability fo your questionnaire??

26
Consent Form

I confirms to have read / been explained requests to participate in

research project on “Factors affect women choose of CS. A descriptive
study”

I have been given a copy of your request / project orientation and are
willing to participate in the project. I have received both verbal and
written information about the study, and I´m aware that my participation
is voluntary. I am informed that at any time, without having to explain it
might withdraw from study if I wish. If needed I can be contacted for a
new interview or clarification of ambiguous relationship.

... ... ... ... ... ... ... ... ... ... ... ... ... ..

(Date) (Signature of informant)

The undersigned confirms that she provided information about the project
and has handed over the above a copy of the request / project orientation
and consent to participation.

... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..

(Date) (Signature of project leader)

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