Determinants of non-medically indicated cesarean deliveries in Burkina Faso

OBJECTIVE

To identify the factors associated with non-medically indicated cesarean deliveries (NMIC) in Burkina Faso in centers where user fees for cesarean delivery were partially removed.

METHODS

We carried out a criteria-based audit in 22 referral hospitals, using data from a 6-month prospective observational study, to assess the proportion of NMIC. Multivariate logistic regression analyses were used to identify factors associated with NMIC.

RESULTS

The decision of cesarean delivery was not medically indicated in 24% of cases. The factors independently associated with NMIC were urban residence (adjusted OR 1.55; 95% CI, 1.12-2.12; P=0.006), spouse's occupation other than breeder or farmer (aOR varying from 1.77 [95% CI, 1.19-2.62] to 2.15 [95% CI, 1.38-3.32] according to the profession), and cesarean decided by a general practitioner (aOR 1.61; 95% CI, 1.13-2.30; P=0.009).

CONCLUSION

The high percentage of unnecessary cesarean deliveries is in contrast to the unmet needs of women who still deliver outside health facilities. NMIC is associated with both socioeconomic determinants and medical factors. Hence, interventions are needed to improve the skills of healthcare professionals and awareness of women concerning the risks associated with unnecessary cesarean delivery.

Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study

BACKGROUND

To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.

METHODS

A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249).

RESULTS

The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect.

CONCLUSIONS

Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities.

TRIAL REGISTRATION

This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).