The present study was a descriptive cross-sectional study which was carried out in the Department of Obstetrics and Gynaecology of Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria. It is a referral centre and the only teaching hospital in the state. Ethical approval for the study was obtained from the Health Research and Ethics Committee of the hospital. The ethical approval number is FETHA/REC/VOL1/201/561. Informed written consent was obtained from the study population.

The study population was recruited between October 2017 and April 2018 which included consenting women attending a gynaecological clinic using structured self-administered questionnaires adapted from previous studies [2,3,7-9]. The questionnaires were pretested for clarity, assessment of the length of time for administration, and comprehension. It was pretested with 30 women not included in the study population with good internal consistency and reliability (Cronbach alpha of 0.82). It took 5-10 minutes to complete the questionnaire. The questionnaire assessed the socio-demographic characteristics of the respondents and the opinions and preferences of the patients on the use of chaperones during pelvic examinations based on the gender of the examining doctor.

Sample size calculation: The minimum sample size (N) was calculated using the formula:

Where

Z=standard normal deviation at 95% CI=1.96

p=0.5 which is the probability of the event occurring, assuming that 50% of women in the study area uses the services of a chaperone during pelvic examination by a doctor

q=1-p=0.5 which is the probability of the event not occurring

e=sampling error of 5%=0.05

N=(1.96)²×0.5×0.5/(0.05)²=384.16

An attrition rate of 10% was added to the sample size hence, the final sample size was approximately 423. The study population was consenting women who came for an initial Gynaecological clinic consultation at our facility.

Inclusion and Exclusion criteria: The study population was a congregation of women from different strata of the society including women on the first visit, those on a return visit, those referred from the general Out Patient Department (OPD), and those referred to the clinic from peripheral hospital. Women on return visits and those who required urgent medical attention were excluded.

Information about the study was given to the gynaecological attendee and their consent sort and those that were selected for the study were further counseled and written consent obtained. They were recruited using the ballot method of the simple random sampling method. An opaque bag containing an equal number of cards that were marked “yes” (inclusion) and “no” (exclusion) was used for the selection of the study population. They were asked to pick a card with replacement from the bag and the selection of a card marked “yes” meant inclusion into the study. The questionnaire was conducted just before the clinic consultation.

The data obtained were analysed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). The results were presented in frequency tables, charts, and contingency tables for categorical variables while continuous variables were presented as mean±SD (Standard Deviation). Chi-square test was used to determine the association of some of the socio-demographic characteristics and preference of chaperone for a pelvic examination. The level of significance was set at p<0.05.

Three hundred and ninety-five respondents completed the survey. This gave a response rate of 93.4%. The mean age was 29.2±6.2 years, while the modal age group was 21-34 years. The majority of the respondents were grand multiparous, married, and had at least a secondary education [Table/Fig-1].

The majority of the respondents would prefer to be seen by a female gynaecologist 342 (86.6%). Out of the 395 respondents, 345 (87.3%) would allow a pelvic examination done on them in the course of their clinical evaluation. More than two-third 264 (76.5%) would prefer to have a chaperone present at any pelvic examination. Avoidance of sexual molestation was the commonest reason given for wanting a chaperone to be present 207 (78.4%), next to this was to allow the women to relax during the pelvic examination. More than half of the respondents would prefer a nurse to be the chaperone 148 (56.1%) [Table/Fig-2].

Age and the marital status of the respondents were not a significant determinant of the requirement for a chaperone. However, nulliparous women were more likely to request for a chaperone to be present at pelvic examination compared with parous women (OR=2.25 95%CI 1.13-4.50). Women who had at least a secondary education were also more likely to request for a chaperone to be present at the examination compared with women who had primary education (OR=7.91 95%CI 4.54-13.78) [Table/Fig-3].

The proportion of respondents that would prefer to be examined in the presence of a chaperone in this study was 76.5%. This is similar to the 75-90% reported in Caucasians by Baker R et al., [10]. This value is also similar to the 75% as reported by Fan VC et al., among Chinese women [12]. In contrast, Baber JA et al., had previously reported a rate of 32% acceptance in Australia [11], other similar studies had reported an acceptance rate of between 54 to 65% [5,7,13,14]. This may suggest an increase in awareness among the populace as more women are increasingly becoming aware of the importance of the presence of a chaperone during pelvic examination [2].

There are still many misconceptions about the benefits of pelvic examination among the respondents. About 13% of the respondents would decline a pelvic examination, the commonest reason given for not allowing pelvic examination is the perception that the clinic setting is uncomfortable for such clinical examination. Others feel the examination would be painful or make them feel embarrassed. Hence, there is an urgent need to provide privacy in the clinics to enable the client to feel at ease. These negative sentiments towards pelvic examination have also been reported by other authors in similar studies [2].

On the preference of the gender of the examining clinician, consistently most women would prefer female gynaecologist irrespective of culture and religious differences [8]. In this study, 86.6% of the respondent would prefer to be seen by a female Gynaecologist/clinician. This value is similar to the 83% reported by Fan VC et al., among Chinese women [12], in that study none of the respondents wanted a male doctor if allowed to choose [12]. In Asia and Islamic societies, there is a huge preference for female physicians according to the study by Rizk DE et al., at United Arab Emirate [15]. In other African countries, a similar trend had been reported. However, a lower preference rate of 51.7% had been reported in a similar local study by Nkwo PO et al., [5]. The preference for female Gynaecologist may not be unrelated to the fact that they feel a female doctor is more likely to understand their complaints [2] and probably less likely to sexually abuse her because of the same sex.

The most important reason why some of the respondents needed a chaperone during the pelvic examination was to prevent the actual occurrence of false accusations of sexual abuse during the examination process [9]. In this study, about 78.4% of those who preferred to be examined in the presence of a chaperone did so to avoid sexual molestation during the pelvic examination. This is one of the concerns of women during pelvic examination [5,6]. Others would prefer to be examined in the presence of a chaperone to enable them to relax. This is at variance with the finding by Amaechina OU et al., where it was reported by some clients that the presence of a chaperone makes the clients agitated and invariably leading to a more discomforting pelvic examination [8].

Nurses are the preferred choice as a chaperone, in this study, 56.1% of the respondents preferred a nurse to be the chaperone; this is similar to the report in other studies. Nkwo PO et al., showed that 83% of their respondents preferred nurses [5], Amaechina OU et al., also reported such preference for nurses [8]. In contrast, Afaneh I et al., noted that most clients in their study preferred their partners as chaperones while teenagers consistently preferred their mothers [14]. The choice of the chaperone is largely dependent on the prevailing environment of the clinic. Many clinics in sub-Saharan Africa are very busy and oftentimes overcrowded and this may limit the use of chaperones in such facilities.

In this study, the age and the marital status of the respondents were not significant determinants of the requirement for a chaperone. Nkwo PO et al., and Fan VC et al., had previously noted that age, educational status, and parity of the patient did not have a significant relationship with the attitude of the respondents towards the presence of chaperones during pelvic examinations [5,12]. However, Amaechina OU et al., had noted that the age of the respondents was an important determinant to the presence and choice of chaperone [8]. Increase in educational attainment by a woman is associated with increased odds of a woman requesting for a chaperone, this assertion was noted in this study as at least a secondary education was an important factor to preferring a chaperone at a pelvic examination. As noted in this study nulliparous women were more likely to request for a chaperone to be present at pelvic examination compared with parous women which is supported by earlier findings [13].

The study is based in the only teaching hospital in the state and the findings from present study could not be generalised on the total population of women in the study area. However, effort was made to limit study population bias by using a probability sampling method in study population selection. There may have been recall bias and some respondents may have been reluctant to disclose information as they might view the interview as an audit of care they have received from the referring hospital. They might fear a possible retributive action from the management. An effort was, however, made to avoid this by interviewing them in a dedicated office and making sure that their identity is not on the questionnaire. The finding in present study might be influenced by the tool used in accessing it. An effort was however, made to reduce these errors by educating the respondent on the study instrument and pretesting the instrument before applying it in the field.

This study has shown that majority of the respondent would prefer a chaperone to be present during pelvic examination and this wish was influenced by the respondent’s parity and education status. It is therefore important that an effort should be made by a gynaecologist to invite a chaperone during a pelvic examination. This will help to assuage the fear of women of been sexually molested during such examinations as seen in this study. It will also help to reduce the risk of legal action against doctors as a misinterpretation of a doctor’s action may occur. Authors therefore, would recommend that a routine offer of a chaperone during the pelvic examination should be done to all women while respecting the patient’s right to refuse.

Authors’ contributions: CCA and CJI: Study design, data collection/analysis, and interpretation of findings, and drafting of the manuscript. COO, OEN, CCI, FCO and BCO: Interpretation of findings and drafting of the manuscript. All participated in the review of the final manuscript. All the authors approved the manuscript.