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Etcheverry C, Betrán AP, de Loenzien M, Kaboré C, Lumbiganon P, Carroli G, Mac QNH, Gialdini C, Dumont A. Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries. Midwifery 2024; 132:103979. [PMID: 38520954 DOI: 10.1016/j.midw.2024.103979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 03/11/2024] [Accepted: 03/18/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE To measure the proportion of women's preferences for CS in hospitals with high caesarean section rates and to identify related factors. DESIGN A cross-sectional hospital-based postpartum survey was conducted. We used multilevel multivariate logistic regression and probit models to analyse the association between women's caesarean section preferences and maternal characteristics. Probit models take into account selection bias while excluding women who had no preference. SETTING Thirty-two hospitals in Argentina, Thailand, Vietnam and Burkina Faso were selected. PARTICIPANTS A total of 1,979 post-partum women with no potential medical need for caesarean section were included among a representative sample of women who delivered at each of the participating facilities during the data collection period. FINDINGS The overall caesarean section rate was 23.3 %. Among women who declared a preference in late pregnancy, 9 % preferred caesarean section, ranging from 1.8 % in Burkina Faso to 17.8 % in Thailand. Primiparous women were more likely to prefer a caesarean section than multiparous women (β=+0.16 [+0.01; +0.31]; p = 0.04). Among women who preferred caesarean section, doctors were frequently cited as the main influencers, and "avoid pain in labour" was the most common perceived benefit of caesarean section. KEY CONCLUSIONS Our results suggest that a high proportion of women prefer vaginal birth and highlight that the preference for caesarean section is linked to women's fear of pain and the influence of doctors. These results can inform the development of interventions aimed at supporting women and their preferences, providing them with evidence-based information and changing doctors' behaviour in order to reduce the number of unnecessary caesarean sections. CLINICAL TRIAL REGISTRY The QUALI-DEC trial is registered on the Current Controlled Trials website (https://www.isrctn.com/) under the number ISRCTN67214403.
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Affiliation(s)
- Camille Etcheverry
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Campus Saint-Germain-des-Prés, 45 rue des Saints-Pères, Paris 75006, France.
| | - Ana Pilar Betrán
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Myriam de Loenzien
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Campus Saint-Germain-des-Prés, 45 rue des Saints-Pères, Paris 75006, France
| | - Charles Kaboré
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Celina Gialdini
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina; Facultat de Ciències de la Salut Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | - Alexandre Dumont
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Campus Saint-Germain-des-Prés, 45 rue des Saints-Pères, Paris 75006, France
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2
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Faysal S, Penn-Kekana L, Day LT, Tripathi V, Khan F, Stafford R, Levin K, Campbell O, Filippi V. Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review. Int J Gynaecol Obstet 2024; 165:43-58. [PMID: 37698080 DOI: 10.1002/ijgo.15079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs). OBJECTIVES To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature. SEARCH STRATEGY The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS. SELECTION CRITERIA English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included. DATA COLLECTION AND ANALYSIS A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework. MAIN RESULTS Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels. CONCLUSIONS There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.
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Affiliation(s)
- Sumeya Faysal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Louise-Tina Day
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Farhad Khan
- EngenderHealth, Washington, District of Columbia, USA
| | | | - Karen Levin
- EngenderHealth, Washington, District of Columbia, USA
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Veronique Filippi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Osaki H, Sørensen JB, Maaløe N, Mbekenga C, Skovdal M. "It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania. Midwifery 2024; 130:103926. [PMID: 38217929 DOI: 10.1016/j.midw.2024.103926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/11/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania. DESIGN A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis. SETTING This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care. PARTICIPANTS Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility. FINDINGS Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility. KEY CONCLUSIONS The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities. IMPLICATIONS FOR PRACTICE Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision. TRIAL REGISTRATION NUMBER NCT04685668 Date of initial trial registration: December 28th, 2020.
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Affiliation(s)
- Haika Osaki
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania.
| | | | - Nanna Maaløe
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania
| | - Columba Mbekenga
- School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania; Faculty of Nursing, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Cleeve A, Annerstedt KS, Betrán AP, Mölsted Alvesson H, Kaboré Wendyam C, Carroli G, Lumbiganon P, Nhu Hung MQ, Zamboni K, Opiyo N, Bohren MA, El Halabi S, Gialdini C, Vila Ortiz M, Escuriet R, Robson M, Dumont A, Hanson C. Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol. Glob Health Action 2023; 16:2290636. [PMID: 38133667 PMCID: PMC10763892 DOI: 10.1080/16549716.2023.2290636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023] Open
Abstract
The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.
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Affiliation(s)
- Amanda Cleeve
- Department of Women’s and Children’s Health, Karolinska Institutet, and Karolinska University Healthcare facility, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | | | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Karen Zamboni
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- The Global Fund, Geneva, Switzerland
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Meghan A. Bohren
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Soha El Halabi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Celina Gialdini
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
- Faculty of Health Sciences, Fundacio Blanquerna, Barcelona, Spain
| | - Mercedes Vila Ortiz
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - Ramón Escuriet
- Faculty of Health Sciences, Fundacio Blanquerna, Barcelona, Spain
- Department of Health, Government of Catalonia, Spain
| | - Michael Robson
- The National Maternity Hospital and University College Dublin, National University of Ireland, Dublin, Ireland
| | - Alexandre Dumont
- Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Faruk MO, Arafat ME, Shanta SH. Socioeconomic, demographic, and cultural determinants of delivery by caesarian section in Ethiopia: Evidence from Ethiopia Mini Demographic and Health Survey 2019. PLoS One 2023; 18:e0288022. [PMID: 37410743 DOI: 10.1371/journal.pone.0288022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/16/2023] [Indexed: 07/08/2023] Open
Abstract
Delivery by cesarean section is a surgical procedure of delivery to a newborn baby, and the process is applied when vaginal delivery is unsafe. This study aims to identify the socioeconomic, demographic, and cultural factors that significantly impact the delivery by caesarean section. The 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS) data were used to conduct this research, and this study considered 2872 ever-married women all over the country who delivered in the clinical setting. Firstly, a frequency distribution table has been constructed to understand the characteristics of the selected explanatory and study variables. Then Chi-square test identifies the association between various socioeconomic and demographic factors and delivery by the caesarian section. Finally, the Binary Logistic Regression was used to determine the factors that substantially impact the caesarian section among women in Ethiopia. The Chi-square test of association showed that mother's age, type of residence, highest education level, religion, socioeconomic status, total children ever born, use of contraception, age of mothers at first birth, and preceding birth interval were significantly associated with the caesarian section. The multivariate binary logistic regression analysis revealed that the mother's current age (Age Group: 31-40; Odds Ratio: 2.487, p<0.05) and religion (Muslim; Odds Ratio: 0.599, p<0.05) substantially influenced the study feature. Moreover, the highest educational level (Secondary and higher; Odds Ratio: 1.581, p<0.05), and the preceding birth interval (>40 months; Odds Ratio: 0.682, p<0.05) were also found to have considerable impacts on the caesarian section. Furthermore, the total number of children ever born (>5; Odds Ratio: 0.498, p<0.05) significantly impacts the delivery by caesarean section in Ethiopia. This study's results would be useful to policymakers to take necessary steps to reduce unnecessary delivery by caesarian section and ensure a safer newborn delivery process.
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Affiliation(s)
- Mohammad Omar Faruk
- Department of Statistics, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Md Eyasin Arafat
- Department of Statistics, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Sabbir Hussain Shanta
- Department of Statistics, Noakhali Science and Technology University, Noakhali, Bangladesh
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6
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Asah-Opoku K, Onisarotu AN, Nuamah MA, Syurina E, Bloemenkamp K, Browne JL, Rijken MJ. Exploring the shared decision making process of caesarean sections at a teaching hospital in Ghana: a mixed methods study. BMC Pregnancy Childbirth 2023; 23:426. [PMID: 37291483 DOI: 10.1186/s12884-023-05739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Caesarean section (CS) rates are rising. Shared decision making (SDM) is a component of patient-centered communication which requires adequate information and awareness. Women in Ghana have varying perceptions about the procedure. We sought to explore mothers' knowledge. perceptions and SDM-influencing factors about CSs. METHODS A transdisciplinary mixed-methods study was conducted at the maternity unit of Korle-Bu Teaching Hospital in Accra, Ghana from March to May, 2019. Data collection was done in four phases: in-depth interviews (n = 38), pretesting questionnaires (n = 15), three focus group discussions (n = 18) and 180 interviewer administered questionnaires about SDM preferences. Factors associated with SDM were analyzed using Pearson's Chi-square test and multiple logistic regression. RESULTS Mothers depicted a high level of knowledge regarding medical indications for their CS but had low level of awareness of SDM. The perception of a CS varied from dangerous, unnatural and taking away their strength to a life-saving procedure. The mothers had poor knowledge about pain relief in labour and at Caesarean section. Health care professionals attributed the willingness of mothers to be involved in SDM to their level of education. Husbands and religious leaders are key stakeholders in SDM. Insufficient consultation time was a challenge to SDM according to health care professionals and post-partum mothers. Women with parity ≥ 5 have a reduced desire to be more involved in shared decision making for Caesarean section. AOR = 0.09, CI (0.02-0.46). CONCLUSION There is a high knowledge about the indications for CS but low level of awareness of and barriers to SDM. The fewer antenatal care visits mothers had, the more likely they were to desire more involvement in decision making. Aligned to respectful maternity care principles, greater involvement of pregnant women and their partners in decision making process could contribute to a positive pregnancy experience. Education, including religious leaders and decision- making tools could contribute to the process of SDM.
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Affiliation(s)
- Kwaku Asah-Opoku
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana.
- Korle-Bu Teaching Hospital, Accra, Ghana.
- Department of Obstetrics, Division Woman and Baby, Wilhelmina's Children Birth Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Aisha N Onisarotu
- Athena Institute, Faculty of Earth and Life Sciences, Vrije University, Amsterdam, Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, the Netherlands
| | - Mercy A Nuamah
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
- Korle-Bu Teaching Hospital, Accra, Ghana
| | - Elena Syurina
- Athena Institute, Faculty of Earth and Life Sciences, Vrije University, Amsterdam, Netherlands
| | - Kitty Bloemenkamp
- Department of Obstetrics, Division Woman and Baby, Wilhelmina's Children Birth Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, the Netherlands
| | - Marcus J Rijken
- Department of Obstetrics, Division Woman and Baby, Wilhelmina's Children Birth Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, the Netherlands
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7
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Maroyi R, Nyakio O, Buhendwa C, Mukanga O, Kalunga K, Kanyinda K, Rukunghu N, Mukundane B, Kakusu D, Mwilo M, Mbaya EII, Madarhi C, Walala B, Kakisingi DJ, Mukwege D. Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited-resource setting. Int J Gynaecol Obstet 2023. [PMID: 36708063 DOI: 10.1002/ijgo.14665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine the success rate of trial of labor after two cesarean sections (TOLA2C) in the low-resource setting of the Democratic Republic of Congo (DRC) and to describe factors associated with success and related complications. METHODS A prospective cohort study was conducted from 2015 to 2020 in a teaching hospital. Patients who underwent TOLA2C were followed across prenatal visits, onset of spontaneous labor, and delivery. Demographics and clinical characteristics were documented. Pearson and Fisher χ2 tests were used. Predictors of successful vaginal delivery were determined by logistic regression (P ˂ 0.05). RESULTS Among 532 patients, the success rate of TOLA2C was 405 (76.1%). Factors associated with success included birth spacing ≥24 months (adjOR: 2.02 ; 95% CI 1.14-3.56; P = 0.015), previous vaginal delivery (adjOR: 5.02; 95% CI 2.71-9.31; P ˂ 0.001), intercalated vaginal delivery (adjOR: 5.15; 95% CI 2.28-11.65; P ˂ 0.001), cervical dilation >6 cm (adjOR: 2.37; 95% CI 1.92-6.05; P = 0.031) and/or complete dilation on arrival in the delivery room (adjOR: 1.96; 95% CI 1.33-11.45; P = 0.047) and oxytocin stimulation (adjOR: 4.24; 95% CI 1.82-9.91; P ˂ 0.001). No association with hemorrhage, uterine rupture, transfer to neonatology, or maternal-neonatal deaths was observed. CONCLUSIONS TOLA2C is possible in a low-resource setting with a high success rate and low rates of complications. Patient selection and obstetrical team competency are required.
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Affiliation(s)
- Raha Maroyi
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Olivier Nyakio
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Cikwanine Buhendwa
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Omari Mukanga
- Department of Statistics, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
| | - Kiminyi Kalunga
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Kalala Kanyinda
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Neema Rukunghu
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Byamungu Mukundane
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
| | - Dieudonné Kakusu
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Mambo Mwilo
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo.,Department of Pediatrics, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
| | - Eloge-IIunga Mbaya
- Department of Obstetrics and Gynecology, University of Kinshasa, School of Medicine, Clinical University of Kinshasa, Kinshasa, The Democratic Republic of Congo
| | - Cirhagane Madarhi
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Boengandi Walala
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - De Joseph Kakisingi
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | - Denis Mukwege
- Department of Obstetrics and Gynecology, Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo.,Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
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8
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Panda S, Begley C, Daly D. Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study. PLoS One 2022; 17:e0279403. [PMID: 36576912 PMCID: PMC9797090 DOI: 10.1371/journal.pone.0279403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 12/07/2022] [Indexed: 12/29/2022] Open
Abstract
Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
- * E-mail:
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Factors Associated with Vaginal/Cesarean Birth Attitudes among Medical Students. Healthcare (Basel) 2022; 10:healthcare10030571. [PMID: 35327049 PMCID: PMC8954109 DOI: 10.3390/healthcare10030571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Polish perinatal care is facing a high, ever-increasing cesarean section (CS) rate that is currently at 43%. Crucially, reports have revealed that the attitudes, experiences, and skills of clinicians directly contribute to this elevated CS rate. Methods: This cross-sectional study, which included 748 Polish medical students, aimed to identify medical students’ attitudes regarding birth methods. A descriptive questionnaire was distributed via the academic email addresses of surveyed medical students. Group comparisons were performed using Welch’s t-test for continuous data or a Chi-squared test for categorical data. We also used the Mann–Whitney U test and Kruskal–Wallis H test. Results: Midwifery students (96.2%) were the most unified group of students, with most agreeing that VB (vaginal birth) presents a safer option for women at low risk for VB-related complications vs. cesarean section. Of Medical Faculty students, 68% believed that fewer complications typically occur during vaginal birth than during CS. Students in their final vs. initial years of study furthermore considered VB more beneficial for women than CS. Conclusions: An important factor identified at the individual clinician level is the presence of leadership and executive support. For medical students, we can interpret this as support from their trainers and supervisors.
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Peter EG, Ali Seif S. The influence of home environment and wound care practice on surgical site infection among post cesarean section women in Dodoma- Tanzania. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2022. [DOI: 10.1016/j.ijans.2022.100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Bam V, Lomotey AY, Kusi-Amponsah Diji A, Budu HI, Bamfo-Ennin D, Mireku G. Factors influencing decision-making to accept elective caesarean section: A descriptive cross-sectional study. Heliyon 2021; 7:e07755. [PMID: 34430742 PMCID: PMC8365447 DOI: 10.1016/j.heliyon.2021.e07755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/09/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022] Open
Abstract
Elective caesarean sections (CS) that have medical indications contribute to better pregnancy outcomes but women have to consent for the procedure to be performed within reasonable time limits for the desired outcomes. This study aimed to determine the factors that influence women's decision-making and the duration of the decision-making process to accept primary or repeat elective CS in a district hospital in Ghana. A descriptive cross-sectional study was conducted among 163 purposively-sampled postnatal women in a hospital, who had experienced a CS. A questionnaire was used to collect data after the women gave their consent to participate. Data was analyzed using SPSS version 25.0 and presented using appropriate descriptive statistics. Chi-square test of independence was done to determine the association between any two categorical variables. Major factors that influenced women's decision-making to accept elective CS were support from their husband/partner/relatives (39.3 %), their baby's life being at risk (24.5 %), history of previous CS and knowledge about the procedure (19.6 %). Age and parity had significant relationship with the influencing factors. However, age was only significant for the influence of husband/partner/relative in the decision-making to accept CS (p < 0.01). Age (R2 = 0.19, p < 0.001); previous CS (R2 = 0.14, p < 0.001) are the major predictors of the duration of the decision-making process. Women's decision-making in consultation with relatives is the main influencer to accept elective caesarean section. There is the need to involve relatives during the antenatal care period in order for younger women in particular to be readily supported to make timely decisions to avoid preventable complications and allay client's fears.
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Affiliation(s)
- Victoria Bam
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Ghana
| | | | | | - Hayford Isaac Budu
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Ghana
| | - Dorothy Bamfo-Ennin
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Ghana
| | - Georgina Mireku
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Ghana
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Colomar M, Opiyo N, Kingdon C, Long Q, Nion S, Bohren MA, Betran AP. Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences. PLoS One 2021; 16:e0251072. [PMID: 33951101 PMCID: PMC8099111 DOI: 10.1371/journal.pone.0251072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS. Methods Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual. Results We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021. Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence). Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence). Conclusions A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS.
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Affiliation(s)
- Mercedes Colomar
- Montevideo Clinical and Epidemiological Research Unit, Montevideo, Uruguay
- * E-mail:
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Carol Kingdon
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Qian Long
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu Province, China
| | - Soledad Nion
- Faculty of Social Sciences, Sociology Department, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Meghan A. Bohren
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Bakker W, Zethof S, Nansongole F, Kilowe K, van Roosmalen J, van den Akker T. Health workers' perspectives on informed consent for caesarean section in Southern Malawi. BMC Med Ethics 2021; 22:33. [PMID: 33781273 PMCID: PMC8008515 DOI: 10.1186/s12910-021-00584-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/14/2021] [Indexed: 11/24/2022] Open
Abstract
Objective Informed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers’ beliefs and experiences related to principles and practice of informed consent. Methods Qualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a focus group discussion were used to collect data. Participants were 22 clincal officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework. Results Definition and purpose of informed consent revolved around providing information, respecting women’s autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman’s refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women’s lack of education and their dependency on others to make decisions. Conclusions Health workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00584-9.
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Affiliation(s)
- Wouter Bakker
- St. Luke's Hospital, Malosa, Malawi. .,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands. .,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Siem Zethof
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
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Doraiswamy S, Billah SM, Karim F, Siraj MS, Buckingham A, Kingdon C. Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study. Reprod Health 2021; 18:34. [PMID: 33563303 PMCID: PMC7871368 DOI: 10.1186/s12978-021-01098-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.
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Affiliation(s)
| | - Sk Masum Billah
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Camperdown, NSW, Australia
| | - Farhana Karim
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
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Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement. Semin Fetal Neonatal Med 2021; 26:101199. [PMID: 33546999 PMCID: PMC8026747 DOI: 10.1016/j.siny.2021.101199] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.
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Ramos S, Romero M, Perrotta C, Sguassero Y, Straw C, Gialdini C, Righetti N, Betran AP. Optimizing the use of cesarean section in Argentina: design and methodology of a formative research for the development of interventions. Reprod Health 2021; 18:23. [PMID: 33499893 PMCID: PMC7836162 DOI: 10.1186/s12978-021-01080-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/18/2021] [Indexed: 11/24/2022] Open
Abstract
Background While cesarean section is an essential life-saving strategy for women and newborns, its current overuse constitutes a global problem. The aim of this formative research is to collect information from hospitals, health professionals and women regarding the use of cesarean section in Argentina. This article describes the methodology of the study, the characteristics of the hospitals and the profile of the participants. Methods This formative research is a mixed-method study that will be conducted in seven provinces of Argentina. The eligibility criteria for the hospitals are (a) use of the Perinatal Information System, (b) cesarean section rate higher than 27% in 2016, (c) ≥ 1000 deliveries per year. Quantitative and qualitative research techniques will be used for data collection and analysis. The main inquiry points are the determining factors for the use of cesarean section, the potential interventions to optimize the use of cesarean section and, in the case of women, their preferred type of delivery. Discussion It is expected that the findings will provide a situation diagnosis to help a context-sensitive implementation of the interventions recommended by the World Health Organization to optimize cesarean section use. Trial registration IS002316 Plain English Summary Cesarean section is an essential medical tool for mothers and their children, but nowadays its overuse is a problem worldwide. Our purpose is to get information from hospitals, health professionals and women about how cesarean section is used in Argentina. In this protocol we describe how we will carry out the study and the characteristics of the hospitals and participants. We will implement this study in seven provinces of Argentina, in hospitals that have more than 1,000 births each year, had a cesarean section rate higher than 27% in 2016 and use the Perinatal Information System. We will gather information using forms, surveys and interviews. We want to identify the factors that decide the use of a cesarean section, the potential interventions that can improve the use of cesarean section and, in the case of women, the type of delivery they prefer. We expect that this study will give us a diagnosis of how cesarean section is used in Argentina, and that this will help to apply the interventions that the World Health Organization recommends to optimize the use of cesarean section in our specific context.
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Affiliation(s)
- Silvina Ramos
- CEDES: Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina.
| | - Mariana Romero
- Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET/CEDES: Centro de Estudios de Estado Y Sociedad, Buenos Aires, Argentina
| | - Carla Perrotta
- School of Public Health, University College Dublin, National University of Ireland, Dublin, Ireland
| | - Yanina Sguassero
- CREP: Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - Cecilia Straw
- Facultad de Ciencias Sociales, Universidad de Buenos Aires/CEDES: Centro de Estudios de Estado Y Sociedad, Buenos Aires, Argentina
| | - Celina Gialdini
- CREP: Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - Natalia Righetti
- CEDES: Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | - Ana P Betran
- Department of Reproductive Health and Research, UNDP, UNFPA, UNICEF, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
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Maroyi R, Ngeleza N, Keyser L, Bosunga K, Mukwege D. Prenatal care counseling and delivery method among women with multiple Cesareans: A cross-sectional study from Democratic Republic of Congo. PLoS One 2020; 15:e0238985. [PMID: 33166279 PMCID: PMC7652330 DOI: 10.1371/journal.pone.0238985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 08/27/2020] [Indexed: 11/18/2022] Open
Abstract
Prenatal care (PNC) and counseling about delivery method is an important strategy to prevent delivery complications among women with multiple prior Cesarean sections (CS). In low income countries, an elective CS is recommended for this population. This cross-sectional study examined factors associated with counseling about delivery method and its influence on the likelihood of an elective CS delivery. A total of 422 women with ≥2 prior CS who delivered across five hospitals in Democratic Republic of Congo (DRC) were interviewed about PNC and counseling. Descriptive statistics and multivariate regression were completed to ascertain factors associated with counseling. Only 33.6% delivered via planned CS; 60.7% required an emergency CS. One-quarter completed four PNC visits; 64.5% received counseling. Number of PNC visits and number of prior CS were significant predictors of receipt of counseling. Women who received ≥2 PNC visits were 2.2 times more likely to have received counseling (p = 0.000). Among women who received counseling, 38.6% had a planned CS compared with 24.7% in the non-counseled group. Counseling was associated with mode of delivery; emergency CS and vaginal delivery were more frequent among women who did not receive counseling (p = 0.008). These findings highlight the importance of counseling during PNC visits. This study also highlights the poor coverage and quality of counseling in this high-risk population and the need for improvements in PNC. Less than 40% of counseled women followed provider recommendations for a planned delivery via CS. The majority labored at home and later delivered emergently. The significant number of women who trial labor without medical supervision despite their high-risk status sheds light on the influence of patient perceptions about CS and acceptance of medical intervention during birth.
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Affiliation(s)
- Raha Maroyi
- Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
- * E-mail:
| | - Nyakio Ngeleza
- Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
| | | | - Katenga Bosunga
- Université de Kisangani, Kisangani, The Democratic Republic of Congo
| | - Denis Mukwege
- Panzi General Referral Hospital, Bukavu, The Democratic Republic of Congo
- Université Evangélique en Afrique (UEA), Bukavu, The Democratic Republic of Congo
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Coates D, Thirukumar P, Spear V, Brown G, Henry A. What are women’s mode of birth preferences and why? A systematic scoping review. Women Birth 2020; 33:323-333. [DOI: 10.1016/j.wombi.2019.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 12/26/2022]
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Panda S, Begley C, Daly D. Influence of women's request and preference on the rising rate of caesarean section - a comparison of reviews. Midwifery 2020; 88:102765. [PMID: 32531664 DOI: 10.1016/j.midw.2020.102765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 05/10/2020] [Accepted: 05/24/2020] [Indexed: 01/12/2023]
Abstract
The rising caesarean section (CS) rates have been, in part, attributed to women's requests. Several individual studies and literature reviews have attempted to determine the degree of influence of women's requests on overall CS rates, and the common reasons behind these requests, from women's, midwives' and obstetricians' viewpoints. Despite many similarities in their findings, there is both a lack of clarity and disparity on the degree of influence women's requests actually has on the decision to perform a CS. This paper presents a critique of a key finding from a recently published systematic review of clinicians' (midwives' and obstetricians') views of factors that influenced their decision to perform a CS, which identified their belief in 'women's request' as a key factor. This finding is contrasted with findings from three other published reviews, which concluded that women's request contributed minimally to the overall rising rates of CS indicating a disparity in evidence around influence and contribution of women's request. Some of the possible reasons for this disparity can be explained by differences in views of women and clinicians, women's decision being guided by clinicians' beliefs of what is 'safe' and unsafe', and women's concerns being interpreted as their request and preferences to birth by CS. An insight into the possible reasons for the disparity in findings can help explain whether maternal request has any influence on the rising rates of CSs.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin. 2 Clare St, Dublin 2 CK80. Ireland.
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin. 2 Clare St, Dublin 2 CK80. Ireland.
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin. 2 Clare St, Dublin 2 CK80. Ireland.
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Zethof S, Bakker W, Nansongole F, Kilowe K, van Roosmalen J, van den Akker T. Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi. BMJ Open 2020; 10:e030665. [PMID: 31911511 PMCID: PMC6955547 DOI: 10.1136/bmjopen-2019-030665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Surgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care. DESIGN Pre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge. SETTING Rural 150-bed mission hospital in Southern Malawi. PARTICIPANTS A total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation. INTERVENTION Based on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers. PRIMARY AND SECONDARY OUTCOME MEASURES Individual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ2 test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process. RESULTS The proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(β)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (β=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly. CONCLUSION Recollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.
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Affiliation(s)
- Siem Zethof
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
- Clinical Department, St. Luke's Hospital, Zomba, Malawi
| | - Wouter Bakker
- Clinical Department, St. Luke's Hospital, Zomba, Malawi
- Athena Institute, Faculty of Science, VU University, Amsterdam, The Netherlands
| | | | - Kelvin Kilowe
- Nursing Department, St. Luke's Hospital, Zomba, Malawi
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
- Athena Institute, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
- Athena Institute, Faculty of Science, VU University, Amsterdam, The Netherlands
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Bohren MA, Opiyo N, Kingdon C, Downe S, Betrán AP. Optimising the use of caesarean section: a generic formative research protocol for implementation preparation. Reprod Health 2019; 16:170. [PMID: 31744493 PMCID: PMC6862737 DOI: 10.1186/s12978-019-0827-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/18/2019] [Indexed: 01/21/2023] Open
Abstract
Background Caesarean section rates are rising across all geographical regions. Very high rates for some groups of women co-occur with very low rates for others. Both extremes are associated with short and longer term harms. This is a major public health concern. Making the most effective use of caesarean section is a critical component of good quality, sustainable maternity care. In 2018, the World Health Organization published evidence-based recommendations on non-clinical interventions to reduce unnecessary caesarean section. The guideline identified critical research gaps and called for formative research to be conducted ahead of any interventional research to define locally relevant determinants of caesarean birth and factors that may affect implementation of multifaceted optimisation strategies. This generic formative research protocol is designed as a guide for contextual assessment and understanding for anyone planning to take action to optimise the use of caesarean section. Methods This formative protocol has three main components: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers and administrators. The document review and readiness assessment include tools for local mapping of policies, protocols, practices and organisation of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to twelve identified interventions that may optimise use of caesarean section. Each intervention is designed as a “module” and includes a description of the intervention, supporting evidence, theory of change, and in-depth interview/focus group discussion guides. All study instruments are included in this protocol. Discussion This generic protocol is designed to underpin the formative stage of implementation research relating to optimal use of caesarean section. We encourage researchers, policy-makers and ministries of health to adapt and adopt this design to their context, and share their findings as a catalyst for rapid uptake of what works.
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Affiliation(s)
- Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, University of Melbourne School of Population and Global Health, 207 Bouverie St, Carlton, VIC, Australia. .,UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland.
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland
| | - Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland
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Dankwah E, Kirychuk S, Zeng W, Feng C, Farag M. Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data. Int J Equity Health 2019; 18:162. [PMID: 31653255 PMCID: PMC6814993 DOI: 10.1186/s12939-019-1063-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate use of Caesarean Section (CS) delivery is partly to blame for Ghana's high maternal mortality rate. However, previous research offered mixed findings about factors associated with CS use. The goal of this study is to examine use of CS in Ghana and the socioeconomic factors associated with it. METHODS Data from the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) was used after permission from the Monitoring and Evaluation to Assess and Use Results (MEASURE) Demographic and Health Survey (DHS) program. Univariable and multivariable logistic regression models were fitted to examine the socioeconomic inequalities in CS use. The independent variables included maternal age, marital status, religion, ethnicity, education, place of residence, wealth quintile, and working status. Concentration index (CI) and rate-ratios were computed to ascertain the level of CS inequalities. RESULTS Out of the 4294 women, 11.4% had CS delivery. However, the percentage of CS delivery ranged from 5% of women in the poorest quintile to 27.5% of women in the richest qunitle. Significant associations were detected between CS delivery and maternal age, parity, education, and wealth quintile . CONCLUSIONS This study revealed that first, even though Ghana has achieved an aggregate CS rate consistent with WHO recommendations, it still suffers from inequities in the use of CS. Second, both underuse of CS among poorer women in Ghana and overuse among rich and educated women are public health concerns that need to be addressed. Third, the results show in spite of Ghana's free maternal care services policies, wealth status of women continues to be strongly and signtificantly associated with CS delivery, indicating that there are indirect health care costs and other reasons preventing poorer women from having access to CS which should be understood better and addressed with appropriate policies.
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Affiliation(s)
- Emmanuel Dankwah
- School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4 Canada
| | - Shelley Kirychuk
- Canadian Centre for Health and Safety in Agriculture (CCHSA), College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 2Z4 Canada
| | - Wu Zeng
- Department of International Health, School of Nursing & Health Studies, Georgetown University, 37th and O Streets, N.W, Washington, DC 20057 USA
| | - Cindy Feng
- School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4 Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand, Ottawa, Ontario K1G 5Z3 Canada
| | - Marwa Farag
- School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4 Canada
- School of Public Administration and Development Economics, Doha Institute for Graduate Studies, Al Tarfa Street, Zone 70, Doha, Qatar
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Kirchengast S, Hartmann B. Recent Lifestyle Parameters Are Associated with Increasing Caesarean Section Rates among Singleton Term Births in Austria. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 16:E14. [PMID: 30577604 PMCID: PMC6338883 DOI: 10.3390/ijerph16010014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Abstract
Caesarean section (CS) rates are increasing in many parts of the world, recently reaching about 20% worldwide. The postmodern lifestyle characteristics, obesity and delayed childbirth, have been put forward as the main reasons for high CS rates. The present study tests the association patterns between lifestyle parameters and delivery mode on a data set of 3786 births in Vienna between 2005 and 2013. The focus is exclusively on singleton term births. As well as maternal age, prepregnancy weight status, maternal body height and gestational weight gain, newborn size (birth weight, birth length, and head circumference), Apgar scores and child presentation were recorded. Planned as well as emergency CS rates increased significantly (p < 0.0001) with increasing maternal age and decreasing maternal body height. Emergency CS rates, however, increased significantly with increasing maternal prepregnancy weight status and gestational weight gain. An especially high risk of emergency CS occurred among four groups of mothers: those older than 40 years (OR = 2.68; 95% CI 1.87⁻3.86), those who were obese (OR = 1.44; 95% 1.15⁻1.81), those experiencing a gestational weight gain above 15 kg (OR = 1.32; 95% CI 1.13⁻1.54), and those shorter than 160 cm (OR = 1.216; 95% CI 1.02⁻1.45). Emergency CS rates were significantly higher among low-weight newborns (<2500 g) and macrosome newborns (>4000 g) than among normal-weight newborns. Furthermore, breech presentation was associated with an increased risk of caesarean delivery (OR 6.97; 95% CI 6.09⁻7.96). Logistic regression analyses reveal that maternal age, maternal body height, prepregnancy weight status, gestational weight gain, birth weight, newborn head circumference and child presentation show an independent, highly significant association with caesarean delivery. We conclude that maternal and newborn characteristics typical of recent lifestyle patterns, such as advanced maternal age, obesity, increased gestational weight gain and increased newborn size, are highly significantly associated with increased emergency CS rates. Moreover, maternal shortness and breech presentation are risk factors for emergency CS.
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Affiliation(s)
- Sylvia Kirchengast
- Department of Anthropology, University of Vienna, A-1090 Vienna, Austria.
| | - Beda Hartmann
- Clinic for Gynaecology and Obstetrics, Danube Hospital, A-1220 Vienna, Austria.
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Panda S, Daly D, Begley C, Karlström A, Larsson B, Bäck L, Hildingsson I. Factors influencing decision-making for caesarean section in Sweden - a qualitative study. BMC Pregnancy Childbirth 2018; 18:377. [PMID: 30223780 PMCID: PMC6142337 DOI: 10.1186/s12884-018-2007-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/04/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden. METHODS A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin. RESULTS The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes. CONCLUSION Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, 2 Clare Street, D02 CK80 Dublin, Ireland
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin, D02 T283 Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin, D02 T283 Ireland
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Karlström
- Department of Nursing, Mid Sweden University, 86170 Sundsvall, Sweden
| | - Birgitta Larsson
- Department of Nursing, Mid Sweden University, 86170 Sundsvall, Sweden
| | - Lena Bäck
- Department of Nursing, Mid Sweden University, 86170 Sundsvall, Sweden
| | - Ingegerd Hildingsson
- Department of Nursing, Mid Sweden University, 86170 Sundsvall, Sweden
- Department of Women’s and Children’s health, Uppsala University, Uppsala, Sweden
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Panda S, Begley C, Daly D. Clinicians' views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. PLoS One 2018; 13:e0200941. [PMID: 30052666 PMCID: PMC6063415 DOI: 10.1371/journal.pone.0200941] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Caesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians' and midwives' views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians' and midwives' views on the factors that influence the decision to perform caesarean section. METHODS The electronic databases of PubMed (1958-2016), CINAHL (1988-2016), Maternity and Infant Care (1971-2016), PsycINFO (1980-2016) and Web of Science (1991-2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians' and/or midwives' views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al's 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies. RESULT The review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: "clinicians' personal beliefs"-('Professional philosophies'; 'beliefs in relation to women's request for CS'; 'ambiguous versus clear clinical reasons'); Theme 2: "health care systems"-('litigation'; 'resources'; 'private versus public/insurance/payments'; 'guidelines and management policy'). Theme 3: "clinicians' characteristics" ('personal convenience'; 'clinicians' demographics'; 'confidence and skills'). CONCLUSION This systematic review and metasynthesis identified clinicians' personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians' characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Stronge S. The challenges of perioperative midwifery in Malawi. J Perioper Pract 2018; 28:44-45. [PMID: 29493392 DOI: 10.1177/1750458918755965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Boatin AA, Agaba E, Nyongozi B, Wylie BJ. Stage of labor at admission among Ugandan women with a prior cesarean, and its impact on management and delivery outcomes. Int J Gynaecol Obstet 2017; 139:14-20. [PMID: 28675426 DOI: 10.1002/ijgo.12252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 05/05/2017] [Accepted: 06/30/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe stage of labor at admission among women with a prior cesarean, and examine its impact on intrapartum management and delivery mode. METHODS In a prospective cohort study, women admitted to Mbarara Regional Referral Hospital, Uganda, for delivery were enrolled between March and June 2015. Rates of vaginal delivery (VBAC) and in-hospital trial of labor (TOL) were compared between early (<4 cm dilation) and late (≥4 cm) presenters. Women were interviewed after delivery about decision making and labor preferences. RESULTS Overall, 188 women comprised the study sample; 98 (52.1%) and 65 (34.6%) women presented at ≥4 cm and ≥6 cm, respectively, and 18 (9.6%) were fully dilated. In-hospital TOL and VBAC rates were 25.5% (42/165) and 9.6% (18/188), respectively. Compared with early presenters, late presenters were significantly more likely to undergo TOL (28/88 [31.8%] vs 14/77 [18.2%]; odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-5.0), and achieve VBAC (16/98 [16.3%] vs 2/90 [2.2%]; OR 7.6, 95% CI 1.7-35.1). CONCLUSION Most women arrived in active labor, but most had a repeat cesarean. Work is needed to understand the clinical decision making and provider management driving low TOL and VBAC rates.
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Affiliation(s)
- Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elly Agaba
- Department of Obstetrics and Gynaecology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Baltazar Nyongozi
- Department of Obstetrics and Gynaecology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Blair J Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Mgaya AH, Kidanto HL, Nystrom L, Essén B. Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania. PLoS One 2016; 11:e0166619. [PMID: 27893765 PMCID: PMC5125608 DOI: 10.1371/journal.pone.0166619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/01/2016] [Indexed: 11/28/2022] Open
Abstract
Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.
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Affiliation(s)
- Andrew H. Mgaya
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Hussein L. Kidanto
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Lennarth Nystrom
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Birgitta Essén
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
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Mgaya AH, Litorp H, Kidanto HL, Nyström L, Essén B. Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania. BMC Pregnancy Childbirth 2016; 16:343. [PMID: 27825311 PMCID: PMC5101816 DOI: 10.1186/s12884-016-1137-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 10/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting. METHODS During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate. RESULTS In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients. CONCLUSION The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.
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Affiliation(s)
- Andrew H. Mgaya
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Helena Litorp
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Hussein L. Kidanto
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Lennarth Nyström
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Birgitta Essén
- Department of Women’s and Children’s Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden
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Lange IL, Kanhonou L, Goufodji S, Ronsmans C, Filippi V. The costs of 'free': Experiences of facility-based childbirth after Benin's caesarean section exemption policy. Soc Sci Med 2016; 168:53-62. [PMID: 27639052 DOI: 10.1016/j.socscimed.2016.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/06/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
Abstract
As one of many similar policies in the region, in 2009 Benin launched a free c-section policy in publicly funded hospitals intended to decrease the barriers to facility delivery and the heavy financial burdens on women and their families. We conducted a qualitative study for eight months between 2012 and 2014 to understand women's experiences of care in maternity wards. We carried out semi-structured interviews with 30 women who had delivered via c-section at five hospitals. Two of these hospitals became case study sites where in-depth research was undertaken that consisted of participant observation in each maternity ward and 32 further interviews with women who had complicated, vaginal and c-section deliveries. Overall, women continue to pay for care, both in the form of under-the-table payments to health workers and prescribed payments for services not covered by the policy, though they consider the costs reasonable compared to what the charges were before. Lifting the fees has facilitated conditions for midwives to alert doctors that the procedure might be needed. Partly because c-sections are still feared by most women, in one hospital this led to some women perceiving them as a threat if their labour was progressing more slowly. Implementation of the policy differed greatly between the two case study hospitals. We conclude that some burdens on women's access to care have been addressed but deterrents remain to the improved perception of quality of care on the part of women. Findings detail how important context is to the implementation of the policy, and suggest that similar user-fee removal policies should be accompanied by other measures addressing staff management and quality of care.
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Affiliation(s)
- Isabelle L Lange
- MARCH Centre and the Faculty of Epidemiology and Population Health, LSHTM, London, UK.
| | - Lydie Kanhonou
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Benin
| | - Sourou Goufodji
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Benin
| | - Carine Ronsmans
- MARCH Centre and the Faculty of Epidemiology and Population Health, LSHTM, London, UK
| | - Véronique Filippi
- MARCH Centre and the Faculty of Epidemiology and Population Health, LSHTM, London, UK
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Harrison MS, Goldenberg RL. Cesarean section in sub-Saharan Africa. Matern Health Neonatol Perinatol 2016; 2:6. [PMID: 27398224 PMCID: PMC4937522 DOI: 10.1186/s40748-016-0033-x] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/17/2016] [Indexed: 12/24/2022] Open
Abstract
Cesarean section is an essential maternal healthcare service. Its role in labor and delivery care in low- and middle-income countries is complex; in many low-resource settings it is underutilized in the most needy of populations and overused by the less needy, without clear methods to ensure that universal access is available. Additionally, even if universal access were available, it is not evident that these countries would have the capacity or the finances to appropriate meet demand for the procedure, or that patients would want to utilize the care. This review summarizes the literature and illustrates the complicated relationship that cesarean section, which is rapidly on the rise around the world, has with individuals, communities, and nations in sub-Saharan Africa.
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Affiliation(s)
- Margo S Harrison
- Columbia University Medical Center, 622 W 168th St, PH16, New York, NY 10032 USA
| | - Robert L Goldenberg
- Columbia University Medical Center, 622 W 168th St, PH16, New York, NY 10032 USA
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Wang L, Xu X, Baker P, Tong C, Zhang L, Qi H, Zhao Y. Patterns and Associated Factors of Caesarean Delivery Intention among Expectant Mothers in China: Implications from the Implementation of China's New National Two-Child Policy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070686. [PMID: 27399752 PMCID: PMC4962227 DOI: 10.3390/ijerph13070686] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/22/2016] [Accepted: 07/05/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study explores the basic demographic characteristics of expectant mothers in the context of their intentions regarding mode of delivery, in particular, the preference for caesarean delivery, and analyzes the social and psychological factors that influence delivery preference. METHOD A cross-sectional survey of pregnant women was conducted during June to August in 2015. This study adopted a stratified sampling method, and 16 representative hospitals in five provinces of China were included. RESULTS 1755 and 590 of expectant mothers in their first and second pregnancies, respectively, were enrolled in this study. 354 (15.10%) intended to deliver by caesarean section and 585 (24.95%) participants were uncertain prior to delivery. 156 (8.89%) of expectant mothers in their first pregnancy and 198 (33.56%) expectant mothers in their second pregnancy intended to deliver by caesarean section. Ordinal logistic regression analysis found that nationality, parity, trimester of pregnancy, and advanced maternal age were factors associated with intention to deliver by caesarean (ordered logistic regression/three-level caesarean delivery intention criterion; odds ratios p < 0.05). CONCLUSIONS 8.89% of first pregnancy expectant mothers and 33.56% of second pregnancy expectant mothers intended to deliver by caesarean section. Any intervention program to reduce the rate of Caesarean delivery should focus on the Han population, older pregnant women, and expectant mothers in their second pregnancy, at an early gestation.
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Affiliation(s)
- Lianlian Wang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Department of Reproduction Health and Infertility, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Xianglong Xu
- School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China.
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China.
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing 400016, China.
| | - Philip Baker
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
- College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester 3182, UK.
| | - Chao Tong
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Lei Zhang
- Research Center for Public Health, School of Medicine, Tsinghua University, Beijing 100062, China.
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3182, Australia.
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3053, Australia.
- Melbourne Sexual Health Centre, Alfred Health, Melbourne 3053, Australia.
| | - Hongbo Qi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Yong Zhao
- School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China.
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China.
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing 400016, China.
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Litorp H, Mgaya A, Mbekenga CK, Kidanto HL, Johnsdotter S, Essén B. Fear, blame and transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting. Soc Sci Med 2015; 143:232-40. [DOI: 10.1016/j.socscimed.2015.09.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 08/28/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
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