Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data

Strengthening caesarean birth: Sub-Saharan Africa health system evaluation: Scoping review

BACKGROUND

 Promoting safe caesarean birth (CB) is a challenge in sub-Saharan Africa (SSA) where maternal and neonatal mortality rates are high due to inadequate maternal health services. Although the CB rate in SSA is lower than the World Health Organization (WHO) recommendation, it is often associated with high maternal and neonatal mortality.

AIM

 The aim of this scoping review was to report on the extent to which SSA health systems deliver safe CB.

METHODS

 A systematic search across various databases identified 53 relevant studies, comprising 30 quantitative, 10 qualitative and 16 mixed methods studies.

RESULTS

 These studies focused on clinical protocols, training, availability, accreditation, staff credentialing, hospital supervision, support infrastructure, risk factors, surgical interventions and complications related to maternal mortality and stillbirth. CB rates in SSA varied significantly, ranging from less than 1% to a high rate of 29.7%. Both very low as well as high rates contributed to significant maternal and neonatal morbidity. Factors influencing maternal and perinatal mortality include poor referral systems, inadequate healthcare facilities, poor quality of CBs, inequalities in access to maternity care and affordable CB intervention.

CONCLUSION

 The inadequate distribution of healthcare facilities, and limited access to emergency obstetric care impacted the quality of CBs. Early access to quality maternity services with skilled providers is recommended to improve CB safety.Contributions: This scoping review contributes to the body of knowledge motivating for the prioritization of maternal service across SSA.

Preference and Associated Factors for Cesarean Delivery Among Pregnant Women: A Cross-Sectional Study

Objective

A cesarean delivery is regarded as a comparatively favourable and secure approach to childbirth when contrasted with vaginal delivery. Over the past decade, its frequency has risen in both industrialized and developing nations. Maternal request for cesarean delivery has been explained for the escalating rate along with other factors like anxiety, fear of childbirth, previous cesarean delivery, previous negative vaginal birth experience, maternal age, maternal education, and socioeconomic factors. Hence, this study was undertaken to assess pregnant women's tendency to have a cesarean birth and to investigate the factors associated with the inclination for cesarean delivery.

Materials and methods

A hospital-based cross-sectional study was carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, a systematic sampling procedure was utilized, and 368 antenatal mothers after 36 weeks of gestation, who do not have any specific medical reasons against vaginal delivery were included in the study. Data collection was done by questionnaire. The information regarding socio-demographic factors, preexisting comorbidities, current obstetric risk factors, emotional factors, previous delivery experience, and their information preference toward the mode of delivery were collected. Univariate and multivariate analysis were performed to identify the independent variables associated with preference for cesarean delivery.

Results

The preference for cesarean delivery and non-preference for cesarean delivery was 114 (30.9%) and 201 (54.6%), respectively whereas 53 (14.4%) participants remained neutral. The Chi-square analysis revealed a notable connection between the inclination towards a preference for cesarean delivery and factors such as obstetric score, parity, comorbidities, and among obstetric risk factors such as pregnancy after in-vitro fertilization (IVF), with a history of abortion, and having a prior history of cesarean delivery. Nevertheless, no meaningful association was observed between the preference for cesarean delivery and the remaining variables. On multivariate logistic analysis, independent variables like preexisting anxiety or depression, pregnancy through IVF, and having a history of previous cesarean delivery have increased the odds of preferring cesarean delivery. The independent variables like increasing gestational age, graduates, and unemployed have decreased the odds of preferring a cesarean delivery.

Conclusion

In conclusion, the prevalence of cesarean delivery is influenced by a complex interplay of medical, cultural, socioeconomic, and healthcare system factors. While cesarean delivery is essential in cases of medical necessity, efforts should be made to avoid unnecessary cesarean delivery that does not provide clear benefits over vaginal delivery. Balancing the risks and benefits of cesarean delivery and promoting evidence-based obstetric practices are crucial for ensuring optimal maternal and infant outcomes.

A Higher Maternal Education Level Could Be a Critical Factor in the Exceeded Cesarean Section Delivery in Indonesia

Background

Cesarean section (CS) could be life-saving with medically indicated, but without it, both women and children could be at risk. The maximum rate for CS is 15%, but it tends to exceed globally.

Objective

We aimed to analyze the education level's role in the delivery of CS in Indonesia.

Methods

We used the 2017 Indonesia Demographic and Health Survey data. The study sampled 15,357 women who delivered in five last years. Besides delivery mode and education level, the study also used nine control variables: residence, age, marital, employment, parity, wealth, insurance, antenatal care, and birth type. The study employed a binary logistics regression.

Results

The results show women with secondary education (16.5% CS) are 2.174 times (AOR 2.174; 95% CI 1.095-4.316), and higher education (33% CS) are 3.241 (AOR 3.241; 95% CI 1.624-6.469) times more likely to deliver by CS than no-school education (4.4% CS). There was no significant difference between primary (9.1%) and no-education women. Apart from education, primiparous women, age 34-34 yr, attending antenatal care ≥4 times, non-poorest, having insurance, living in the city, and being unemployed also related to higher risk of CS.

Conclusion

Exceeded CS in Indonesia occurs mostly in higher education women. Higher education women were more likely to access more information and technology, therefore health promotion on healthy normal birth on social media or m-Health (mobile device-based health promotion) and involving health authorities at every level were suitable to reduce the overuse of the CS.

Association between the stage of labour during caesarean delivery with adverse maternal and neonatal outcomes among referred mothers to tertiary centres in resource-limited settings

OBJECTIVE

Although the caesarean delivery (CD) rate has substantially increased, little is known about its impacts when performed in the first and second stages of labour on fetomaternal outcomes, especially among referred mothers. Thus, this study aimed to investigate the association between CDs performed during the first and second stages of labour and poor maternal and neonatal outcomes among mothers referred to tertiary centres.

SETTING

This retrospective cohort study analysed medical records of mother-infant pairs from September 2020 to May 2023 in Southern Ethiopia.

PARTICIPANTS

We retrospectively collected data from 848 participants who underwent emergency CD on a referral basis during the study period.

PRIMARY OUTCOME MEASURE

The primary outcomes of interest were adverse maternal and neonatal outcomes. Data were analysed using descriptive and inferential statistics.

RESULTS

Of the 848 CDs, 722 (85.2%) and 126 (14.8%) were performed at the first and second stages of labour, respectively. Caesarean sections performed at the second stage were higher with nulliparity, increased maternal age, and birth weight. Compared with the first-stage CD, the second-stage CD was associated with a significantly increased risk of adverse maternal (OR 3.7, 95% CI 2.4 to 5.7) and neonatal outcomes (OR 2.0; 95% CI 1.3 to 2.9), including neonatal death.

CONCLUSION

Second-stage CDs have an increased risk of adverse maternal and neonatal outcomes. Strengthening and improving obstetric emergency surgical services and intensive neonatal care for those populations would help decrease the maternal and fetal negative consequences.

Individual and community-level factors associated with caesarean section in Haiti: secondary analysis of data from the 2016-2017 Haitian Demographic and Health Survey

INTRODUCTION

For several decades, the rate of caesarean section (CS) has been increasing in the world. In some countries, the CS rate is below the WHO recommended range (10-15%), while in other countries, it is significantly higher. The aim of this paper was to identify individual and community-level factors associated with CS in Haiti.

METHODS

Secondary data analysis was conducted on nationally representative cross-sectional survey data from the 2016-2017 Haitian Demographic and Health Survey (HDHS). The analysis was restricted to 6303 children born in 5 years prior the survey (of the interviewed women). The study population' characteristics, and the prevalence of CS were analysed using descriptive analysis (univariate/bivariate). In addition, multilevel binary logistic regression analysis was performed to identify factors associated with CS. Both descriptive and multivariate analysis were conducted using STATA 16.0 software (Stata Corp, Tex, USA). Statistical significance was declared at p < 0.05.

RESULTS

The overall prevalence of CS delivery was estimated at 5.4% (95% CI 4.8-6.0) in Haiti. Results also revealed that mothers aged 35 and above (aOR = 1.38; 95% CI 1.00-1.96); who attended secondary (aOR = 1.95; 95% CI 1.39-2.76) and higher education level (aOR = 3.25; 95% CI 1.92-5.49); who were covered by health insurance (aOR = 2.57; 95% CI 1.57-4.19); with less than 3 children (aOR = 4.13; 95% CI 2.18-7.85) or 3-4 children (aOR = 2.07; 95% CI 1.09-3.94); who received 9 or more antenatal visits (aOR = 2.21; 95% CI 1.40-3.50) were significantly more likely to deliver by CS. Children in communities with high preponderance of private health facilities had greater odds to be delivered through CS (aOR = 1.90; 95% CI 1.25-2.85). Furthermore, children with an average birth weight (aOR = 0.66; 95% CI 0.48-0.91) were less likely to be delivered through CS than their counterparts with high birth weight.

CONCLUSIONS

While the CS prevalence was low in Haiti, it masks significant geographic, social and economic disparities. To better develop and implement maternal and child health programs that address CS deliveries, the government authorities and NGOs operating in the field of women's health in Haiti should take these disparities into account.

Survival Status, Length of Stay, and Predictors of Mortality Among Neonates Admitted in the Neonatal Intensive Care Unit of Gurage Zone Public Hospitals

Background

Many countries need to accelerate their progress to achieve the sustainable development goal target of neonatal death. It is still high in Ethiopia. Thus, this study aimed to assess the mortality predictors and length of hospital stay among Neonates admitted to the Neonatal Intensive Care Unit of Gurage zone public Hospitals.

Method

In this study, a facility-based retrospective follow-up study was applied among 375 neonates admitted to the NICU of selected public hospitals in the Gurage zone from June 1, 2019 to June 30, 2021. The researchers used Epi-Data entry 3.1 for the data entry and then exported it to STATA version 14 for analysis. The Kaplan-Meier survival curve and log-rank test were used to estimate and compare the survival time of categorical variables, respectively.

Result

The researchers observed about 85 (22.7% with 95%CI: 18.7, 27.2) deaths from the 2305 person-days follow-up. The median survival time was 14 days. The overall incidence density rate was 36.9 per 1000 person-days observed (95%CI: 29.8, 45.6). Perinatal asphyxia (AHR: 2.9[CI: 1.8; 4.8]), cesarean section as a mode of delivery (AHR: 1.1[CI; 1.01; 1.15]), maternal age of greater or equal to 35 years (AHR: 1.1[95% CI: 1.01, 1.15]), and twin pregnancy (AHR: 2.3[95% CI: 1.2, 4.3]) were predictors of neonatal mortality.

Conclusion

The survival rate of neonates was higher compared to other studies. So, to reduce the burden of neonatal mortality, health care providers should give special attention to twin pregnancies, neonates delivered via cesarean section, and neonates with a problem of perinatal asphyxia.

Survival patterns of neonates born to adolescent mothers and the effect of pregnancy intentions and marital status on newborn survival in Kenya, Uganda, and Tanzania, 2014-2016

Background

Adolescent pregnancy and associated neonatal mortality are major global health challenges. In low-income settings where 90% of the 21 million global adolescent pregnancies occur, half are unintended and a fifth experience unsafe abortion. In Kenya, Uganda, and Tanzania, the survival patterns of neonates born to adolescents are unclear.

Objectives

To assess survival patterns among neonates born to adolescents and the effect of pregnancy intentions and marital status on survival in Kenya, Uganda, and Tanzania.

Methods

Cross-sectional data from demographic and health surveys in Kenya, Uganda, and Tanzania 2014–2016 were used. Kaplan-Meier estimates investigated patterns of neonatal survival among adolescent mothers, aged 15–19 years, compared to mothers aged 20–29 years. Cox proportional hazards regression determined the hazard ratios (HR) for the predictors of neonatal survival.

Results

About 50% of adolescent pregnancies were unintended and neonatal death rate was twice as high than older mothers (26.6 versus 12.0 deaths/1000 live births). The median survival time was two days for adolescent-born babies and four days among older mothers. The hazard of death for all adolescent-born neonates was about twofold that of 20–29 years-old-mothers, HR 1.80 (95% CI 1.22–2.63). Among married adolescents with unintended newborn pregnancies, the HR was 4-folds higher than corresponding older mothers, HR 4.08 (95% CI 1.62–10.31). Among married, primiparous adolescents with unintended pregnancies, the HR was six times higher than corresponding older mothers.

Conclusion

Our findings reveal how unintended pregnancies and deaths of neonates born to adolescents contribute substantially to preventable neonatal deaths in East Africa. Full implementation of existing adolescent health policies and utilization of contraceptives should be ensured. Partnership with youths and novel efforts that address sociocultural norms to reduce adolescent pregnancies or marriage should be supported. Regulations requiring adolescents’ obstetric care conducted by only skilled personnel should be introduced and implemented.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century

Introduction

Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates.

Material and methods

This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels.

Results

The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off.

Conclusions

This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study

OBJECTIVE

To investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD).

DESIGN

Prospective cohort study.

SETTING

10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.

PARTICIPANTS

Individual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%-49% across facilities.

PRIMARY OUTCOME MEASURES

Stillbirth, predischarge neonatal mortality and maternal mortality.

RESULTS

The adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral.

CONCLUSION

In this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother-baby dyad is necessary to identify opportunities to improve quality of intrapartum care.

TRIAL REGISTRATION NUMBER

NCT03112018.

Socioeconomic, geographic and health system factors associated with rising C-section rate in Indonesia: a cross-sectional study using the Indonesian demographic and health surveys from 1998 to 2017

INTRODUCTION

Caesarean section (C-section) has been a public health concern globally. This study investigated the change in C-section rate in 1998-2017 in Indonesia and explored the socioeconomic, geographic and health system factors associated with the use of C-section.

METHODS

We analysed data from demographic health surveys in 2002-2003, 2007, 2012 and 2017 in Indonesia. We included women who reported giving birth within 5 years of each round of the survey (n=56 462) into the analysis. Cross-tabulation was used to examine change of C-section rate by year. We conducted bivariate and multivariate logistic regressions to study the determinants of C-section use.

RESULTS

In Indonesia, the C-section rate increased from 4.0% in 1998 to 18.5% in 2017. In 2017, the C-section rate in urban areas (22.9%) was almost two times that in rural areas (11.8%). It was almost three times among the richest wealth quintile (36.5%), compared with the poorest wealth quintile (12.9%). Between 2008 and 2017, the difference in the C-section rate by public services enlarged between the poorest and the richest groups. The absolute increase of the C-sections by private services was more than public services over time. In 2013-2017, the C-section rates by public and private services were 22.5% and 23.1%, respectively. After adjusting for all variables, higher education, higher household wealth, primiparity and use of public childbirth services were positively associated with C-section.

CONCLUSIONS

The C-section rate increased steadily in the past two decades in Indonesia. Women's socioeconomic status and health system factors were associated with the increased use of C-section.

Rationale of indications for caesarean delivery and associated factors among primigravidae in Tanzania

Objective

This study aimed to determine the prevalence of modes of delivery and associated maternal and newborn outcomes among singleton primigravidae in the Iringa region of Tanzania.

Methods

A cross-sectional, analytical hospital-based study was conducted in the Iringa region among 356 singleton primigravidae between April and August 2018. Convenience sampling and consecutive collection of data using a face-to-face interviewer-administered questionnaire was done.

Results

A total of 356 singleton primigravid women with a mean age of 22.0 years (range: 15–49) participated in the study. The majority of the participants (73.0%, n = 250) were in the 20–35 age group. Caesarean and vaginal delivery were performed in 41.3% (n = 147) and 58.7% (n = 209) of the cases, respectively. The maternal height and weight of the newborn were significantly associated with caesarean delivery; (p = 0.001) and (p = 0.029), respectively. After adjusting for all variables, birth asphyxia (AOR = 3.25, 95% CI: 1.867–5.646, p = 0.000) and low birth weight (AOR = 0.03, 95% CI: 0.003–0.211, p = 0.001) were associated with caesarean delivery.

Conclusions

The findings of our study indicated the prevalence of caesarean section to be three times more than that recommended by the World Health Organization. Pregnant women with a height of less than 150 cm should be considered for caesarean section. Therefore, it is necessary for stakeholders in the health sector to formulate guidelines for absolute indications for caesarean section.

Frequentist and Bayesian Regression Approaches for Determining Risk Factors of Child Mortality in Ghana

Background

Child mortality is a global health problem. The United Nations' 2018 report on levels and trends on child mortality indicated that under-five mortality is one of the major public health problems in Ghana with a rate of 60 deaths per 1000 live births. To further mitigate this problem, it is important to identify the drivers of under-five mortality in order to achieve the United Nations SDG Goal 3 target 2.

Methods

In this study, we investigated the effects of some selected risk factors on child mortality using data from the 2014 Ghana Demographic Health Survey. We modelled the relationship between child mortality and the risk factors using a logistic regression model under the frequentist and Bayesian frameworks. We used the Metropolis-Hastings Algorithm to simulate parameter estimates from the posterior distributions, and statistical analyses were carried out using STATA version 14.1.

Results

Results from the frequentist framework are in line with those from the Bayesian framework. The results showed an increased risk of death among children who were delivered through caesarean and reduced relative odds of death among children whose sizes are average or large at birth and whose mothers have formal education.

Conclusions

There is a need for improved health facilities for better health-care for mothers and children. Education should, among other things, emphasise on the need for mothers to go for regular check-ups during antinatal and postnatal periods for improved mother and child health.