Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study

Background

Caesarean section (CS) rate increased dramatically worldwide, exceeding the World Health Organization's benchmark (10-15 %) in many countries. This rate varies in different regions of the continent. Using various study designs, researchers from across East African countries investigated the prevalence of caesarean section and the factor associated with it but no study shows a pooled prevalence of caesarean section in the Eastern African region. Therefore, this review aimed to systematically summarize and estimate the pooled prevalence of caesarean section and its associated factors in Eastern Africa, 2023.

Methods

PubMed, Web of Science, EMBASE, Scopus and CINAHL were rigorously searched to find relevant studies. All identified observational studies reporting the prevalence of CS and its associated factors in East Africa published till August 2023 were considered. Heterogeneity across the studies was evaluated using the I2 test. Publication bias was assessed by funnel plot and Egger's regression test. Finally, a random effect meta-analysis model was computed to estimate the pooled prevalence of CS and qualitative analysis was employed for associated factors. The study protocol was registered in PROSPERO.

Results

This review was assessed using twenty-six eligible studies from a total of 2223 articles with a total of 600,431 participants. In this meta-analysis, the pooled prevalence of caesarean section in Eastern Africa was 24.0 % (95%CI: 22-27 %). The highest pooled prevalence of caesarean section was in Ethiopia, 28.30 % (95%CI; 21.3-35.2 %), and the lowest was seen in Uganda, 11.9 % (95%CI; 7.9-15.9 %). Urban residency, having high level of wealth asset, education level college and above, advanced maternal age, big birth weight, history of previous caesarean section, private institution delivery, multiple pregnancies, pregnancy-induced hypertension, antepartum haemorrhage and fetal malpresentation were linked with a greater likelihood of having CS.

Conclusions

and recommendation: The overall pooled prevalence of CS in Eastern Africa was high compared to the WHO proposed recommended range. Therefore, the finding implies that each East African countries Ministry of Health and health care professionals shall be given particular emphasis made on strengthening antenatal care services and ensure more women have access to skilled healthcare professionals during childbirth. This can help in providing appropriate interventions, support to women and reducing the need for emergency and unnecessary CSs. The result of this research are a baseline data for future researchers to conduct further studies to better understand the reasons behind the high rates and identify potential interventions and solutions specific to the African context.PROSPERO protocol number: CRD42023440131.

Cesarean delivery rates based on time and indication using the Robson Ten-Group Classification System: Assessment at a Turkish tertiary center

OBJECTIVE

This study aimed to evaluate increasing cesarean delivery (CD) rates, their causes, and changes over the years in a Turkish tertiary center using the Robson Ten-Group Classification System (RTGCS).

METHODS

Data of deliveries involving birth weight of ≥500 g or ≥24 weeks of gestation period from 2013 to 2020 were retrospectively collected and classified from the hospital digital record system using obstetric concepts and parameters described in the RTGCS.

RESULTS

The overall CD rate for all births (69051) from 2013 to 2020 was 55.5%. Groups 3, 5, and 1 were the most represented groups (29.1%, 23.9%, and 19.4%, respectively). The major contributors to the overall CD rate were Groups 5, 2, and 10 (23.8%, 9.9%, and 5.6%, respectively). Groups 2 and 4 (nullipara, multipara, single cephalic at term) had high CD rates associated with high rates of pre-labor CD (88.9% and 73.3%, respectively). The CD rate was 99.7% in Group 5, which showed recurrent CD, and 67.2% in Group 10. The overall CD rate was 60.8% in 2020 owing to the significant increase in the contributions by Groups 5, 8, and 10. The most common indication for CD was previous CD (46.1%), fetal distress (13.2%), and cephalopelvic disproportion (CPD) (8%).

CONCLUSION

Groups 1, 2, 5, and 10 were the major contributors to the overall CD rate at this tertiary center. To reduce overall CD rates, policies that reduce primary CD and support vaginal delivery after cesarean section should be established.

Assessing geographical and economic inequalities in caesarean section rates between the districts of Bihar, India: a secondary analysis of the National Family Health Survey

BACKGROUND

In Bihar, one of the most populous and poorest states in India, caesarean sections have increased over the last decade. However, an aggregated caesarean section rate at the state level may conceal inequities at the district level.

OBJECTIVES

The primary aim of this study was to analyse the inequalities in the geographical and socioeconomic distribution of caesarean sections between the districts of Bihar. The secondary aim was to compare the contribution of free-for-service government-funded public facilities and fee-for-service private facilities to the caesarean section rate.

SETTING

Bihar, with a population in the 2011 census of approximately 104 million people, has a low GDP per capita (US$610), compared with other Indian states. The state has the highest crude birth rate (26.1 per 1000 population) in India, with one baby born every two seconds. Bihar is divided into 38 administrative districts, 101 subdivisions and 534 blocks. Each district has a district (Sadar) hospital, and six districts also have one or more medical college hospitals.

METHODS

This retrospective secondary data analysis was based on open-source national datasets from the 2015 and 2019 National Family Health Surveys, with respective sample sizes of 45 812 and 42 843 women aged 15-49 years.

PARTICIPANTS

Secondary data analysis of pregnant women delivering in public and private institutions.

RESULTS

The caesarean section rate increased from 6.2% in 2015 to 9.7% in 2019 in Bihar. Districts with a lower proportion of poor population had higher caesarean section rates (R²=0.45) among all institutional births, with 10.3% in private and 2.9% in public facilities. Access to private caesarean sections decreased (R²=0.46) for districts with poorer populations.

CONCLUSION

Marked inequalities exist in access to caesarean sections. The public sector needs to be strengthened to improve access to obstetric services for those who need it most.

Can the Robson 10 Group Classification System help identify which groups of women are driving the high caesarean section rate in major private hospitals in eastern Ethiopia? A cross-sectional study

OBJECTIVE

The rates of caesarean section (CS) in Ethiopian private hospitals are high compared with those in public facilities, and there are limited descriptions of groups of women contributing to these high rates. The objective of this study was to describe the groups contributing to increased CS rates using the Robson classification in two major private hospitals in eastern Ethiopia.

DESIGN

Cross-sectional study.

SETTING

Two major private hospitals in eastern Ethiopia.

PARTICIPANTS

All women who gave birth from 9 January 2019 to 8 January 2020 in two major private hospitals in eastern Ethiopia.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the Robson 10 Group Classification System. The secondary outcome was indication for CS as recorded in the medical files.

RESULTS

Of 1203 births in both hospitals combined during the study period, 415 (34.5%) were by CS. Women with a uterine scar due to previous CS (group 5), single cephalic term multiparous women in spontaneous labour (group 3) and single cephalic term nulliparous women in spontaneous labour (group 1) were the leading groups contributing 33%, 27.5% and 17.1%, respectively. The leading documented indications were fetal compromise (29.4%), previous CS (27.2%) and obstructed labour (12.3%).

CONCLUSION

More than three-fourths of CS were performed among Robson groups 5, 3 and 1, indicating inadequate trial of labour after CS or management of labour among relatively low-risk groups (3 and 1). Improving management of spontaneous labour and strengthening clinical practice around safely providing the option of vaginal birth after CS practice are strategies required to reduce the high CS rates in these private facilities.

Mid forceps did not cause "compromised babies" - "compromise" caused forceps: an approach toward safely lowering the cesarean delivery rate

OBJECTIVE

Over 5 decades, Cesarean Delivery rates (CDR) have risen 6-fold while vaginal operative deliveries [VODs] decreased from >20% to ∼3%. Poor outcomes (HIE and cerebral palsy) haven't improved. Potentiating the virtual abandonment of forceps (F), particularly midforceps (Mid), were allegations about various poor neonatal outcomes. Here, we evaluate VOD and CDR outcomes controlling for prior fetal risk metrics (PR) ascertained an hour before birth.

METHODS

Our 45-year-old database from a labor research unit of moderate/high risk laboring patients (288 NSVDs, 120 Lows, 30 Mids, and 32 CDs) had multiple fetal scalp samples for base excess (BE), pH, cord blood gases (CB), and umbilical artery bloods. ANOVA established relationships between birth methods and outcomes (Cord blood BE and pH and 1 and 5 min Apgar scores); correlations, and two-step multiple regression assessed PR for delivery method and neonatal outcomes. The main outcome measures were correlations of outcome measures with fetal scalp sample BE and pH up to an hour before delivery and fetal reserve index scores scored concurrently.

RESULTS

NSVDs had the best immediate neonatal outcomes with significantly higher CB pH and BE as compared to forceps and CDs. However, controlling for PR revealed: (1) PR at 1 h before delivery correlated with delivery mode, i.e. the decrements in outcomes were already present before the delivery was performed; and (2) The presumed deleterious effects of interventional deliveries, per se, were significantly reduced, and (3) Fetal Reserve Index predicted neonatal outcomes better than fetal scalp sample BE, pH, or delivery mode.

CONCLUSION

The historical belief that MF deliveries caused poorer outcomes than NSVDs seems mostly backwards. Appreciating PR's impact on delivery routes, and when appropriate, properly performing VODs could safely reduce CDR. If our approach lowered CDR by only ∼2%, in the United States about 80,000 CDs might be avoided, saving ∼$750 Million yearly. In the post pandemic world, safely apportioning medical expenses will be even more critical than previously.

Analysis of cesarean section rates using Robson ten group classification system in a tertiary teaching hospital, Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

Cesarean section (CS) is an important indicator of access to, and quality of maternal health services. The World Health Organization recommends the Robson ten group classification system as a global standard for assessing, monitoring and comparing CS rates at all levels. This study aimed to assess the rate of CS and perform an analysis based on Robson classification system.

METHODS

A facility-based cross-sectional study was conducted at a tertiary hospital in Addis Ababa, Ethiopia. Data were collected from medical charts of all women who delivered from January-June 2018. The overall CS rate was calculated then women were categorized into one of the ten Robson groups. Relative size of each group, contribution of each group to the overall CS rate, and CS rate within each group were calculated.

RESULTS

A total of 4,200 deliveries were analyzed. Of these 1,459 (34.7%) were CS. The largest contributors to the overall CS rate were Group 10 (19.1%), Group 2 (18.3%), Group 5 (17.1%), and Group 4 (15.8%). There was also a high rate of pre-labor CS in Group 2, Group 4, and Group 10.

CONCLUSION

Through implementation of the Robson ten group classification system, we identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Group 10 was the leading contributor to the overall CS rate. This study also revealed a high rate of CS among low-risk groups. These target groups require more in-depth analysis to identify possible modifiable factors and to apply specific interventions to reduce the CS rate. Evaluation of existing management protocols and further studies into indications of CS and outcomes are needed to design tailored strategies and improve outcomes.

Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study

OBJECTIVE

Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania.

DESIGN

Observational retrospective study.

SETTING

St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania.

PARTICIPANTS

3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015.

RESULTS

The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%).

CONCLUSION

We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions.

Changing rates of the modes of delivery over the decades (1976, 1986, 1996, 2006, and 2016) based on the Robson-10 group classification system in a single tertiary health care center

AIM

To identify the underlying factors that may affect the changing rates of modes of delivery over the decades based on Robson-10 group classification system (TGCS) in a single tertiary health care center.

MATERIALS AND METHODS

This study included data from 10,458 deliveries in 1976, 1986, 1996, 2006, and 2016 with fetuses more than or equal to 500 g at the Department of Obstetrics and Gynecology at Hacettepe University Hospital. Patient characteristics and the mode of delivery were evaluated according to the TGCS.

RESULTS

The cesarean section (CS) rates were 11.4% (304/2668), 19.2% (459/2393), 44.7% (783/1751), 69.3% (1213/1751), and 77.9% (1477/1895) in 1976, 1986, 1996, 2006, and 2016, respectively. CS has become the preferred method of delivery for multiple pregnancies and breech presentations over the years. TGCS Group 5 was the greatest contributor to increased CS ratios. Relative contributions of TGCS Groups 1 and 3 were decreased and relative contributions of Groups 2 and 4 were increased. Operative vaginal deliveries decreased over the years.

CONCLUSION

In conclusion, effective management of labor induction, choosing vaginal delivery for appropriate breech presentations and multifetal pregnancies, proper education of obstetricians for operative vaginal delivery and objective evaluation of labor dystocia might be key points in CS rate debates.