Caesarean delivery and neonatal mortality rates in 46 low- and middle-income countries: a propensity-score matching and meta-analysis of Demographic and Health Survey data

Emerging trends in research on perineal trauma management: A bibliometric analysis of articles published since 1985

BACKGROUND

The purpose of this bibliometric analysis is to explore global trends in scientific research involving spontaneous perineal tears sustained during childbirth. This research is critical as a significant number of women have vaginal lacerations after birth resulting in complications such as pain and pelvic floor dysfunction.

METHODS

The articles used in this bibliometric analysis were collected from PubMed, Web of Science, Cochrane library and Scopus. Analysis was carried out in Python and R programming languages with some visualizations created using VOS software. Apart from traditional methods, this analysis also involved time series forecasting and assessment of rolling correlations.

RESULTS

Results indicate authors and institutions from the United Kingdom as the most productive in the research on this subject research. National level analyses for six countries showed that productivity was positively correlated with GDP/capita, average health expenditure and negatively associated with proportion of C-sections. Recent and emerging themes include those involving pharmacological interventions for pain management.

CONCLUSION

There is a growing global interest in the research on postnatal perineal trauma with authors from the UK playing a leading role so far. Countries with high vaginal birth rates, need to promote research in this field to minimise trauma-associated comorbidities.

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study

BACKGROUND

This study examined the neonatal mortality for newborn of women who delivered by caesarean section or vaginally using a prospective cohort.

METHODS

A total of 6,989 live births registered from 2016 to 2018, were followed for neonatal survival from the selected slums of Dhaka (North and South) and Gazipur city corporations, where icddr,b maintained the Health and Demographic Surveillance System (HDSS). Neonatal mortality was compared by maternal and newborn characteristics and mode of delivery using z-test. Logistic regression model performed for neonatal mortality by mode of delivery controlling selected covariates and reported adjusted odd ratios (aOR) with 95% confidence interval (CI).

RESULTS

Out of 6,989 live births registered, 27.7% were caesarean and the rest were vaginal delivery; of these births, 265 neonatal deaths occurred during the follow-up. The neonatal mortality rate was 2.7 times higher (46 vs. 17 per 1,000 births) for vaginal than caesarean delivered. Until 3rd day of life, the mortality rate was very high for both vaginal and caesarean delivered newborn; however, the rate was 24.8 for vaginal and 6.3 per 1,000 live births for caesarean delivered on the 1st day of life. After adjusting the covariates, the odds of neonatal mortality were higher for vaginal than caesarean delivered (aOR: 2.63; 95% CI: 1.82, 3.85). Additionally, the odds were higher for adolescent than elderly adult mother (aOR: 1.60; 95% CI: 1.03, 2.48), for multiple than singleton birth (aOR: 5.40; 95% CI: 2.82, 10.33), for very/moderate (aOR: 5.13; 95% CI: 3.68, 7.15), and late preterm birth (aOR: 1.48; 95% CI: 1.05, 2.08) than term birth; while the odds were lower for girl than boy (aOR: 0.74; 95% CI: 0.58, 0.96), and for 5th wealth quintile than 1st quintile (aOR: 0.59, 95% CI: 0.38, 0.91).

CONCLUSION

Our study found that caesarean delivered babies had significantly lower neonatal mortality than vaginal delivered. Therefore, a comprehensive delivery and postnatal care for vaginal births needed a special attention for the slum mothers to ensure the reduction of neonatal mortality.

Caesarean section in Sudan: findings from nationwide household surveys on rates, trends, and geographic and sociodemographic variability

Background

Medically unjustifiable caesarean section (CS) deliveries have been rising rapidly in many developed countries over the last three decades. While many developing countries show rates beyond optimal levels, few poorer countries appear to have sub-optimal obstetric care in relation to essential surgeries. The objective of this study is to document the rates of CS delivery, its time trend, and geographic and sociodemographic variability in Sudan.

Methods

We utilized a number of Multiple Indicator Cluster Surveys (MICS) conducted in 2014, 2010, and 2006 to quantify CS rates per 1000 live births. We also documented absolute changes in rates over three-time points and variation in CS rates across geographic regions and areas of residence.

Results

Over a decade, CS rates in Sudan increased steadily from 4.3% in 2006 to 6.7% in 2010 and 9.1% in 2014. During this period, CS rates varied considerably across regions showing higher rates in the Northern region (7–25%) and lower rates in Darfur (2–3%). Urban areas experienced rapidly increasing rates (6–14%), while rural areas showed negligible changes to absolute CS rates over time (5–7%). We also found geographic regions, maternal age, maternal education, receiving antenatal care, and birth order of the child were important determinants of CS in Sudan.

Conclusion

Sudan may be facing a double burden of problems associated with surgical interventions for childbirth. While the wealthier parts of Sudan are experiencing a rapid surge in CS, some poor parts of rural Sudan may not be getting the essential surgical intervention for birth when mandated. Urgent improvement to obstetric care and the development of appropriate public health interventions that focus on regional disparities are warranted.

Prevalence of home birth among 880,345 women in 67 low- and middle-income countries: A meta-analysis of Demographic and Health Surveys

Objective

The objective of this study was to determine the prevalence of home birth in low-middle income countries (LMIC) according to geographic area and sociodemographic characteristics between 2000 and 2019.

Methods

A meta-analysis was carried out using the most recent demographic and health surveys as a data source (total countries: 67). A random-effects meta-analysis was obtained to calculate pooled prevalence estimates of home birth for all the countries included and by geographic region of the world. Likewise, a subgroup analysis was performed to estimate the prevalence of home birth according to the sociodemographic factors considered for this study.

Results

The global prevalence of home birth was 28% (95% CI: 0.24–0.33), with the lowest prevalence in the region of Europe & Central Asia (5%, 95% CI: 0.03–0.07) and the highest in East Asia & Pacific region (38%, 95% CI: 0.26–0.51). Twelve countries had proportions of home births greater than 50% (seven belonged to the Sub-Saharan Africa region). The countries with the highest proportion of home births were Chad (78%), Ethiopia (73%), and Niger and Yemen (70% each). Concerning the wealth index, in general, the richest quintile (quintile 5) presented the lowest proportion of home births. In contrast, the poorest (quintile 1) generally had the highest prevalence of home births. Regarding educational level, women without education presented the highest proportions of home births in general. In relation to the area of residence, in almost all the countries studied, women in rural areas generally had a higher proportion of home births than those in urban areas.

Conclusions

Home births occurred in approximately 3 out of 10 women in LMIC. There are also differences in the proportion of home births according to socioeconomic factors such as educational level, wealth index, and rurality.

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Home births occurred in approximately 3 out of 10 women in LMIC.

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Women without education presented the highest proportions of home births.

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Women in rural areas generally had a higher proportion of home births.

Risk factors for Caesarean sections in Ghana: evidence from the Ghana Maternal Health Survey

A Caesarean section can be a life-saving intervention in case of pregnancy complications or difficult labour. The prevalence of Caesarean section continues to increase, especially in sub-Saharan Africa, yet the reasons for this remain largely unexplored. This study investigated risk factors contributing to the decision to perform Caesarean sections in Ghana using data from 8645 women aged 15-49 years from the 2017 Ghana Maternal Health Survey. The data were analysed by applying complementary log-log and logit models. The majority of Ghanaian women (about 87%) reported preferring vaginal delivery to Caesarean section. Of those who had undergone a Caesarean section for their most recent birth, about 55% had an elective rather than an emergency section. Women with labour complications (prolonged/obstructed labour) were significantly more likely to have a Caesarean section (OR=4.09, 95% CI=3.10-5.41). Furthermore, women with maternal complications, particularly prolonged/obstructed labour, were less likely to have an elective Caesarean section than those who had no such complications (OR=0.25, 95% CI=0.14-0.46). Compared with poorer women, wealthy women were significantly more likely to have an elective Caesarean section (OR=1.84, 95% CI=1.08-3.14). The findings suggest that beyond maternal complications, women's socioeconomic and demographic characteristics are important risk factors for undergoing a Caesarean section in Ghana.

Adverse infant outcomes associated with caesarean section delivery in India

Background

Caesarean section delivery is increasing worldwide and in India, yet little is known about the effect on infants. We examined the association between caesarean delivery and adverse infant outcomes in an Indian national survey, accounting for factors related to the mode of delivery.

Methods

Inverse probability weighted logistic regression analysis of the 2015–2016 India National Family Health Survey obtained adjusted ORs (aORs) and 95% CIs. Infant outcomes were maternal report of recent concomitant diarrhoea and acute respiratory infection (ARI) in infants age ≤6 mo and neonatal death.

Results

Of the 189 143 reported most recent singleton births, 15.4% were delivered by caesarean, 860 (3.2%) of all infants age ≤6 mo had concomitant diarrhoea and ARI and 3480 (1.8%) neonatal deaths were reported. In adjusted analysis, caesarean delivery was not associated with concomitant diarrhoea and ARI (aOR 0.96 [95% CI 0.71 to 1.32]) but was associated with neonatal death (aOR 1.19 [95% CI 1.02 to 1.39]).

Conclusions

Using nationally representative cross-sectional data for India, caesarean section delivery was found to be associated with neonatal death after accounting for factors associated with the mode of delivery. Prospective exploration of the relationship between caesarean delivery and adverse infant outcomes is warranted.

Improving estimation of the association between alcohol use and intimate partner violence in low-income and middle-income countries

BACKGROUND

Alcohol use is a consistent correlate of intimate partner violence (IPV) in low-income and middle-income countries (LMICs). However, the magnitude of this association differs across studies, which may be due to contextual and methodological factors. This study aims to estimate and explore sources of heterogeneity in the association between alcohol use and IPV in 28 LMICs (n=109 700 couples).

METHODS

In nationally representative surveys, partnered women reported on IPV victimisation and male partner's alcohol use. We estimated the relationship between alcohol use and IPV using logistic regression and full propensity score matching to account for confounding. Country-specific ORs were combined using a random-effects model. Country-level indicators of health and development were regressed on ORs to examine sources of variability in these estimates.

RESULTS

Partner alcohol use was associated with a 2.55-fold increase in the odds of past-year IPV victimisation (95% CI 2.27 to 2.86) with substantial variability between regions (I2=70.0%). Countries with a low (<50%) prevalence of past-year alcohol use among men displayed larger associations between alcohol use and IPV. Exploratory analyses revealed that colonisation history, religion, female literacy levels and substance use treatment availability may explain some of the remaining heterogeneity observed in the strength of the association between alcohol use and IPV across countries.

CONCLUSION

Partner alcohol use is associated with increased odds of IPV victimisation in LMICs, but to varying degrees across countries. Prevalences of male alcohol use and cultural factors were related to heterogeneity in these estimates between countries.

Prevalence, indications, and outcomes of caesarean section deliveries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Caesarean section rates have increased worldwide in recent decades. Caesarean section is an essential maternal healthcare service. However, it has both maternal and neonatal adverse outcomes. Therefore this systematic review and meta-analysis aimed to estimate the prevalence, indication, and outcomes of caesarean section in Ethiopia.

METHODS

Twenty three cross-sectional studies with a total population of 36,705 were included. Online databases (PubMed/Medline, Hinari, Web of Science, and Google Scholar) and online university repository was used. All the included papers were extracted and appraised using the standard extraction sheet format and Joanna Briggs Institute respectively. The pooled prevalence of the caesarean section, indications, and outcomes was calculated using the random-effect model.

RESULT

The overall pooled prevalence of Caesarean section was 29.55% (95% CI: 25.46-33.65). Caesarean section is associated with both maternal and neonatal complications. Cephalopelvic disproportion [18.13%(95%CI: 12.72-23.53] was the most common indication of Caesarean section followed by non-reassuring fetal heart rate pattern [19.57% (95%CI: 16.06-23.08]. The common neonatal complications following Caesarean section included low APGAR score, perinatal asphyxia, neonatal sepsis, meconium aspiration syndrome, early neonatal death, stillbirth, and prematurity whereas febrile morbidity, surgical site infection, maternal mortality, severe anemia, and postpartum hemorrhage were the most common maternal complications following Caesarean section.

CONCLUSION

In this systematic review and meta-analysis, the rate of Cesarean section was high. Cephalopelvic disproportion, low Apgar score, and febrile morbidity were the most common indication of Caesarean section, neonatal outcome and maternal morbidity following Caesarean section respectively. Increasing unjustified Caesarean section deliveries as a way to increase different neonatal and maternal complications, then several interventions needed to target both the education of professionals and the public.

Cesarean Section and Maternal-fetal Mortality Rates in Nigeria: An Ecological Lens into the Last Decade

BACKGROUND OR OBJECTIVES

Despite the global decline in maternal mortality within the last decade, women continue to die excessively from pregnancy-related complicationsin developing countries. We assessed the trends in maternal mortality, fetal mortality and cesarean section (C-Section) rates within 25 selected Nigerian hospitals over the last decade.

METHODS

Basic obstetric data on all deliveries were routinely collected by midwives using the maternity record book developed for the project in all the participating hospitals. Trends of C-Section Rates (CSR), Maternal Mortality Rates (MMR), Fetal Mortality Rates (FMR) and Spontaneous Vaginal Delivery rates (SVD) were calculated using joinpoint regression models.

RESULTS

The annual average percent change in CSR was 12.2%, which was statistically significant, indicating a rise in CSR over the decade of the study. There was a noticeable fall in MMR from a zenith of about 1,868 per 100,000 at baseline down to 1,315/100,000 by the end of the study period, representing a relative drop in MMR of about 30%. An average annual drop of 3.8% in FMR and 1.5% drop in SVD over time were noted over the course of the study period.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

We observed an overall CSR of 10.4% and a significant rise in CSR over the 9-year period (2008-2016) of about 108% across hospital facilities in Nigeria. Despite the decrease in MMR, it was still high compared to the global average of 546 maternal deaths per 100 000 livebirths. The FMR was also high compared with the global average. The MMR found in this study clearly indicates that Nigeria is far behind in making progress toward achieving the Sustainable Development Goal 3 (SGD 3) which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.

Obtaining district-level health estimates using geographically masked location from Demographic and Health Survey data

Background

Demographic and Health Survey (DHS) data are an important source of maternal, newborn, and child health as well as nutrition information for low- and middle-income countries. However, DHSs are often unavailable at the administrative unit that is most interesting or useful for program planning. In addition, the location of DHS survey clusters are geomasked within 10 km, and prior to 2009, may have crossed district boundaries. We aim to use DHS surveyed information with these geomasked coordinates to estimate district assignments for use in health program planning and evaluation.

Methods

We developed three methods to assign a district to a geomasked survey cluster in two DHS surveys from Malawi: 2000 and 2004. Method A assigns districts of origin in proportion to the likelihood that results from repeated simulated geomasking, allowing more than one possible district of origin. Method B assigns a single district of origin which contains the greatest proportion of simulated geomasked survey clusters. Method C maps the geomasked survey cluster’s location to a district polygon. We used these method assignments to estimate a selection of commonly used coverage indicators for each district. We compared the district coverage estimates, confidence intervals, and concordance correlation coefficients, by each of the methods, to those which used validated district assignments in 2004, and we looked at coverage change from 2000 to 2004.

Results

The methods we tested each approximated the validated estimates in 2004 by confidence interval comparison and concordance correlation coefficient. Estimated agreement for method A was between .14 and .98, for method B the estimated agreement was between .97 and .99, and for method C the agreement ranged from .93 to .99 when compared with the validated district assignments. Therefore, we recommend the protocol which is the simplest to implement—method C—overlaying geomasked survey cluster within district polygon.

Conclusions

Using geomasked survey clusters from DHSs to assign districts provided district level coverage rates similar to those using the validated surveyed locations. This method may be applied to data sources where survey cluster centroids are available and where district level estimates are needed for program implementation and evaluation in low- and middle-income settings. This method is of special interest to those using DHSs to study spatiotemporal trends as it allows for the utilization of historic DHS data where geomasking hinders the generation of reliable subnational estimates of health in areas smaller than the first-order administrative unit (ADM1).

Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study

Background

Caesarean section (CS) is an important lifesaving intervention that can reduce maternal and newborn morbidity and mortality. The dramatic increase in CS rates globally has prompted concerns that the procedure may be overused or used for inappropriate indications. In Egypt, CS rates are alarmingly high, accounting for 52% of all deliveries. This study sought to (1) explore indications and risk factors for CS in public hospitals in four governorates in Egypt and (2) examine health care provider factors impacting the decision to perform a CS.

Methods

We reviewed medical records for all deliveries that took place during April 2016 in 13 public hospitals situated in four governorates in Egypt (Cairo, Alexandria, Assiut and Behera), and extracted information pertaining to medical indications and women’s obstetric characteristics. We also interviewed obstetricians in the study hospitals to explore factors associated with the decision to perform CS.

Results

A total of 4357 deliveries took place in the study hospitals during that period. The most common medical indications were previous CS (50%), an “other” category (13%), and fetal distress (9%). Multilevel analysis revealed that several obstetric risk factors were associated with increased odds of CS mode of delivery – including previous CS, older maternal age, and nulliparity – while factors such as partograph completion and oxytocin use were associated with reduced odds of CS. Interviews with obstetricians highlighted non-medical factors implicated in the high CS rates, including a convenience incentive, lack of supervision and training in public hospitals, as well as absence of or lack of familiarity with clinical guidelines.

Conclusion

A combination of both medical and non-medical factors drives the increase in CS rates. Our analysis however suggests that a substantial number of CS deliveries took place in the absence of strong medical justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.

The changing temporal association between caesarean birth and neonatal death in Ethiopia: secondary analysis of nationally representative surveys

OBJECTIVE

To examine the changing temporal association between caesarean birth and neonatal death within the context of Ethiopia from 2000 to 2016.

DESIGN

Secondary analysis of Ethiopian Demographic and Health Surveys.

SETTING

All administrative regions of Ethiopia with surveys conducted in 2000, 2005, 2011 and 2016.

PARTICIPANTS

Women aged 15-49 years with a live birth during the 5 years preceding the survey.

MAIN OUTCOME MEASURES

We analysed the association between caesarean birth and neonatal death using log-Poisson regression models for each survey adjusted for potential confounders. We then applied the 'Three Delays Model' to 2016 survey to provide an interpretation of the association between caesarean birth and neonatal death in Ethiopia.

RESULTS

The adjusted prevalence ratios (aPR) for neonatal death among neonates born via caesarean section versus vaginal birth increased over time, from 0.95 (95% CI: 0.29 to 3.19) in 2000 to 2.81 (95% CI: 1.11 to 7.13) in 2016. The association between caesarean birth and neonatal death was stronger among rural women (aPR (95% CI) 3.43 (1.22 to 9.67)) and among women from the lowest quintile of household wealth (aPR (95% CI) 7.01 (0.92 to 53.36)) in 2016. Aggregate-level analysis revealed that an increased caesarean section rates were correlated with a decreased proportion of neonatal deaths.

CONCLUSIONS

A naïve interpretation of the changing temporal association between caesarean birth and neonatal death from 2000 to 2016 is that caesarean section is increasingly associated with neonatal death. However, the changing temporal association reflects improvements in health service coverage and secular shifts in the characteristics of Ethiopian women undergoing caesarean section after complicated labour or severe foetal compromise.

The relationship between maternal mental health during pregnancy and type of delivery in the suburbs of Bandar Abbas during 2017-2018

Background: The effect of maternal mental health during pregnancy on Cesarean section through implications of pre- and postnatal birth have narrowly been investigated. The aim of the present study was to investigate the effect of maternal mental health during pregnancy on the type of delivery in the suburbs of Bandar Abbas. Methods: This study used data of 200 mothers registered in a prospective cohort study on pregnant women in the suburbs of Bandar Abbas, South of Iran, during 2016-18. The presence of depression, anxiety, or stress in expecting mothers were measured by DASS-21 questionnaire and the outcome defined as having Cesarean section (Cesarean section) was measured at postpartum. The relative risk (95% CI) was calculated using Cox regression models. All analyses were performed using STATA statistical package, with a significance level of 5%. Results: Information of 196 mothers were collected (98% response rate); the mean age of the participants was 27.28 (±5.62) years. The prevalence of depression, anxiety, and stress was 13.8% (27), 40.4% (40), and 7.6% (15), respectively. Nearly 40% of mothers went through Cesarean section. Compared to mothers with good mental health, the risk of Cesarean section was 96% higher in depressed mothers (RR=2, 95% CI: 1.43-2.74) (p=0.001), 81% higher in anxious mothers (RR=1.81, 95% CI: 1.29-2.53) (p=0.003), and 75% higher in stressed mothers (RR=1.75, 95% CI: 0.86-3.56) (p=0.121). Conclusion: The findings of this study showed that poor mental health, especially anxiety and depression, during pregnancy could increase the risk of Cesarean section. Accordingly, screening protocols for mental health status and prenatal counseling sessions are suggested for pregnant mothers to increase their informed decision on types of delivery.

Impact of caesarean section on breastfeeding indicators: within-country and meta-analyses of nationally representative data from 33 countries in sub-Saharan Africa

OBJECTIVE

To examine the impact of caesarean section on breastfeeding indicators-early initiation of breastfeeding, exclusive breastfeeding under 6 months and children ever breastfed (at least once)-in sub-Saharan Africa.

DESIGN

Secondary analysis of Demographic and Health Surveys (DHS).

SETTING

Thirty-three low-income and middle-income countries with a survey conducted between 2010 and 2017/2018.

PARTICIPANTS

Women aged 15-49 years with a singleton live last birth during the 2 years preceding the survey.

MAIN OUTCOME MEASURES

We analysed the DHS data to examine the impact of caesarean section on breastfeeding indicators using the modified Poisson regression models for each country adjusted for potential confounders. For each breastfeeding indicator, the within-country adjusted prevalence ratios (aPR) were pooled in random-effects meta-analysis.

RESULTS

The within-country analyses showed, compared with vaginal birth, caesarean section was associated with aPR for early initiation of breastfeeding that ranged from 0.24 (95% CI 0.17 to 0.33) in Tanzania to 0.89 (95% CI 0.78 to 1.00) in South Africa. The aPR for exclusive breastfeeding under 6 months ranged from 0.58 (95% CI 0.34 to 0.98) in Angola to 1.93 (95% CI 0.46 to 8.10) in Cote d'Ivoire, while the aPR for children ever breastfed ranged from 0.91 (95% CI 0.82 to 1.02) in Gabon to 1.02 (95% CI 0.99 to 1.04) in Gambia. The meta-analysis showed caesarean section was associated with a 46% lower prevalence of early initiation of breastfeeding (pooled aPR, 0.54 (95% CI 0.48 to 0.60)). However, meta-analysis indicated little association with exclusive breastfeeding under 6 months (pooled aPR, 0.94 (95% CI 0.88 to 1.01)) and children ever breastfed (pooled aPR, 0.98 (95% CI 0.98 to 0.99)) among caesarean versus vaginally born children.

CONCLUSIONS

Caesarean section had a negative influence on early initiation of breastfeeding but showed little difference in exclusive breastfeeding under 6 months and children ever breastfed in sub-Saharan Africa.

The effect of the health transformation plan on cesarean section in Iran: a systematic review of the literature

OBJECTIVE

Cesarean section (CS) is one of the most common surgical procedures in the world. In developed and developing countries, CS has grown significantly over the past decades. The Iranian Ministry of Health and Medical Education has developed a health transformation plan (HTP) in order to reduce CS rate and promote vaginal delivery. This study was conducted with the aim of reviewing the results of published studies on the impact of the HTP on CS in Iran.

RESULTS

We searched Embase, PubMed/MEDLINE, ISI/Web of Sciences, Scopus, as well as Iranian databases (MagIran, SID and Barakatkns), from May 2014 to October 2018. To assess the quality of studies, the checklist "A Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions" was utilized. Twelve studies were selected. Seven studies reported statistically significant results, showing a positive impact of the implementation of the HTP on CS reduction. Despite the decreased CS rate in Iran after about 4 years of the implementation of this policy, the goal of a yearly reduction by 10% has not been achieved yet. Increasing access to maternity services and community-based education through mass media could help changing the attitudes of Iranian mothers towards CS.

Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries

Background

Around the world, the incidence of multiple pregnancies reaches its peak in the Central African countries and often represents an increased risk of death for women and children because of higher rates of obstetrical complications and poor management skills in those countries. We sought to assess the association between twins and early neonatal mortality compared with singleton pregnancies. We also assessed the role of skilled birth attendant and mode of delivery on early neonatal mortality in twin pregnancies.

Methods

We conducted a secondary analysis of individual level data from 60 nationally-representative Demographic and Health Surveys including 521 867 singleton and 14 312 twin births. We investigated the occurrence of deaths within the first week of life in twins compared to singletons and the effect of place and attendance at birth; also, the role of caesarean sections against vaginal births was examined, globally and after countries stratification per caesarean sections rates. A multi-level logistic regression was used accounting for homogeneity within country, and homogeneity within twin pairs.

Results

Early neonatal mortality among twins was significantly higher when compared to singleton neonates (adjusted odds ratio (aOR) 7.6; 95% confidence interval (CI) = 7.0-8.3) in these 60 countries. Early neonatal mortality was also higher among twins than singletons when adjusting for birth weight in a subgroup analysis of those countries with data on birth weight (n = 20; less than 20% of missing values) (aOR = 2.8; 95% CI = 2.2-3.5). For countries with high rates (>15%) of caesarean sections (CS), twins delivered vaginally in health facility had a statistically significant (aOR = 4.8; 95% CI = 2.4-9.4) increased risk of early neonatal mortality compared to twins delivered through caesarean sections. Home twin births without SBA was associated with increased mortality compared with delivering at home with SBA (aOR = 1.3; 95% CI = 1.0-1.8) and with vaginal birth in health facility (aOR = 1.7; 95% CI = 1.4-2.0).

Conclusions

Institutional deliveries and increased access of caesarian sections may be considered for twin pregnancies in low- and middle- income countries to decrease early adverse neonatal outcomes.

Rates, indications, and outcomes of caesarean section deliveries: A comparison of tribal and non-tribal women in Gujarat, India

BACKGROUND

Even though the caesarean section is an essential component of comprehensive obstetric and newborn care for reducing maternal and neonatal mortality, there is a lack of data regarding caesarean section rates, its determinants and health outcomes among tribal communities in India.

OBJECTIVE

The aim of this study is to estimate and compare rates, determinants, indications and outcomes of caesarean section. The article provides an assessment on how the inequitable utilization can be addressed in a community-based hospital in tribal areas of Gujarat, India.

METHOD

Prospectively collected data of deliveries (N = 19923) from April 2010 to March 2016 in Kasturba Maternity Hospital was used. The odds ratio of caesarean section was estimated for tribal and non-tribal women. Decomposition analysis was done to decompose the differences in the caesarean section rates between tribal and non-tribal women.

RESULTS

The caesarean section rate was significantly lower among tribal compared to the non-tribal women (9.4% vs 15.6%, p-value < 0.01) respectively. The 60% of the differences in the rates of caesarean section between tribal and non-tribal women were unexplained. Within the explained variation, the previous caesarean accounted for 96% (p-value < 0.01) of the variation. Age of the mother, parity, previous caesarean and distance from the hospital were some of the important determinants of caesarean section rates. The most common indications of caesarean section were foetal distress (31.2%), previous caesarean section (23.9%), breech (16%) and prolonged labour (11.2%). There was no difference in case fatality rate (1.3% vs 1.4%, p-value = 0.90) and incidence of birth asphyxia (0.3% vs 0.6%, p-value = 0.26) comparing the tribal and non-tribal women.

CONCLUSION

Similar to the prior evidences, we found higher caesarean rates among non-tribal compare to tribal women. However, the adverse outcomes were similar between tribal and non-tribal women for caesarean section deliveries.

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal

OBJECTIVES

To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia.

DESIGN

Cross-sectional study.

SETTING

81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban).

PARTICIPANTS

45,327 births occurring in the study areas between 2005 and 2012.

OUTCOME MEASURES

Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location.

RESULTS

Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57).

CONCLUSIONS

Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring.

Grand multiparity: is it still a risk in pregnancy?

Background

The association of grand multiparity and poor pregnancy outcome has not been consistent for decades. Classifying grand multiparous women as a high-risk group without clear evidence of a consistent association with adverse outcomes can lead to socioeconomic burdens to the mother, family and health systems. We compared the maternal and perinatal complications among grand multiparous and other multiparous women in Dar es Salaam in Tanzania.

Methods

A cross-sectional study was undertaken at Muhimbili National Hospital (MNH). A standard questionnaire enquired the following variables: demographic characteristics, antenatal profile and detected obstetric risk factors as well as maternal and neonatal risk factors. Predictors of adverse outcomes in relation to grand multiparous women were assessed at p = 0.05.

Results

Grand multiparas had twice the likelihood of malpresentation and a threefold higher prevalence of meconium-stained liquor and placenta previa compared with lower-parity women even when adjusted for age. Neonates delivered by grand multiparous women (12.1%) were at three-time greater risk of a low Apgar score compared with lower-parity women (5.4%) (odds ratio (OR), 2.9; 95% confidence interval (CI), 1.5–5.0). Grand multiparity and low birth weight were independently associated with a low Apgar score (OR, 2.4; 95%, CI 1.4–4.2 for GM; OR, 4.2; 95% CI, 2.3–7.8) for low birth weight.

Conclusion

Grand multiparity remains a risk in pregnancy and is associated with an increased prevalence of maternal and neonatal complications (malpresentation, meconium-stained liquor, placenta previa and a low Apgar score) compared with other multiparous women who delivered at Muhimbili National Hospital.