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Ghosh R, Santos N, Butrick E, Wanyoro A, Waiswa P, Kim E, Walker D. Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study. BMJ Open 2022; 12:e055904. [PMID: 35387820 PMCID: PMC8987792 DOI: 10.1136/bmjopen-2021-055904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 03/09/2022] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- University of California San Francisco, San Francisco, California, USA
| | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Eliana Kim
- University of California San Francisco, San Francisco, California, USA
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- University of California San Francisco Department of Obstetrics Gynecology and Reproductive Sciences, San Francisco, California, USA
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Reducing Decision to Incision Time Interval for Emergency Cesarean Sections: 24 Months' Experience from Rural Sierra Leone. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168581. [PMID: 34444330 PMCID: PMC8392021 DOI: 10.3390/ijerph18168581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 12/02/2022]
Abstract
Background: This study aimed at describing the changes in the completeness of documentation and changes in decision to incision time interval of emergency cesarean sections after an audit and feedback project a rural hospital in Sierra Leone. Methods: We documented and monitored the decision and incision times for emergency cesarean sections over the course of two years. Year one focused on the introduction of the project and year two focused on the continuous monitoring of the project. We compared the completeness of decision to incision data and used the 30-min benchmark as target for the decision to incision time interval. Results: A total of 762 emergency cesarean sections were included. While the completion of decision time data (72%) did not change between the two reporting periods, documentation of incision time increased from 95% to 98% (p < 0.001). Complete documentation for both decision and incision time was available for 540 (70.9%) emergency cesarean sections. The decision to incision time interval decreased from 105 min to 42 min (p < 0.001). The proportion of cesarean sections started within 30 min increased from 8.5% to 37% (p < 0.001). Conclusion: Although not all cesarean sections were performed within the 30-min threshold, the decision to incision interval decreased significantly. Improvements in documentation and routine reporting of the decision to incision time interval is recommended.
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van Duinen AJ, Adde HA, Fredin O, Holmer H, Hagander L, Koroma AP, Koroma MM, Leather AJ, Wibe A, Bolkan HA. Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone. BMJ Glob Health 2020; 5:e003943. [PMID: 33355267 PMCID: PMC7754652 DOI: 10.1136/bmjgh-2020-003943] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.
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Affiliation(s)
- Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håvard A Adde
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ola Fredin
- Geological Survey of Norway, Trondheim, Norway
- Department of Geography, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Hagander
- Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alimamy P Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Michael M Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew Jm Leather
- King's Centre for Global Health & Health Partnerships, King's College London, London, UK
| | - Arne Wibe
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Mooij R, Mwampagatwa IH, van Dillen J, Stekelenburg J. Association between surgical technique, adhesions and morbidity in women with repeat caesarean section: a retrospective study in a rural hospital in Western Tanzania. BMC Pregnancy Childbirth 2020; 20:582. [PMID: 33012289 PMCID: PMC7534160 DOI: 10.1186/s12884-020-03229-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 09/01/2020] [Indexed: 11/18/2022] Open
Abstract
Background The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. Methods A cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012. Results Of the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%). Conclusions Our results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.
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Affiliation(s)
- R Mooij
- Ndala Hospital, 15, Ndala, Tanzania. .,Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, The Netherlands.
| | - I H Mwampagatwa
- College of Health Sciences, University of Dodoma, 395, Dodoma, Tanzania
| | - J van Dillen
- Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - J Stekelenburg
- Leeuwarden Medical Centre, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.,University Medical Centre Groningen/University of Groningen, Antonius Deusinglaan 1, 9700 AD, Groningen, The Netherlands
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