Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement

Cesarean sections and sociodemographic disparities in Ecuador: A nationwide study from hospital registries between 2015 and 2022

OBJECTIVE

This study aimed to analyze sociodemographic factors associated with cesarean sections (c-sections) in Ecuador.

METHODS

Data were extracted from the Ecuadorian National Institute of Statistics and Censuses (INEC). Multivariate binary and multinomial logistic regression analyses were performed to assess sociodemographic factors associated with c-sections overall and with each type of c-section (elective or emergency c-section).

RESULTS

This study included 1 118 842 in-hospital deliveries during 2015-2022 in Ecuador, of which 41.3% were c-sections. This exceeds the recommended levels of medical justified c-sections. Those who were older than 20-29 years showed a higher probability for c-sections overall. Regarding ethnicity, Montubios had 57% higher probability for c-sectioned with an adjusted odds ratio (aOR) of 1.57 and a 95% confidence interval (CI) of 1.45-1.71; while indigenous, black, and white individuals exhibited 73%, 29%, and 21% lower probabilities, respectively. However, this varied according to specific type of c-sections: black individuals had 11% higher probability of elective c-section but 44% lower probability of emergency c-section. Deliveries in private healthcare facilities exhibited significantly higher probabilities of c-sections overall (aOR 15.38, 95% CI 15.20-15.56). Higher probability of emergency c-section was also observed during 2020-2022.

CONCLUSION

Cesarean sections in Ecuador still exceed the recommended levels of medically justified c-sections, highlighting the importance of adopting an approach to childbirth that reduces unnecessary interventions. These results suggest an important role of sociodemographic factors, which aligns with the reported need for multicomponent and locally tailored strategies for addressing c-section overuse. The increase in c-sections during the COVID-19 pandemic (2020-2022) might suggest the influence of external health crises on maternal healthcare.

Midwife-led obstetric triage to increase providers' knowledge and improve timeliness of care: A pre and posttest design

BACKGROUND

Research in low- and middle-income countries has shown that maternal mortality is directly related to inadequate or absent obstetric (OB) triage systems. Standard triage systems and knowledge on triaging for obstetric emergencies are often absent or lacking in most healthcare systems in Liberia.

OBJECTIVE

The objective of this research was to address the third delay defined as receiving adequate, quality care when a facility is reached by increasing knowledge through the establishment of a midwife-led, hospital-based OB triage system to stratify care based on risk and imminence of birth and to improve timely assessment at two district referral hospitals.

METHODS

A quasi-experimental study design using a pre/post survey was employed for a midwife-led OB triage training course. Using a train-the-trainer model, five midwives were trained as champions, who in turn trained an additional 62 providers. Test results were analyzed with the R statistical software using paired sample t-test and descriptive statistics.

RESULTS

Pretest results revealed a knowledge and practice gap among OB providers on key components of the standard triage package. However, post-test mean scores were significantly higher (M = 79.6, SD = 2.32) than pre-test mean scores (M = 59.0, SD = 2.30) for participants following a 2-day training (p = <0.001).

DISCUSSION

Following a structured OB triage training, participants showed significant improvement in post-test OB triage scores.

CONCLUSION

Standard OB triage protocols incorporated into the policies and procedures of obstetric wards have the potential to improve knowledge and practice, addressing the third delay and reducing preventable, obstetrics-related deaths.

The 2023 Gerard W. Ostheimer Lecture. A Contemporary Narrative Review of Maternal Mortality and Morbidity: Opportunities to Improve Peripartum Outcomes

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists-recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.

Geographic and socioeconomic inequities in cesarean delivery rates at the district level in Madhya Pradesh, India: A secondary analysis of the national family health survey-5

BACKGROUND

In India, caesarean delivery (CD) accounts for 17% of the births, of which 41% occur in private facilities. However, areas to CD in rural areas are limited, particularly for the poor populations. Little information is available on state-wise district-level CD rates by geography and the population wealth quintiles, especially in Madhya Pradesh (MP), the fifth most populous and third poorest state.

OBJECTIVE

Investigate geographic and socioeconomic inequities of CD across the 51 districts in MP and compare the contribution of public and private healthcare facilities to the overall state CD rate.

METHODS

This cross-sectional study utilised the summary fact sheets of the National Family Health Survey (NFHS)-5 performed from January 2019 to April 2021. Women aged 15 to 49 years, with live births two years preceding the survey were included. District-level CD rates in MP were used to determine the inequalities in accessing CD in the poorer and poorest wealth quintiles. CD rates were stratified as <10%, 10-20% and >20% to measure equity of access. A linear regression model was used to examine the correlation between the fractions of the population in the two bottom wealth quintiles and CD rates.

RESULTS

Eighteen districts had a CD rate below 10%, 32 districts were within the 10%-20% threshold and four had a rate of 20% or higher. Districts with a higher proportion of poorer population and were at a distance from the capital city Bhopal were associated with lower CD rates. However, this decline was steeper for private healthcare facilities (R2 = 0.382) revealing a possible dependency of the poor populations on public healthcare facilities (R2 = 0.009) for accessing CD.

CONCLUSION

Although CD rates have increased across MP, inequities within districts and wealth quintiles exist, warranting closer attention to the outreach of government policies and the need to incentivise CDs where underuse is significant.

A log-binomial Bayesian geoadditive semiparametric analysis of geographical inequalities in caesarean births in Ghana

BACKGROUND

Caesarean section is a clinical intervention aimed to save the lives of women and their newborns. In Ghana, studies have reported inequalities in use among women of different socioeconomic backgrounds. However, geographical differentials at the district level where health interventions are implemented, have not been systematically studied. This study examined geographical inequalities in caesarean births at the district level in Ghana. The study investigated how pregnancy complications and birth risks, access to health care and affluence correlate with geographical inequalities in caesarean section uptake.

METHODS

The data for the analysis was derived from the 2017 Ghana Maternal Health Survey. The log-binomial Bayesian Geoadditive Semiparametric regression technique was used to examine the extent of geographical clustering in caesarean births at the district level and their spatial correlates.

RESULTS

In Ghana, 16.0% (95% CI = 15.3, 16.8) of births were via caesarean section. Geospatial analysis revealed a strong spatial dependence in caesarean births, with a clear north-south divide. Low frequencies of caesarean births were observed among districts in the northern part of the country, while those in the south had high frequencies. The predominant factor associated with the spatial differentials was affluence rather than pregnancy complications and birth risk and access to care.

CONCLUSIONS

Strong geographical inequalities in caesarean births exist in Ghana. Targeted and locally relevant interventions including health education and policy support are required at the district level to address the overuse and underuse of caesarean sections, to correspond to the World Health Organisation recommended optimal threshold of 10% to 15%.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Trends and Determinants of Operative Vaginal Delivery at Two Academic Hospitals in Johannesburg, South Africa 2005-2019

Operative Vaginal delivery (OVD) can reduce perinatal and maternal morbidity and mortality especially in low resource setting such as South Africa. We evaluated the trends and determinants of OVD rates using join point regression at Charlotte Maxeke Johannesburg (CMJAH) and Chris Hani Baragwaneth (CHBAH) Academic Hospitals from 1 January 2005−31 December 2019 and conducted a comparative study of OVD (n = 179) and normal delivery (n = 179). Over the 15-year study period (2005−2019), 323,617 deliveries and 4391 OVDs were conducted at CHBAH giving an OVD rate of 1.36 per 100 births. In CMJAH, 74,485 deliveries and 1191 OVDs were conducted over an eleven-year period (2009−2019) with OVD rate of 1.60 per 100 births. OVD rate at CHBAH increased from 2005−2014 at 9.1% per annum and declined by 13.6% from 2014−2019, while OVD rates fluctuates at CMJAH. Of the 179 patients who had OVD, majority (n = 166,92.74%) had vacuum. Women who had OVDs were younger than those who vaginal delivery (p-value < 0.001). The prevalence of OVDs was higher among nulliparous women (p-value < 0.001), HIV negative women (p-value = 0.021), underweight (p-value < 0.001) as compared to normal delivery. The OVD rates has dramatically reduced over the study period This study heightens the need to further evaluate barriers to OVD use in our environment