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Determinants of unjustified cesarean section in two hospitals southwestern Ethiopia: retrospective record review

  • Tensay Kahsay W/gebriel
  • Tegene Legesse Dadi
  • Kebadnew Mulatu Mihrete
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Abstract

Objective

The study aimed to identify determinants of unjustified cesarean section in two hospitals southwestern Ethiopia using retrospective record review from January 2015 to January 2016.

Result

A total of 727 charts were included in the analysis. About 25% of the study participants had delivered by cesarean section in 1 year. Antenatal care visit (AOR = 0.003, 95% CI 0.00–0.07), labor abnormality (AOR = 10.1, 95% CI 4.61–22.1), and post term pregnancy (AOR = 10.6, 95% CI 4.85–23.1) were significantly associated with cesarean section when compared to their respective counterparts.

Keywords

Cesarean section Determinants Ethiopia 

Abbreviations

ANC

antenatal care

APH

antepartum hemorrhage

AOR

adjusted odds ratio

CI

confidence interval

C/S

cesarean section

CPD

cephalic pelvic disproportion

OR

odds ratio

PROM

premature rupture of membrane

SD

standard deviation

SNNPR

Southern Nations, Nationalities, and Peoples Region

WHO

World Health Organization

Introduction

Giving birth in its natural process is likely to introduced risks for the mother and/or her fetus, irrespective of the route of delivery (cesarean or vaginal delivery) [1]. This declares that the unreserved efforts of health professionals to minimize pregnancy and delivery outcomes with less likely complications in the mother and fetus. To make this cesarean section delivery is one of the obstetric managements introduced [2]. Cesarean section (C/S) is a term commonly used in obstetrics to describe the delivery of a viable fetus through an incision in the abdominal wall (laparotomy) and the uterus (hysterotomy) [3]. Even if C/S delivery can be life-saving for the mother and/or fetus, the quick rise in the rate of C/S delivery without indication to decrease in maternal and neonatal morbidity is overused [4].

Currently, World Health Organization (WHO) stated that there is no additional health benefits associated with a caesarean section rate above 15% [5]. Although WHO estimates the levels of C/S between 10 and 15% were stated as high but conventional at the time, average C/S rates in most developed regions were now exceeded 20% [6]. Increasing caesarean section rate is an issue of public health concern globally for last 30 years; its use has increased since 1970 to a level that is medically unjustified. Thus bringing negative economic and health related repercussions [7]. The study aimed at to identify determinants of unjustified cesarean section in two hospitals southwestern Ethiopia using retrospective record review from January 2015 to January 2016.

Main text

Methods

Institutional based retrospective chart reviews was done to analyze the data from maternal charts registered in the logbook of obstetrics and gynecology units for different health services in Mizan-Tepi university Teaching and Bonga general hospital from January 2015 to January 2016, southwest Ethiopia. The hospitals provide different health care services for about 5 million populations.

Data were collected using questionnaire which was adapted from Ethiopia maternal death surveillance guideline [8]. The tool contains of socio-demographic data, obstetric and delivery history, presence of co-morbidities, and birth outcome. Three midwives and nurses were recruited as data collectors and trained for 2 days prior the data collection time about the objective of the study, ethical considerations and how to collect necessary data from the maternal chart. Overall the data collection process was supervised by two midwives and one registered nurse. In addition, the principal investigators have closely monitored and followed the data collection process.

A total of 763 maternal charts which were registered in obstetrics and gynecology logbook for different maternal care service in 1 year in the two hospitals were reviewed. Of which, 36 charts were incomplete, so discarded from the analysis. Finally 727 maternal charts were included in the analysis.

After data collection, questionnaires were coded by the principal investigators. Data were entered to Epi Data version 3.1 and then exported to STATA version 13.1 for analysis. Descriptive frequency was carried out to check for any entry errors and corrections was made for identified errors.

First bivariate analysis was carried out, and then multivariate logistic regression analysis was used to identify the association between dependent and independent variable and the confounder. Confidence interval of 95% was used to see the precision of the study and the level of significance was taken at p ≤ 0.05. Results were presented in text, tables and figures.

Ethical approval was waived from the college of health sciences Mizan-Tepi university ethical committees according the university ethical clearance rule and regulation. Then, approbation letter was also obtained from the hospital administers and Bench-Maji and Kefa Zonal Health Offices. The maternal information collected from the charts was kept confidential throughout the study.

Result

Out of 763 maternal charts reviewed, 727 were included in the analysis. Majority 567 (77.99%). of the participants were aged at 20–34 years. about 507 (69.7%) study subjects had ANC visit, of which, 252 (50%) had 4 and above ANC visits. From all, 99 (14%) mothers had greater than 24 h length of labor, while 137 (19%) had obstetric complication (PROM, malpresentation, oligo and poly hydamnos). Women who were referred from other facilities accounts 247 (34%). In 8 (1%), 11 (1.5%) and 29 (4%) of the participants had previous C/S delivery, preeclampsia, and vaginal bleeding (Table 1). The overall caesarean section use in the hospitals in this study was 182 (25.07%) (Fig. 1).
Table 1

Obstetrics findings of women attending health service utilization in Mizan-Tepi university teaching and Bonga general hospitals, 2016

Variables

Frequency

Percent

Age in years

 < 20

109

15

 20–34

567

78

 > 34

51

7

No. of gravidity

  

 ≤ 2

484

66.57

 3–4

154

21.18

 ≥ 5

89

12.24

No. of parity

 ≤ 2

590

81.16

 3–4

97

13.34

 ≥ 5

40

5.5

ANC attendance

 No

220

30.26

 Yes

507

69.74

No of ANC visits

 1

135

26.63

 2–3

120

23.67

 ≥4

252

49.7

Referral to the hospitals

 No

480

66.02

 Yes

247

33.98

Length of labour (h)

 < 24

627

86.36

 ≥ 24

99

13.64

Labour abnormality

 No

552

76.03

 Yes

174

23.97

Birth attendant

 Doctors

125

17.22

 Midwives

496

68.32

 Master in emergency obstetrics

105

14.46

Weight of new born (kg)

 < 2.5

29

3.99

 ≥ 2.5

698

96.01

ANC antenatal care, APH antepartum hemorrhage, C/S cesarean section

Fig. 1

Overall cesarean section performed among women attending health service utilization in Mizan-Tepi university teaching and Bonga general hospitals, 2016 (n = 727)

Determinants of unjustified cesarean section

The result of bivariate logistic regression analysis showed that, age, ANC visit, gravidity, referral history, obstetric complication, post term pregnancy, labour abnormality, and the weight of fetus were associated with cesarean section (Table 2). However, on multivariable variable logistic regression analysis ANC visit, referral history, labour abnormality, obstetric complication, weight of fetus, and post term pregnancy were found to be significantly associated with cesarean section as clearly depicted on table below (Table 2).
Table 2

Determinants of cesarean section among women attending health service utilization in Mizan-Tepi university teaching and Bonga general hospitals, 2016 (n = 727)

Variables

Frequency (%)

Crude OR (95%)

Adjusted OR

95% CI

p-value

Age category

 < 20

109 (14.99)

Reference group

    

 20–34

567 (77.99)

0.370 (0.307, 0.445)

 

3.843

(1.246, 11.86)

0.019

 > 34

51 (7.02)

0.700 (0.401, 1.223)

 

4.514

(0.807, 25.24)

0.086

No. of gravidity

 ≤ 2

484 (66.57)

0.295 (0.238, 0.365)

0.153

2.042

(0.767, 5.441)

0.153

 3–4

154 (21.18)

0.426 (0.302, 0.601)

0.950

1.034

(0.357, 2.995)

0.95

 ≥ 5

89 (12.24)

Reference group

    

ANC attendance

 No

220 (30.26)

Reference group

    

 Yes

507 (69.74)

0.281 (0.228, 0.347)

 

0.003

(0.000, 0.07)*

< 0.001

Number of ANC visits

 1

135 (26.63)

0.288 (0.192, 0.433)

 

1.215

(0.592, 2.49)

0.596

 2–3

120 (23.67)

0.237 (0.151, 0.37)

 

0.744

(0.365, 1.52)

0.417

 ≥ 4

252 (49.7)

Reference group

    

Referred

 No

480 (66.02)

Reference group

    

 Yes

247 (33.98)

0.388 (0.294, 0.512)

 

0.41

(0.19, 0.86)*

0.019

Length of labour (h)

 < 24

627 (86.36)

Reference group

    

 ≥ 24

99 (13.64)

0.800 (0.538, 1.189)

 

1.172

(0.512, 2.68)

0.706

Labour abnormality

 No

552 (76.03)

Reference group

    

 Yes

174 (23.97)

1.260 (0.934, 1.699)

 

10.089

(4.61, 22.1)*

< 0.001

Obstetric complications

 No

590 (81.16)

Reference group

    

 Yes

137 (18.84)

1.894 (1.330, 2.696)

 

10.579

(4.9, 23.06*)

< 0.001

Post term pregnancy

 No

704 (96.84)

Reference group

    

 Yes

23 (3.16)

22.00 (2.96,163.21)

 

10.000

(1.14, 87.9)*

0.038

Placenta previa

 No

716 (98.49)

Reference group

    

 Yes

11 (1.51)

1.200 (0.366, 3.932)

 

0.632

(0.04, 10.13)

0.0746

APH

 No

698 (96.01)

Reference group

    

 Yes

29 (3.99)

0.933 (0.451, 1.934)

 

1.382

(0.116, 16.4)

0.798

Multiple gestation

 No

697 (95.87)

Reference group

    

 Yes

30 (4.13)

0.071 (0.017, 0.300)

 

0.078

(0.008, 0.8)*

0.028

Weight of new born (kg)

 < 2.5

29 (3.99)

Reference group

    

 ≥ 2.5

698 (96.01)

0.351 (0.296, 0.415)

 

5.598

(0.35, 90.1)*

0.024

ANC antenatal care, APH antepartum hemorrhage, C/S cesarean section

* Shows significantly association at 95% CI, p-value of < 0.05

There is strong association between ANC visit and cesarean section. Those who had ANC follow up were 99% less likely to have cesarean section than their counterparts (AOR = 0.003, 95% CI 0.00–0.07). And those who were referral to come to the hospitals were 3 times increased the odds of having cesarean section than their counterparts (AOR = 3, 95% CI 0.195–0.862) (Table 2).

Labour abnormality was also significantly associated with cesarean section. Women who had labour abnormality were 10 times at increased risk of cesarean section when compared to their counterparts (AOR = 10.1, 95% CI 4.61–22.1). Similarly those who had post term pregnancy were 10 times more likely to be at risk for cesarean section than their counterparts (AOR = 10.6, 95% CI 4.85–23.1) and Women who were multiple gestations where 92% less likely to have unjustified C/S compared to their counterparts (Table 2).

Infant weight greater than 2.5 kg were 5.6 times more at risk for cesarean section than those whose infant weight less than 2.5 kg (AOR = 5.6, 95% CI 0.35–90.11). Significant association was observed between obstetric complications and C/S. That is those who had obstetric complications 10 times odds of cesarean section than their counterparts (AOR = 10.5, 95% CI 4.85, 23.1) and women waving length of labour, placenta previa and APH were not significantly associated with unjustified C/S (Table 2).

Discussion

In this study the proportion of women who underwent C/S delivery in the study hospitals was 25%. This result is inline with findings showed in other parts of Ethiopia [9, 10, 11]. On the other hand, it was less than the study that was conducted in Ethiopia [12] and outside of Ethiopia [13, 14]. However, it is unjustified than World Health Organization (WHO) recommendation which is 5–15%. That is the frequency of cesarean section depends on the socio-demographic pattern, hospital policies regarding management of cases of dystocia, mal presentation and previous cesarean section, and consideration of maternal choice and wishes. This magnitude C/S may be attributed to high number of referred cases and the catchment areas with the two hospitals.

The study also showed that ANC visit has significant association with cesarean section. That is those who had ANC visit were 99% less likely for cesarean section than their counterparts. This is similar with the finding of [9]. It also showed that, those who had obstetric complication, like APH, preeclampsia, and multiple gestations were 10 times increase the odds of having cesarean sections when compared with those who did not have obstetric complication. This finding is in line with the findings that was done in other parts of Ethiopia [9, 15] and outside of Ethiopia [16, 17, 18].

There is also a significant statistical association between labour abnormality and cesarean section. That is women who had labor abnormality such as mal presentation were 10 times increase the odds of having cesarean section than those did not have labour abnormality. This finding was in agreement with the study findings that were done inside country [9, 10] and outside of the country [18]. And those women who had baby weight greater than 2.5 were 5.6 times increase the likely hood of having cesarean section than their counter parts. This finding is in line with other study findings which were done in other parts of Ethiopia [10, 11] and outside [19]. This might be explained by when the weight of the fetus becomes large, it might lead to cephalo-pelvic disproportion which is the major indication for cesarean section.

Those women who come by referral from different health institutions were 59% less likely for C/S than those who did not haves. The current finding is different from findings that were done in Attat Hospital, Ethiopia, which implicates those referred women were most likely to C/S [9]. It might be explained by those who were referred might be self-referral for better investigation and might get early intervention other than C/S augmentation and instrumental delivers most helpful to minimize C/S.

Conclusions and recommendations

The study showed that the overall cesarean section performed in 1 year was 25% in the study hospitals. It is above 15%, which is recommended by WHO for developing countries, so this indicates unjustified use of the service in the study areas. If it is not seen critically, the rate might reach intolerable levels. It is fact; Cesarean section that is performed for appropriate medical or obstetric indications is life saving for both the mother and the new born. But the unjustified use of C/S, does not mean that the perinatal outcome is improved rather it has risks for the mother and the neonate. The study also showed that post-term pregnancy, labour abnormality, baby weight, ANC visit, and referral history were determinants to unjustified cesarean section in the study area.

Health extension worker should work in strengthen manner in the community to increase the uptake of ANC utilization. In order to decrease high use of C/S, each woman should be carefully assessed and followed to identify the option for vaginal delivery.

Limitation of study

  • Since this is secondary data it has limitation related with missing of information or pertinent variables.

Notes

Authors’ contributions

TLD, KMM and TKW conceived the study, involved in the study design, data analysis, drafted the manuscript and critically reviewed the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to acknowledge Bench Maji, and Kefa Zonal Health Office for their cooperation in conducting this study. We would like to express our deepest gratitude for data collectors for their hard work and sincere contribution.

Competing interests

The authors declare that they have no competing interests.

Available of the data and materials

The datasets used during the current study is available from the corresponding author on reasonable request.

Consent for publication

Not applicable as there is no image or other confidentiality related issues.

Ethics approval and consent to participate

Ethical approval was waived from the college of health sciences Mizan-Tepi university ethical committees according the university ethical clearance rule and regulation by the Reference Number of MTU/05/1264/444/2016.

Funding

This study was funded by Mizan-Tepi University.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. 1.
    Guise JM, Eden K, Emeis C, Denman MA, Marshall N, Fu R, et al. Vaginal birth after cesarean: new insights. Evidence report/technology assessment no. 191. AHRQ publication no. 10-E003. Rockville (MD): Agency for healthcare research and quality; 2010. http://www.ahrq.gov/research/findings/evidence-based-reports/vbacup-evidence-report.pdf. Accessed 7 Nov 2013.
  2. 2.
    Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC III, Hauth JC, Wenstrom KD. Williams obstetrics. 21st ed. New York: McGraw-Hill; 2001. p. 1668.Google Scholar
  3. 3.
    Scott JR, Gibbs RS, Karlan BY, Haney AF. Danforth’s obstetrics and gynecology, 9th edn. Lippincott williams & wilkins; 2003.Google Scholar
  4. 4.
    Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012;29:7–18.CrossRefPubMedGoogle Scholar
  5. 5.
    Belizan JM, Althabe F, Barros FC, et al. Rates and implications of caesarean sections in Latin America. BMJ. 1999;319:1397–402.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Betrán AP, Merialdi M, Lauer JA, Bing-shun W, Thomas J, Van Look P, et al. Rates of caesarean section: analysis of global, regional and national estimates. Pediatric Perinatal Epidemiol. 2007;28:98–113.CrossRefGoogle Scholar
  7. 7.
    Padua KS, Osis MJ, Faunder A, Barbosa AH, Filho OB. Factors associated with caesarean section in Brazilian hospitals. Rev Saude Publica. 2010;44(1):70–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Federal Democratic Republic of Ethiopia Ministry of Health. Maternal death surveillance and response (MDSR) technical guideline. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2012.Google Scholar
  9. 9.
    Moges A, Ademe B, Akessa G. Prevalence and outcome of caesarean section in Attat Hospital, Gurage Zone, SNNPR, Ethiopia. Arch Med. 2015;7:4.Google Scholar
  10. 10.
    Fantu E, et al. Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review. Reprod Health. 2016;13:6.Google Scholar
  11. 11.
    Abdissa Z, Awoke T, Belayneh T, Tefera Y. birth outcome after caesarean section among mothers who delivered by caesarean section under general and spinal anesthesia at Gondar University Teaching Hospital North-West Ethiopia. J Anesthe Clin Res. 2013;4:335.  https://doi.org/10.4172/2155-6148.1000335.CrossRefGoogle Scholar
  12. 12.
    Hussen A, Shiferaw N, Lukman Y. Cesarean delivery practices in teaching public and non- government/private MCH hospitals, Addis Ababa. Ethiop J Health Dev. 2014;28(1):22–8.Google Scholar
  13. 13.
    Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS Data Brief. 2010;(35):1–8.Google Scholar
  14. 14.
    Althabe F, Sosa C, Belizán JM, Gibbons L, Jacquerioz F, et al. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: an ecological study. Birth. 2006;33:270–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Tsega F, Mengistie B, Dessie Y, Mengesha M. Prevalence of cesarean section in urban health facilities and associated factors in eastern Ethiopia: hospital based cross sectional study. J Preg Child Health. 2015;2(3):169–73.Google Scholar
  16. 16.
    Patel R, Peters T, Murphy D. Prenatal risk factors for caesarean section. Analyses of the ALSPAC cohort of 12,944 women in England. Int J Epidemiol. 2005;34(2):353–67.CrossRefPubMedGoogle Scholar
  17. 17.
    Karim F, et al. Trends and determinants of ceasarean section. Surg Pakistan. 2011;16:1.Google Scholar
  18. 18.
    Kathryn C, et al. Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from medicines Sans Frontieres. PLoS ONE. 2012;7(9):e44484. http://www.plosone.org.
  19. 19.
    Stivanello E, et al. Determinants of cesarean section delivery: a classification tree analysis. BMC Pregnancy Childbirth. 2014;4(215):1471–2393.Google Scholar

Copyright information

© The Author(s) 2018

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Tensay Kahsay W/gebriel
    • 1
  • Tegene Legesse Dadi
    • 2
  • Kebadnew Mulatu Mihrete
    • 2
  1. 1.School of Nursing, College of Health SciencesMekelle UniversityMekelleEthiopia
  2. 2.Department of Public Health, College of Health SciencesMizan-Tepi UniversityMizanEthiopia

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