Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh

Effects of maternal exposure to biomass cooking fuel on birth size and body proportionality in full-term infants born by vaginal delivery

It remains unclear whether and how maternal exposure to biomass fuel influences infant anthropometry or body proportionality at birth, which are linked to their survival, physical growth, and neurodevelopment. Therefore, this study seeks to explore the association between household-level exposure to biomass cooking fuels and infant size and body proportionality at birth among women in rural Bangladesh. A total of 909 women were derived from the Pregnancy Weight Gain study, which was conducted in Matlab, a rural area of Bangladesh. Infant's weight (g), length (cm), head circumference (cm), small for gestational age (SGAW), short for gestational age (SGAL), low head circumference for gestational age (SGAHC), ponderal index, and cephalization index at birth were the outcomes studied. Of the women, 721 (79.3%) were dependent on biomass fuel. Compared to infants born to mothers who used gas for cooking, those born to biomass users had lower weight (β - 94.3, CI - 155.9, - 32.6), length (β - 0.36, 95% CI - 0.68, - 0.04), head circumference (β - 0.24, CI - 0.47, - 0.02) and higher cephalization index (β 0.03, CI 0.01, 0.05) at birth. Maternal biomass exposure is more likely to lead to symmetric SGA, although there is evidence for some brain-sparing effects.

Malpresentation and autism spectrum disorder in the study to explore early development

BACKGROUND

An infant's presentation at delivery may be an early indicator of developmental differences. Non-vertex presentation (malpresentation) complicates delivery and often leads to caesarean section, which has been associated with neurodevelopmental delays, including autism spectrum disorder (ASD). However, malpresentation could be an early sign of an existing developmental problem that is also an upstream factor from caesarean delivery. Little research has been done to investigate the association between malpresentation and ASD.

OBJECTIVES

We examine the association between malpresentation at delivery and ASD and whether this association differs by gestational age.

METHODS

We used data from the Study to Explore Early Development (SEED), a multi-site, case-control study of children with ASD compared to population controls. The foetal presentation was determined using medical records, birth records and maternal interviews. We defined malpresentation as a non-vertex presentation at delivery, then further categorised into breech and other malpresentation. We used multivariable logistic regression to estimate the adjusted odds ratio (aOR) for the association between malpresentation and ASD.

RESULTS

We included 4047 SEED participants, 1873 children with ASD and 2174 controls. At delivery, most infants presented vertex (n = 3760, 92.9%). Malpresentation was associated with higher odds of ASD (aOR 1.31, 95% confidence interval [CI] 1.02, 1.68) after adjustment for maternal age, poverty level, hypertensive disorder and smoking. The association was similar for breech and other types of malpresentation (aOR 1.28, 95% CI 0.97, 1.70 and aOR 1.40, 95% CI 0.87, 2.26, respectively) and did not differ markedly by gestational age.

CONCLUSIONS

Malpresentation at delivery was modestly associated with ASD. Early monitoring of the neurodevelopment of children born with malpresentation could identify children with ASD sooner and enhance opportunities to provide support to optimise developmental outcomes.

Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries

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.

An Analysis of the Mode of Delivery, Risk Factors, and Subgroups with High Caesarean Birth Rates Using Robson Classification System

OBJECTIVE

We aimed to understand the utilization of the mode of delivery and related risk factors. Further aimed to apply the Robson classification system to evaluate the data quality and analyze the CS rates in subgroups.

METHODS

We conducted a retrospective descriptive study by reviewing the medical records of all women who delivered at the State Hospital in 2019. A proforma was developed for extracting data from patient records. All women with six obstetric parameters were categorized into Robson groups to determine the absolute and relative contributions of each group to the overall CS rate.

RESULTS

Of 797 deliveries, 401 (50.2%) were CSs. Being older, being Turkish Cypriot, having preterm births, previous CS, multiple fetuses, and having breech or transverse fetal presentations were related to having higher risks of CS. The most common medical indication for CSs (52.3%) was a history of previous CSs. Robson Group 5 contributed the most (50.7%) to the overall CS rate, with the highest absolute contribution of 21.8%. Group 10 and Group 8 were the second and third highest contributors to the overall CS rate, with relative contributions of 25.3% and 9.0%, respectively.

CONCLUSIONS

Findings revealed the substandard quality of obstetric data and a noticeably high overall CS rate. The top priority should be given to improving the quality of medical records. It underscored the necessity of implementing the Robson classification system as a standard clinical practice to enhance data quality, which helps to effectively evaluate and monitor the CS rates in obstetric populations.

Perinatal colonization with extended-spectrum beta-lactamase-producing and carbapenem-resistant Gram-negative bacteria: a hospital-based cohort study

BACKGROUND

Antimicrobial resistance (AMR) is a growing global health threat that contributes to substantial neonatal mortality. Bangladesh has reported some of the highest rates of AMR among bacteria causing neonatal sepsis. As AMR colonization among newborns can predispose to infection with these bacteria, we aimed to characterize the frequency of and risk factors for colonization of mothers and newborns during hospitalization for delivery.

METHODS

We enrolled pregnant women presenting for delivery to a tertiary care hospital in Faridpur, Bangladesh. We collected vaginal and rectal swabs from mothers pre- and post-delivery, rectal swabs from newborns, and swabs from the hospital environment. Swabs were plated on agars selective for extended-spectrum-beta-lactamase producing bacteria (ESBL-PB) and carbapenem-resistant bacteria (CRB). We performed logistic regression to determine factors associated with ESBL-PB/CRB colonization.

RESULTS

We enrolled 177 women and their newborns during February-October 2020. Prior to delivery, 77% of mothers were colonized with ESBL-PB and 15% with CRB. 79% of women underwent cesarean deliveries (C-section). 98% of women received antibiotics. Following delivery, 98% of mothers and 89% of newborns were colonized with ESBL-PB and 89% of mothers and 72% of newborns with CRB. Of 290 environmental samples, 77% were positive for ESBL-PB and 69% for CRB. Maternal pre-delivery colonization was associated with hospitalization during pregnancy (RR for ESBL-PB 1.24, 95% CI 1.10-1.40; CRB 2.46, 95% CI 1.39-4.37). Maternal post-delivery and newborn colonization were associated with C-section (RR for maternal CRB 1.31, 95% CI 1.08-1.59; newborn ESBL-PB 1.34, 95% CI 1.09-1.64; newborn CRB 1.73, 95% CI 1.20-2.47).

CONCLUSIONS

In this study, we observed high rates of colonization with ESBL-PB/CRB among mothers and newborns, with pre-delivery colonization linked to prior healthcare exposure. Our results demonstrate this trend may be driven by intense use of antibiotics, frequent C-sections, and a contaminated hospital environment. These findings highlight that greater attention should be given to the use of perinatal antibiotics, improved surgical stewardship for C-sections, and infection prevention practices in healthcare settings to reduce the high prevalence of colonization with AMR organisms.

How does hospital organisation influence the use of caesarean sections in low- and middle-income countries? A cross-sectional survey in Argentina, Burkina Faso, Thailand and Vietnam for the QUALI-DEC project

BACKGROUND

Improving the understanding of non-clinical factors that lead to the increasing caesarean section (CS) rates in many low- and middle-income countries is currently necessary to meet the challenge of implementing effective interventions in hospitals to reverse the trend. The objective of this study was to study the influence of organizational factors on the CS use in Argentina, Vietnam, Thailand and Burkina Faso.

METHODS

A cross-sectional hospital-based postpartum survey was conducted in 32 hospitals (8 per country). We selected women with no potential medical need for CS among a random sample of women who delivered at each of the participating facilities during the data collection period. We used multilevel multivariable logistic regression to analyse the association between CS use and organizational factors, adjusted on women's characteristics.

RESULTS

A total of 2,092 low-risk women who had given birth in the participating hospitals were included. The overall CS rate was 24.1%, including 4.9% of pre-labour CS and 19.3% of intra-partum CS. Pre-labour CS was significantly associated with a 24-hour anaesthetist dedicated to the delivery ward (ORa = 3.70 [1.41; 9.72]) and with the possibility to have an individual room during labour and delivery (ORa = 0.28 [0.09; 0.87]). Intra-partum CS was significantly associated with a higher bed occupancy level (ORa = 1.45 [1.09; 1.93]): intrapartum CS rate would increase of 6.3% points if the average number of births per delivery bed per day increased by 10%.

CONCLUSION

Our results suggest that organisational norms and convenience associated with inadequate use of favourable resources, as well as the lack of privacy favouring women's preference for CS, and the excessive workload of healthcare providers drive the CS overuse in these hospitals. It is also crucial to enhance human and physical resources in delivery rooms and the organisation of intrapartum care to improve the birth experience and the working environment for those providing care.

TRIAL REGISTRATION

The QUALI-DEC trial is registered on the Current Controlled Trials website ( https://www.isrctn.com/ ) under the number ISRCTN67214403.

Association of dietary diversity of 6-23 months aged children with prenatal and postnatal obstetric care: evidence from a nationwide cross-sectional study

BACKGROUND

Dietary diversity is a key determinant of infant and young child eating patterns for a variety of food groups taken by children between the ages of 6-23 months. The study aimed to examine the association between prenatal and postnatal obstetric care factors of mother and child's dietary diversity, and specific food practices in Bangladesh.

METHODS

This study analyzed the data of 2497 children between the age of 6-23 extracted from the latest countrywide Bangladesh Demographic Health Survey 2017-2018 and explored relationships between prenatal and postnatal obstetric care received by mother and dietary diversity score (DDS), minimum dietary diversity (MDD), and introduction of solid, semi-solid, and soft foods (ISSSF) of their children.

RESULTS

Findings revealed that ≥ 4 antenatal care (ANC) visits care visits increased the DDS (adjusted [Formula: see text]: 0.32, 95% CI [0.21, 0.43]), increased the likelihood of MDD (AOR 1.54, 95% CI [1.23, 1.93]), and ISSSF (AOR 1.24, 95% CI [1.08, 1.48]), consuming eggs (AOR 1.47, 95% CI [1.23, 1.76]), and vitamin A vegetables and fruits (AOR 1.38, 95% CI [1.15, 1.66]). Moreover, DDS (adjusted β: 0.05, 95% CI [0.00, 0.11]) and MDD (AOR 1.66, 95% CI [1.31, 2.11]) are linked to childbirth in a medical facility. The C-section delivery influences the DDS (adjusted [Formula: see text]: 0.05, 95% CI [0.00, 0.10]), MDD (AOR 1.39, 95% CI [1.10, 1.75]), and ISSSF (AOR 1.22, 95% CI [1.02, 1.48]). Besides, postnatal visits within 48 h of delivery linked to MDD (AOR 0.66, 95% CI [0.49, 0.89]) and ISSSF (AOR 0.76, 95% CI [0.59, 0.97]), and physicians or professionals providing postnatal checkups were significantly associated with DDS (adjusted [Formula: see text]: 0.09, 95% CI [0.02, 0.16]), MDD (AOR 1.69, 95% CI [1.26, 2.26]), and ISSSF (AOR 1.30, 95% CI [1.04, 1.62]).

CONCLUSION

Knowledge of child nutritional feeding should emphasize during prenatal and postnatal obstetric care of mother, particularly during antenatal and postnatal visits, C-section delivery, and birth in a healthcare facility to eradicate malnutrition and establish healthy child feeding practices.

Influence of transcutaneous electrical nerve stimulation on pain intensity and functional activities following lower segment cesarean section

BACKGROUND

Postoperative incisional pain following lower segment cesarean section (LSCS) is one of the commonly reported complaints which may affect mother-infant bonding, and restrict mobility and functional activities.

PURPOSE

To study the influence of transcutaneous electrical nerve stimulation (TENS) on pain intensity and functional activities using the Numerical Pain Rating Scale (NPRS) and the Patient Specific Functional Scale (PSFS) following LSCS from the postoperative day (POD) 1 to POD 4.

METHODS

This quasi-experimental study consisted of 50 postpartum women who underwent LSCS and were assigned to an intervention group (IG) that received TENS and a control group (CG) that received routine hospital care.

RESULTS

NPRS scores between CG and IG (pre-TENS application) showed a statistically significant difference (ηp2 = 0.542, p < .001) from POD 1 to POD 4. Study participants showed an improvement in PSFS scores (ηp2 = 0.412, 0.488, 0.661, 0.304, 0.262, and 0.395, p < .001) in IG compared to CG for bed transitions, bed transfers, sitting, sit to stand, walking, and toileting activities respectively from POD 1 to POD 4 which was statistically significant.

CONCLUSIONS

Our study results suggest that administration of TENS following LSCS shows an improvement in pain intensity and functional activities as reported on NPRS and PSFS respectively.

Prediction of Emergency Cesarean Section Using Detectable Maternal and Fetal Characteristics Among Saudi Women

Background

The worldwide rate of cesarean section (CS) is increasing. Development of prediction models for a specific population may improve the unmet need for CS as well as reduce the overuse of CS.

Objective

To explore risk factors associated with emergency CS, and to determine the accuracy of predicting it.

Methods

A retrospective analysis of the medical records of women who delivered between January 1, 2021-December 2022 was conducted, relevant maternal and neonatal data were retrieved.

Results

Out of 1793 deliveries, 447 (25.0%) had emergency CS. Compared to control, the risk of emergency CS was higher in primiparous women (OR 2.13, 95% CI 1.48 to 3.06), in women with higher Body mass index (BMI) (OR 1.77, 95% CI 1.27 to 2.47), in association with history of previous CS (OR 4.81, 95% CI 3.24 to 7.15) and in women with abnormal amniotic fluid (OR 2.30, 95% CI 1.55 to 3.41). Additionally, women with hypertensive disorders had a 176% increased risk of emergency CS (OR 2.76, 95% CI 1.35-5.63). Of note, the risk of emergency CS was more than three times higher in women who delivered a small for gestational age infant (OR 3.29, 95% CI 1.93-5.59). Based on the number of risk factors, a prediction model was developed, about 80% of pregnant women in the emergency CS group scored higher grades compared to control group. The area under the curve was 0.72, indicating a good discriminant ability of the model.

Conclusion

This study identified several risk factors associated with emergency CS in pregnant Saudi women. A prediction model showed 72% accuracy in predicting the likelihood of emergency CS. This information can be useful to individualize the risk of emergency CS, and to implement appropriate measures to prevent unnecessary CS.

Arnold-Chiari Malformations in Pregnancy and Labor: Challenges and Management Strategies

Arnold-Chiari malformations (ACMs) present unique challenges in pregnancy and labor, requiring a comprehensive understanding and multidisciplinary approach to care. This review article provides an overview of ACMs, including their definition, classification, and prevalence. The challenges in diagnosing ACMs during pregnancy, the available imaging modalities, and screening recommendations are discussed. The impact of ACMs on maternal health, fetal development, and the management strategies employed during pregnancy and labor are explored. Emphasis is placed on the importance of a multidisciplinary approach involving neurologists, obstetricians, and other specialists. Medical management options for symptom relief, surgical interventions, and anesthetic considerations during labor and delivery are also addressed. The importance of postpartum care, breastfeeding considerations, and long-term follow-up for women with ACMs who desire future pregnancies are highlighted. Finally, areas for further research and advancements in ACM management are identified. By improving our understanding and management of ACMs in pregnancy and labor, healthcare professionals can optimize care and improve outcomes for mothers and babies affected by this condition.

Prevalence and determinants of socioeconomic inequality in caesarean section deliveries in Bangladesh: an analysis of cross-sectional data from Bangladesh Demographic Health Survey, 2017-18

BACKGROUND

Caesarean section deliveries, which involve incisions in the abdomen and uterus of the mother, have been a widespread event among women with obstructed labour. The current study not only estimated the socioeconomic and demographic factors of caesarean deliveries in Bangladesh but also decomposed the existing socioeconomic inequality in caesarean deliveries.

DATA AND METHODS

2017-18 Bangladesh Demographic and Health Survey (BDHS) data was used for this study. The adequate sample size for the analysis was 5,338 women aged 15-49 years who had given birth at a health facility for three years preceding the survey. Explanatory variables included women's age, women's educational level, women's working status, mass media exposure, body mass index (BMI), birth order, Ante Natal Care (ANC) visits, place of delivery, partner's education and occupation, religion, wealth index, place of residence, and divisions. Descriptive statistics along with bivariate and multivariate logistic regression analysis was performed to identify the factors associated with the outcome variable. Concentration index and concentration curve were made to measure the socioeconomic inequality in caesarean births in Bangladesh. Further, Wagstaff decomposition analysis was used to decompose the inequalities in the study.

RESULTS

About one-third of the deliveries in Bangladesh were caesarean. Education of the women and the family's wealth had a positive relationship with caesarean delivery. The likelihood of caesarean delivery was 33% less among working women than those who were not working [AOR: 0.77; CI: 0.62-0.97]. Women who had mass media exposure [AOR: 1.27; CI: 0.97-1.65], overweight/obese [AOR: 1.43; CI: 1.11-1.84], first birth order, received four or more Antenatal check-ups (ANC) [AOR: 2.39; CI: 1.12-5.1], and delivered in a private health facility [AOR: 6.69; CI: 5.38-8.31] had significantly higher likelihood of caesarean delivery compared to their counterparts. About 65% of inequality was explained by place of delivery followed by wealth status of the household (about 13%). ANC visits explained about 5% of the inequality. Furthermore, the BMI status of the women had a significant contribution to caesarean births-related inequality (4%).

CONCLUSION

Socioeconomic inequality prevails in the caesarean deliveries in Bangladesh. The place of delivery, household wealth status, ANC visits, body mass index, women's education and mass media have been the highest contributors to the inequality. The study, through its findings, suggests that the health authorities should intervene, formulate specialized programs and spread awareness about the ill effects of caesarean deliveries amongst the most vulnerable groups of women in Bangladesh.

Review of socioeconomic risk factors for cesarean births: a population-based study

OBJECTIVES

The reasons for increased cesarean section (CS) rates are complex and multifactorial. The goal of this study was to look at different social and economic factors that might be causing more cases of CS in the population.

STUDY DESIGN

A retrospective population-based cohort study. Data was taken from the Perinatal Neonatal Outcomes Research study in the Arabian Gulf (PEARL study) registry. Data from 60,728 live births ≥ 24 weeks of gestation were analyzed. In this study, various socioeconomic factors, such as maternal nationality, religion, educational level, employment status, parental income, consanguinity, housing, preterm birth, and tall stature, were examined for women undergoing cesarean section (CS) and their economic outcomes. Women who underwent vaginal delivery (VD) were compared. There are risks associated with pregnancy, smoking, assisted conception, and prenatal care.

RESULTS

60,728 births ≥ 24 weeks gestation were included in the analysis. 17,535 women delivered by CS (28.9%). Women with university-level -education and above were more likely to deliver by CS (61%), as compared to illiterate women or women with basic education at elementary or secondary levels (OR 0.73, CI 95%: P: <0.0001). Working women were more likely to deliver by CS (OR 1.40, CI 95%, P value <0.0001). Women living in rented houses were less likely to achieve a normal delivery (71.8%) (OR 1.40, CI 95%; P: <0.0001) as compared to women living in owned houses (74.7%). Women over 20 years old tended to achieve more VD compared to women less than 20 years old. P value <0.0001. Smoking was associated with lower chances of VD, with 42.4% of smokers delivered by CS compared to 28.3% of non-smokers (OR 1.87, CI 95%; P: <0.0001). Assisted conception was associated with higher CS rates as compared to spontaneous conceptions (OR 0.39; P: <0.0001). We found no statistically significant differences in how babies were born based on the mother's nationality, the father's job, or the mother's income.

CONCLUSIONS

Higher education, employed mothers, smoking, and living in rented houses were socioeconomic factors associated with a higher rate of CS in our population. Furthermore, women who had regular antenatal care were more at risk for delivery by cesarean section, which could be related to other comorbidities increasing the likelihood of cesarean birth rather than antenatal care itself. In our population, assisted reproduction was associated with a higher probability of cesarean delivery.

Prevalence and determinants of caesarean section deliveries in the Kintampo Districts of Ghana

BACKGROUND

Globally, the increasing rate of caesarean section (CS) delivery has become a major public health concern due to its cost, maternal, neonatal, and perinatal risks. In Ghana, the Family Health Division of the Ghana Health Service in 2016 opted to initiate a program to prevent the abuse of CS and identify the factors contributing to its increase in the country. This study aimed to determine the prevalence and factors influencing CS deliveries in the Kintampo Districts of Ghana.

METHODS

The current study used secondary data from the Every Newborn-International Network for the Demographic Evaluation of Populations and their Health (EN-INDEPTH) project in Kintampo, Ghana. The outcome variable for this study is CS delivery. The predictor variables were socio-demographic and obstetric factors.

RESULTS

The prevalence of CS delivery in the study area was 14.6%. Women with secondary education were 2.6 times more likely to give birth by CS than those with primary education. Unmarried women were about 2.5 times more likely to deliver by CS compared to those who were married. There was an increasing order of CS delivery among women in the wealthy quintiles from poorer to richest. The likelihood of women with gestational ages from 37 to 40 weeks to give birth by CS was about 58% less compared to those with less than 37 gestational weeks. Women who had 4-7 and 8 or more antenatal care (ANC) visits were 1.95 and 3.5 times more likely to deliver by CS compared to those who had less than 4 ANC visits. The odds of women who have had pregnancy loss before to deliver by CS was 68% higher compared to women who have not lost pregnancy before.

CONCLUSIONS

Caesarean section delivery prevalence in the study population was within the Ghana Health Service and World Health Organization ranges. In addition to known socio-demographic and obstetric factors, this study observed that a history of pregnancy loss increased the chances of a woman undergoing a CS. Policies should aim at addressing identified modifiable factors to stem the rise in CS deliveries.

Individual and community-level factors associated with caesarean section in Haiti: secondary analysis of data from the 2016-2017 Haitian Demographic and Health Survey

INTRODUCTION

For several decades, the rate of caesarean section (CS) has been increasing in the world. In some countries, the CS rate is below the WHO recommended range (10-15%), while in other countries, it is significantly higher. The aim of this paper was to identify individual and community-level factors associated with CS in Haiti.

METHODS

Secondary data analysis was conducted on nationally representative cross-sectional survey data from the 2016-2017 Haitian Demographic and Health Survey (HDHS). The analysis was restricted to 6303 children born in 5 years prior the survey (of the interviewed women). The study population' characteristics, and the prevalence of CS were analysed using descriptive analysis (univariate/bivariate). In addition, multilevel binary logistic regression analysis was performed to identify factors associated with CS. Both descriptive and multivariate analysis were conducted using STATA 16.0 software (Stata Corp, Tex, USA). Statistical significance was declared at p < 0.05.

RESULTS

The overall prevalence of CS delivery was estimated at 5.4% (95% CI 4.8-6.0) in Haiti. Results also revealed that mothers aged 35 and above (aOR = 1.38; 95% CI 1.00-1.96); who attended secondary (aOR = 1.95; 95% CI 1.39-2.76) and higher education level (aOR = 3.25; 95% CI 1.92-5.49); who were covered by health insurance (aOR = 2.57; 95% CI 1.57-4.19); with less than 3 children (aOR = 4.13; 95% CI 2.18-7.85) or 3-4 children (aOR = 2.07; 95% CI 1.09-3.94); who received 9 or more antenatal visits (aOR = 2.21; 95% CI 1.40-3.50) were significantly more likely to deliver by CS. Children in communities with high preponderance of private health facilities had greater odds to be delivered through CS (aOR = 1.90; 95% CI 1.25-2.85). Furthermore, children with an average birth weight (aOR = 0.66; 95% CI 0.48-0.91) were less likely to be delivered through CS than their counterparts with high birth weight.

CONCLUSIONS

While the CS prevalence was low in Haiti, it masks significant geographic, social and economic disparities. To better develop and implement maternal and child health programs that address CS deliveries, the government authorities and NGOs operating in the field of women's health in Haiti should take these disparities into account.

Pneumonia Deterioration Occurring After C-section in a Preeclamptic Patient: A Case Report

Pneumonia is a type of lung infection that can be caused by bacteria, viruses, or fungi. It is a serious condition that can affect people of all ages, but it is more dangerous for certain populations, such as the elderly, young children, and people with weakened immune systems. Pneumonia can cause higher risk in patients undergoing surgery, including C-sections. In this case report, we present a pregnant woman who was scheduled for a C-section due to preeclampsia and was initially suspected of concomitant pneumonia. The patient successfully underwent the C-section, but unfortunately experienced a deterioration in her pneumonia after the surgery. She was later admitted to ICU and placed on mechanical ventilation due to the deterioration. Despite the acknowledged risks, including the possibility of death, the patient's family chose to bring the patient home due to their belief that there had been no improvement in the patient's condition and a feeling of resignation. In conclusion, pregnant patients who have pneumonia may require an emergency C-section due to several conditions such as preeclampsia, and the C-section can be conducted successfully. However, it is important for physicians to be aware of the potential for the worsening of pneumonia postoperatively. Post-operative pneumonia is a serious condition that can have a significant impact on the health of patients who have undergone a C-section.

Alarming Trends of Cesarean Section-Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India

BACKGROUND

Cesarean section (CS) delivery rate has increased significantly both globally and in India, thereby posing a burden on overstretched health systems.

OBJECTIVE

This study plans to understand the factors associated with CS rate with an objective to (1) analyze the trends of CS delivery from 1998-99 to 2019-21 and (2) understand the proximate determinants of CS deliveries in India.

METHODS

Analysis of secondary data (National Family Health Survey) of a nationally representative sample of 230,870 women (year 2019-21) was undertaken to explore the trends, distribution, and determinants of CS deliveries in India and within states. Multivariable analyses were performed to determine the proximate variables associated with CS and elective CS. The relative interaction effect of confounding factors, such as number of antenatal care (ANC) visits, place of residence, and wealth status, on cesarean delivery was assessed. A composite index was generated using trust, support, and intimate partner violence variables (termed the partner human capital index [PHI]) to study its influence on CS deliveries, with a low PHI indicating abusive partner and a high PHI indicating supportive partner. Statewise spatial distribution of the most significantly associated factors, namely, wealth quintile and ANC checkups, were also analyzed.

RESULTS

The overall prevalence of CS was 21.50% (49,634/230,870) which had risen from 16.72% (2312/13,829) in 1998-99. The adjusted odds of CS deliveries were significantly higher among women who were highly educated (odds ratio [OR] 7.30, 95% CI 7.02-7.60; P<.001), had 4 or more ANC visits (OR 2.28, 95% CI 2.15-2.42; P<.001), belonging to the high-wealth quintile (OR 7.87, 95% CI 7.57-8.18; P<.001), and from urban regions. Increasing educational level of the head of the household (OR 3.05, 95% CI 2.94-3.16; P<.001) was also found to be a significant determinant of CS deliveries. The odds of selection of elective and emergency CS were also significantly higher among women from richer families (OR 1.66, 95% CI 1.25-2.21; P<.001) and those belonging to Christian religion (OR 1.67, 95% CI 1.14-2.43; P=.008). Adjusting the cesarean delivery by PHI, the odds of outcome were significantly higher among women with moderate and high PHI compared with those with low PHI (OR 1.46, 95% CI 1.36-1.56 and OR 1.61, 95% CI 1.49-1.74, respectively; P<.001 for both). The interaction effect result reiterates that women with more than 4 ANC checkups, high PHI, and belonging to the richer wealth quintile were more likely to undergo cesarean delivery (OR 22.22, 95% CI 14.99-32.93; P<.001) compared with those with no ANC visit, low PHI, and poorest women.

CONCLUSIONS

The increasing trend of CS deliveries across India is raising concerns. Better education, wealth, and good support from the partner have been incriminated as the contributory factors. There is a need to institute proper monitoring mechanisms to assess the need for CS, especially when performed electively.

An Analysis of the Rate, Indications, and Associated Maternal Mortality for Cesarean Sections at a Tertiary Care Hospital, First Report from Somalia

Background

There has been an increase in worldwide cesarean section rates, although they remain low in most Sub-Saharan African countries, including Somalia. The present is the first hospital-based study that analyzes the rate, indications, and associated maternal mortality of cesarean deliveries reported from Somalia.

Methods

This retrospective study reviewed data of all deliveries from 2015 to 2021 using electronic medical records in the hospital information system. Retrieved data include baseline demographic characteristics, mode of delivery, indications and the type of cesarean section, and the documented maternal mortality during the study period.

Results

During seven years, there were 12,540 total deliveries. Among these, 2703 were cesarean sections giving an overall cesarean section rate of 21.6%. The mean age of the patients was 26.7±7.3 years [14-44 years]. Multiparous mothers constituted 67.7% during the study period. According to cesarean deliveries, nulliparous mothers (55.7%) underwent the maximum number of cesarean sections. Emergency cesarean section was the predominant intervention compared to elective C-sections (59.2% vs 40.8%). Primary CS was the most common predominant, while repeat CS increased timely, 77.7% vs 22.3%, respectively. Overall, previous C-sections and fetal distress were the two most common indications for cesarean delivery (22.3% and 22.1%), respectively. C-sections were predominant in women of younger age, Primiparity, having term deliveries, and did not receive regular antenatal care. The maternal mortality rate was 1.7%, and 61% was due to direct obstetric hemorrhage, including postpartum hemorrhage, Placenta abruption, and uterine rupture.

Conclusion

The study findings showed a slight increase in cesarean delivery rates during the study period. This rate is higher than the 10-15% recommended by the WHO in developing countries. Policies and efforts to decrease unnecessary cesarean sections should be promoted and implemented at each health facility.

Robson Classification for cesarean section in a Public Hospital in Distrito Federal

Abstract Objectives: to evaluate cesarean taxes by looking at Robson classification on 10 groups (G) and the principal indications at the prevalent groups and at G10. Methods: cross-sectional, observational, retrospective study, including all deliveries performed in a public hospital in Distrito Federal in 2019. Data were collected from medical records and pregnant women were classified in 10 groups. Pearson’s chi-squared test was used to calculate the p-value. The risk estimate for cesarean was defined by common odds ratio of Mantel-Haenszel, with calculation of odds ratio (OR) and 95% confidence interval (CI95%). Results: there were 2,205 deliveries, 1,084 (49.1%) of which were cesarean and 1,121 (50.9%) vaginal deliveries. The principal factors for cesarean were G5 (39.3%), G2 (21.2%) and G1 (13.6%). At G10, cesarean had 51.5% of births, not differing statistically from the other groups (p>0.05). Considering all preterm births, G6 to G10 and the other groups, there is a bigger chance of cesarean happening in relation to normal labor (OR=1.4; CI95%= 1.011-2.094; p=0.042). Dystocia remained at G1 and G2, previous cesarean at G5 and hypertensive syndrome at G10. Conclusion: cesarean was most prevalent delivery route, showing elevated rates even in primiparous and preterm births. Preponderance of dystocia and acute fetal distress suggests better evaluation of the diagnostic criteria, mainly in G1, G2 and G10.

Can programmatic inputs improve adolescent mothers’ access to maternal care in rural Bangladesh? Nine years of evidence from a cohort study

Background

Adolescent mothers (Girls aged 15–19) constitute 8% of annual global births, but account for 10% of annual maternal deaths. WHO recommended 4–8 Antenatal Care (ANC) visits, in addition to quality care and facility-based deliveries, are well-documented interventions to reduce maternal and child morbidity and mortality. Determinants of maternal and child health care in Bangladesh have received considerable attention, but less attention has been focused on adolescent mothers. This study explores the factors associated with 4 or more (4 +) ANC visits and facility-based delivery among adolescent mothers in one rural area of Bangladesh.

Methods

This study uses Health and Demographic Surveillance System (HDSS) data. We conducted a comparative study on trends in 4 + ANC visits and facility-based deliveries among adolescent mothers (10–19 years) residing in an intervention area (icddr,b service area, ISA) against a comparison area (government service areas, GSA) of HDSS between 2007 and 2015. Totally, 4,996 adolescent mothers were included in the final analysis. Binary logistic regression was used to document the statistical difference on outcome indicators in the two study areas.

Results

Trends in 4 + ANC visits and facility-based deliveries were higher in the ISA relative to the GSA. The adjusted odds of an adolescent mother accessing 4 + ANC visits in the GSA, relative to ISA, were 0.57 (95% CI 0.49–0.66, p value < 0.05); the adjusted odds of an adolescent mother accessing facility-based delivery in the ISA, relative to GSA, were 6.63 (95% CI: 5.85–7.52, p value < 0.05). Increasing numbers of ANC visits were associated with increases in facility-based births in both the ISA and GSA.

Conclusion

This study documented that both 4 + ANC visits and facility delivery rates among adolescent mothers are much higher in the ISA than GSA. Increasing 4 + ANC visits and facility deliveries over the years, particularly in the ISA, coincide with programmatic efforts to improve the quality and availability of maternal and newborn health services. Learning from existing interventions in ISA and applying them to other areas will strengthen Bangladesh’s efforts to improve maternal and newborn health outcomes and achieve the Sustainable Development Goal 3 (SDG 3).

Unpacking cesarean in rural Bangladesh: Who, what, when, and where

BACKGROUND

Bangladesh has experienced an alarming increase in birth through cesarean over the last decade. In this article, we examine rural Bangladeshi women's reporting of why they underwent cesarean, who proposed the cesarean, and when in the process, the decision for a surgical birth was made.

METHODS

We conducted a cross-sectional household survey of 2299 women in Kushtia district. Of these, 1233 who gave birth through cesarean completed a supplemental questionnaire. Descriptive statistics were used to report cesarean rates, which were disaggregated by sociodemographic characteristics and by antenatal care contacts with health services. We analyzed women's reported reasons for having a cesarean, when the decision was taken, and who proposed the intervention.

FINDINGS

Over half (54%) of women gave birth through cesarean. The proportion of cesareans was significantly higher among women with higher educational attainment, higher socioeconomic status, and increased antenatal care during pregnancy, particularly if this care was sought in private facilities (P &lt; .05). Women reported that health service providers primarily proposed the cesarean (73%), followed by family members (21%) and finally, the birthing person themselves (6%). With respect to the reasons for cesarean, 34% of women reported nonmedical reasons (convenience and avoidance of labor pain), and 44% mentioned only medical reasons. Over half of the women reported that the decision to undergo a cesarean was made on the day of birth.

CONCLUSIONS

Women in rural Bangladesh often report avoidable reasons for cesarean. Better regulation of cesarean services in both public and private health services, as well as improved counseling of women with respect to cesarean indications and their consequences, is recommended.

Sex differences in the care of the fetus in the mother's womb and the neonate on her lap: Evidence from demographic surveillance and survey data from Bangladesh

Valuation of sons over daughters introduces sex-biased health, economic, and socio-demographic inequalities in many societies. This study aims to examine fetus-sex differences in maternity services and sex differences in medical care for terminally ill neonates in Bangladesh, using secondary data from the Matlab Health and Demographic Surveillance System (HDSS), maintained by icddr,b since 1966 along with data from the Bangladesh Maternal Mortality and Health Care Survey (BMMS) 2016. The HDSS follows a well-defined rural population (0.24 million in 2018) to register vital events and migrations and records the use of maternity services for the index birth and medical care-seeking during the terminal illness of each death in verbal autopsy. The BMMS 2016 recorded maternity care and maternal complications for the last live birth of mothers in the same population (weighted n = 27,133; unweighted n = 26,939). Bivariate analyses estimated the use (in %) of maternity services for the index live births and medical services for terminally ill neonates for each socio-demographic variable. Logistic regression models estimated odds ratios (AORs) adjusted for socio-demographic variables and clustering of births to the same mothers. The HDSS registered 49,827 live births and 1,049 neonatal deaths during 2009-2018. We found similar prenatal care-seeking for male and female fetuses but higher facility delivery (AOR = 1.17, 95% CI: 1.12-1.23) and C-sections (AOR = 1.20, 95% CI: 1.15-1.25) for male fetus pregnancies, differences that remain after adjusting for maternal complications. Sex differences persisted in seeking care for terminally ill neonates. Trained provider consultation (AOR = 1.46, CI: 1.00-2.12); hospital admissions (AOR = 1.43, CI: 1.01-2.03); and dying in hospital (AOR = 1.91, CI: 1.31-2.78) were all higher for male neonates. Other variables positively associated with delivery care and medical care-seeking were lower birth order of the child, higher maternal education, and higher household wealth status. Policy and decision-makers need to be aware of gender disparities in maternity care and care of sick neonates and plan remedial actions.

Gestational Diabetes Mellitus as an Effect Modifier of the Association of Gestational Weight Gain with Perinatal Outcomes: A Prospective Cohort Study in China

The association of gestational weight gain (GWG) with perinatal outcomes seems to differ between women with and without gestational diabetes mellitus (GDM). Whether GDM is an effect-modifier of the association has not been verified. This study aimed to assess the modifying effect of GDM on the association of GWG with perinatal outcomes. Data on 12,128 pregnant women (3013 with GDM and 9115 without GDM) were extracted from a prospective, multicenter, cohort study in China. The associations of total and trimester-specific GWG rates (GWGR) with perinatal outcomes, including small size for gestational age, large size for gestational age (LGA), preterm birth, cesarean delivery, and gestational hypertension disorders, were assessed. The modifying effect of GDM on the association was assessed on both multiplicative and additive scales, as estimated by mixed-effects logistic regression. As a result, total GWGR was associated with all of the perinatal outcomes. GDM modified the association of total GWGR with LGA and cesarean delivery on both scales (all p < 0.05) but did not modify the association with other outcomes. The modifying effect was observed in the third trimester but not in the first or the second trimester. Therefore, maternal GWG is associated with perinatal outcomes, and GDM modifies the association with LGA and cesarean delivery in the third trimester.

Caesarean delivery and its association with educational attainment, wealth index, and place of residence in Sub-Saharan Africa: a meta-analysis

Caesarean delivery (C-section) has been increasing worldwide; however, many women from developing countries in Sub-Saharan Africa are deprived of these lifesaving services. This study aimed to explore the impact of certain socioeconomic factors, including respondent's education, husband's education, place of residence, and wealth index, on C-section delivery for women in Sub-Saharan Africa. We used pooled data from 36 demographic and health surveys (DHS) in Sub-Saharan Africa. Married women aged 15-49 years who have at least one child in the last five years were considered in this survey. After inclusion and excluding criteria, 234,660 participants were eligible for final analysis. Binary logistic regression was executed to determine the effects of selected socioeconomic factors. The countries were assembled into four sub-regions (Southern Africa, West Africa, East Africa, and Central Africa), and a meta-analysis was conducted. We performed random-effects model estimation for meta-analysis to assess the overall effects and consistency between covariates and utilization of C-section delivery as substantial heterogeneity was identified (I² > 50%). Furthermore, the meta-regression was carried out to explain the additional amount of heterogeneity by country levels. We performed a sensitivity analysis to examine the effects of outliers in this study. Findings suggest that less than 15% of women in many Sub-Saharan African countries had C-section delivery. Maternal education (OR 4.12; CI 3.75, 4.51), wealth index (OR 2.05; CI 1.94, 2.17), paternal education (OR 1.71; CI 1.57, 1.86), and place of residence (OR 1.51; CI 1.44, 1.58) were significantly associated with the utilization of C-section delivery. These results were also consistent in sub-regional meta-analyses. The meta-regression suggests that the total percentage of births attended by skilled health staff (TPBASHS) has a significant inverse association with C-section utilization regarding educational attainment (respondent & husband), place of residence, and wealth index. The data structure was restricted to define the distinction between elective and emergency c-sections. It is essential to provide an appropriate lifesaving mechanism, such as C-section delivery opportunities, through proper facilities for rural, uneducated, impoverished Sub-Saharan African women to minimize both maternal and infant mortality.

An Uninformed Decision-Making Process for Cesarean Section: A Qualitative Exploratory Study among the Slum Residents of Dhaka City, Bangladesh

The decision-making process and the information flow from physicians to patients regarding deliveries through cesarean section (C-section) has not been adequately explored in Bangladeshi context. Here, we aimed to explore the extent of information received by mothers and their family members and their involvement in the decision-making process. We conducted a qualitative exploratory study in four urban slums of Dhaka city among purposively selected mothers (n = 7), who had a cesarean birth within one-year preceding data collection, and their family members (n = 12). In most cases, physicians were the primary decision-makers for C-sections. At the household level, pregnant women were excluded from some crucial steps of the decision-making process and information asymmetry was prevalent. All interviewed pregnant women attended at least one antenatal care visit; however, they neither received detailed information regarding C-sections nor attended any counseling session regarding decisions around delivery type. In some cases, pregnant women and their family members did not ask health care providers for detailed information about C-sections. Most seemed to perceive C-sections as risk-free procedures. Future research could explore the best ways to provide C-section-related information to pregnant women during the antenatal period and develop interventions to promote shared decision-making for C-sections in urban Bangladeshi slums.

Inequalities in prevalence of birth by caesarean section in Ghana from 1998-2014

BACKGROUND

Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014.

METHODS

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014).

CONCLUSION

Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated.

Time-to-recovery after cesarean section delivery among women who gave birth through cesarean section at Hawassa University Comprehensive Specialized Hospital, South Ethiopia: A prospective cohort study

Cesarean deliveries have become a major public health problem worldwide in recent decades. In addition, information on the quality of service, as measured by timely recovery is scarce. This study was assessed predictors of recovery time after cesarean section among women who delivered by cesarean section at Hawassa University Comprehensive Specialized Hospital (HU-CSH) Southern Ethiopia. Institution-based prospective cohort study design was conducted among 381 study participants from July to August 2020. A consecutive sampling technique employed to select study participants. A pre-tested structured questionnaire was used to collect the data. The data were entered and analyzed by Epi info version 7 and SPSS respectively. Bivariable and multivariable Cox regression used to identify the predictors of time-to-recovery after cesearean section. Adjusted Hazard Ratio (AHR) with the respective 95% confidence intervals (CIs)and p-value <0.5 was used to declare statistical significance. A total of 369 mothers who undergone cesearean section were followed for 1,042 person-days of observation. The timely recovery (within 4 days) was found to be 96.2% [95%CI: 94.04-98.4%] and the overall median (IQR) time of recovery was 2.00 (2, 3) days. The study revaled that the Incidence density rate (IDR) of timely recovery was found to be 0.34 per person-days or 2.38 per person-week. Whereas, the cumulative probability of not recovered on the 1st and 4th day was 0.995 and 0.038 respectively. This study found that women who had ANC follow-up (AHR = 1.49, 95%, CI: 1.05-2.10) and discharge from the wound site (AHR = 0.13, 95%, CI: 0.03-0.56) were identified as a significant positive and negative predictors of time-to-recovery after CS delivery respectively. The rate of early recovery obtained by this study was comparable to the global level figures. Still, the cleanness of the surgical site to prevent the incidence of postsurgical site CS delivery is very essential.

Prevalence and Factors Associated With Caesarean Delivery in Nepal: Evidence From a Nationally Representative Sample

Background Caesarian sections (CS) are life-saving management for a pregnant mother and fetus subject to obstetric complications. The World Health Organization (WHO) expected CS rates not to exceed 10 to 15 per 100 live births in any country. This study aimed to assess the prevalence of CS and its associated factors from the 2016 Nepal Demographic and Health Survey (NDHS), building on previous studies mentioned in detail in the latter part of the paper. Methods This study analyzed the secondary data from the 2016 Nepal Demographic and Health Survey (NDHS), conducted from June 19, 2016, to January 31, 2017. The survey is undertaken every five years; consequently, the data capture the information in the previous five years from the data collection period. We used the 2016 NDHS, which is implemented by the new Enumeration Area (EA) under the support of the Ministry of Health (MOH) and funded by the U.S. Agency for International Development (USAID). In the rural areas, the sample is stratified and selected in two stages. In the first stage, wards are selected as the primary sampling units (PSU), with households subsequently chosen from the PSUs. In the urban areas, the sample is nominated in three stages. In the first stage, wards are selected as PSUs; in the second stage, one EA is chosen from each PSU, and finally, households are selected from the EAs. Then data were collected from the women in the reproductive age group within the selected households. Results The prevalence of CS in Nepal conforms to the WHO standard with 7.8, 7.5, and 8.1 per 100 deliveries, or 9.8, 8.9, and 9.1 per women's last births in the previous one, three, and five years, respectively. Older mothers of 30 years old or more, having high incomes, being overweight and obese, using the internet, ante-natal care (ANC) visits of more than four times, ANC by doctors, twin delivery, and having babies of 4 kg or more, had higher odds for a CS while having two or more children seemed to be protective towards CS. Conclusion These findings can be used to update health policies surrounding CS delivery to limit unnecessary CS and ensure better health as CS is not without complications.

Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey

BACKGROUND

Caesarian section is a vital emergency obstetric intervention for saving the lives of mothers and newborns. However, factors which are responsible for caesarian section (CS) were not well established in the country level data. Therefore, this study aimed to assess the prevalence and associated factors of caesarian section in Ethiopia.

METHODS

Data from the Ethiopian Mini Demographic and Health survey 2019 were used to identify factors associated with the caesarian section in Ethiopia. We applied multi-level logistic regression and a p-value of <0.25 to include variables before modeling and a p-value<0.05 with 95% confidence interval (CI) for final results.

RESULT

The prevalence of caesarian section in Ethiopia was 5.44% (95% CI; 0.048-0.06) in2019. Women in age group of 30-39 and 40-49 years had a higher odd of caesarian section (AOR = 2.14, 95%CI = 1.55-2.94) and (AOR = 2, 95%CI = 1.20-3.97) respectively compared to women in age group of 15-29 years. Women with secondary and higher educational level had higher odds of caesarian section (AOR = 2.15, 95%CI = 1.38-3.34) and (AOR = 2.8, 95%CI = 1.73-4.53) compared to those in no education category. Compared to Orthodox, Muslims and Protestant religions had lower odds of caesarian section with AOR of 0.50 (0.34-0.73) and 0.53 (0.34-0.85). Having <2 births was also associated with the low caesarian section 0.61(0.52-1.22). Using modern contraceptive methods, having ANC visits of 1-3, 4th, 5 plus, and urban residence were associated with higher odds of caesarian section as 1.4 (1.05-1.80]), 2.2 (1.51-3.12), 1.7 (1.12-2.46), and 2.4 (1.65-3.44) 1.6(1.04-2.57) respectively.

CONCLUSION

Although evidence indicates that the caesarian deliveries increased both in developed and underdeveloped countries, the current magnitude of this service was very low in Ethiopia which might indicate missing opportunities that might costing lives of mothers and newborns. Women's age, religion, educational status, parity, contraceptive method, and ANC visit were individual level factors influenced caesarian section. whereas, region and place of residence were community level factors affected caesarian section in the country. Depending on these factors, the country needs policy decisions for further national level interventions.

Adopting Andersen's behavior model to identify factors influencing maternal healthcare service utilization in Bangladesh

BACKGROUND

Equitable maternal healthcare service access and it's optimum utilization remains a challenge for many developing countries like Bangladesh, and different predisposing, enabling, and need-based factors affect the level of maternal healthcare use. The evidently poor maternal healthcare service utilization and disparities among groups in Bangladesh are concerning considering its effect on maternal health outcomes. The study aimed to identify the factors that influence maternal healthcare service (MHS) utilization in Bangladesh by adopting Andersen's behavior model of health service use as the theoretical framework.

METHODS

The 2017-18 Bangladesh Demographic Health Survey (2017-18 BDHS) data were used which is nationally representative. The survey study used two-stage stratified sampling to select study households, and data were collected through face-to-face interviews. The desirable, moderate, and undesirable maternal health service (MHS) package was developed based on antenatal, and delivery care services use during pregnancy and childbirth. Multinomial logistic regression and discriminant analysis were performed to analyze the factors that affect MHS use.

RESULTS

Out of 5,011 ever-married women, only 31.2% of women utilized the desirable level of MHS. The likelihood of using the desirable level of MHS package, relative to the undesirable category, was 9.38 times (OR: 9.38, 95% CI: 4.30-20.44) higher for women with a higher level of education compared to illiterate women, and the same trend was noticed for husband's education. The wealth index had the highest standardized function coefficients (Beta coefficient: 0.49) in discriminatory function. Women with the richest wealth index were more than 23 times (OR: 23.27, 95% CI: 12.69-42.68) likely to have utilized desirable MHS than their poorest counterparts. The likelihood of service uses also varied according to the child's birth order, administrative regions, and area of residence (rural vs. urban).

CONCLUSIONS

Policies and interventions directed towards poverty reduction, universal education, and diminishing geographical disparities of healthcare access might influence the desirable use of maternal healthcare services in Bangladesh.

Prevalence and factors associated with skin-to-skin contact (SSC) practice: findings from a population-based cross-sectional survey in 10 selected districts of Bangladesh

BACKGROUND

Skin-to-skin contact (SSC) practice improves newborn survival and child development through preventing hypothermia in newborns, improving early initiation of breastfeeding practice, and strengthening mother-child bonding. Despite having numerous benefits, it is one of the least practiced interventions in low and middle-income countries (1 to 74%). In Bangladesh, the prevalence of SSC was 26% in 2014. In this study, we aimed to estimate the prevalence of SSC in the study districts and identify factors that facilitate or inhibit SSC practice so that context-specific recommendations can be made to advance the use of this intervention.

METHODS

We used baseline household survey data of USAID's MaMoni MNCSP project conducted in 10 districts of Bangladesh in 2019. Our analysis included 13,695 recently delivered women (RDW) with a live birth outcome. Our primary outcome was the mother's reported practice of SSC. We examined various antepartum, intrapartum, newborn, and sociodemographic factors associated with SSC using a multivariable generalized linear model. Our findings were reported using adjusted Prevalence Risk Ratios (aPRRs) and 95% Confidence Intervals (CIs).

RESULTS

Overall, 28% of RDW reported practicing SSC across the 10 surveyed districts. Our multivariable analysis showed that public facility delivery (aPRR 2.01; 95%CI: 1.80, 2.26), private facility delivery (aPRR 1.23; 95%CI: 1.06, 1.42) and ≥ 4 antenatal care (ANC) visits at least one from a medically trained provider (MTP) (aPRR 1.17; 95%CI: 1.03, 1.26) had a significant positive association with SSC practice. Caesarean section (aPRR 0.64; 95%CI: 0.56, 0.73) had a significant negative association with SSC practice compared to vaginal births. We also found a significant positive association of SSC practice with mothers' who perceived the birth size of their baby to be small, mothers with a higher education level (≥10 years), and mothers from households in the highest wealth quintile.

CONCLUSIONS

The prevalence of SSC is very low in the surveyed districts of Bangladesh. Considering the factors associated with SSC, relevant stakeholders need to increase their efforts on improving ANC and facility delivery coverages as well as improving SSC practice in the facilities especially after caesarean deliveries. Countries with a high burden of home deliveries, also need to emphasize community-based interventions and increasing coverage of skilled birth attendance for improving this life-saving intervention.

Geographical variability and factors associated with caesarean section delivery in India: a comparative assessment of Bihar and Tamil Nadu

Background

Caesarean section delivery is a major life-saving obstetric surgical intervention for mothers and babies from pregnancy and childbirth related complications. This paper attempts to investigate the geographical variations and correlating factors of caesarean section delivery in India, particularly focusing on the states of Bihar and Tamil Nadu, accounting for one of the lowest and highest prevalence states of caesarean section delivery respectively.

Methods

This study is based on secondary data, collected from the fourth round of the National Family Health Survey (NFHS-4), 2015–16. We utilized 190,898 women aged 15–49 years who had a living child during the past 5 years preceding the survey. In this study, caesarean section delivery was the outcome variable. A variety of demographic, socio-economic, and pregnancy- and delivery-related variables were considered as explanatory variables. Descriptive statistics, bivariate percentage distribution, Pearson’s Chi-square test, and multivariate binary logistic regression models were employed to draw the inferences from data.

Results

Of participants, about 19% of women had undergone caesarean section delivery in the country. The state-wise distribution shows that Telangana (60%) followed by Andhra Pradesh (42%) and Tamil Nadu (36%) represented the topmost states in caesarean delivery, while Bihar (7%), Madhya Pradesh (10%), and Jharkhand (11%) placed at the bottom end. Multivariate logistic models show that the likelihood of caesarean delivery was higher among older women (35–49 years), women with higher levels of education, Muslims, women belonging to the upper quintiles of the household wealth, and those who received antenatal care (ANC), experienced pregnancy loss and delivery complications. Moreover, the odds of caesarean section delivery were remarkably greater for the private health sector than the public health sector in both focused states: Bihar (odds ratio [OR] = 12.84; 95% confidence interval [CI]: 10.90, 15.13) and Tamil Nadu (OR = 2.90; 95% CI: 2.54, 3.31).

Conclusion

Findings of this study suggest that improvement in female education, providing economic incentives, and spreading awareness through mass media could raise the caesarean section delivery among women whose vaginal delivery could be unsafe for them as well as for their babies. Moreover, providing adequate ANC and well-equipped public healthcare services would facilitate caesarean delivery among needy women.

A national assessment of elective cesarean sections in Bangladesh and the need for health literacy and accessibility

There has been a gradual rise in the number of cesarean sections (CSs) in Bangladesh. The present study identified the cohort of women, who were more likely to opt for an elective CS based on their sociodemographic characteristics, pre-delivery care history, and media exposure, using the Bangladesh Multiple Indicator Cluster Survey-2019. The survey stratification adjusted logistic regression model and interpretable machine learning method of building classification trees were utilized to analyze a sample of 9202 women, alongside district-wise heat maps. One-in-five births (20%) were elective CSs in the 2 years prior to the survey. Women residing in affluent households with educated house-heads, who accessed antenatal care prior to delivery (AOR 4.12; 95% CI 3.06, 5.54) with regular access to media (AOR 1.31; 95% CI 1.10, 1.56) and who owned a mobile phone (AOR 1.25; 95% CI 1.04, 1.50) were more likely to opt for elective CSs, which suggests that health access and health literacy were crucial factors in women's mode of delivery. Spatial analyses revealed that women living in larger cities had more elective CS deliveries, pointing towards the availability of better health and access to multiple safe delivery options in peripheral areas.

Institute of Medicine Recommendations on the Rate of Gestational Weight Gain and Perinatal Outcomes in Rural Bangladesh

Although validated in other parts of the world, the suitability of the U.S. Institute of Medicine (IOM) 2009 recommendations on gestational weight gain (GWG) for Bangladeshi women remains to be examined. We evaluated the association between the weekly rate of weight gain during the second and third trimester of pregnancy, categorized according to IOM recommendations, and adverse perinatal outcomes among 1569 pregnant women with singleton live births in rural Matlab, Bangladesh. Gaining weight at rates below the IOM recommendations was associated with higher odds of preterm birth (adjusted odds ratio (AOR) = 2.0, 95% CI: 1.1-3.6), low birth weight (AOR = 1.4, 95% CI: 1.03-2.0), small-for-gestational-age newborns (AOR = 1.3, 95% CI: 1.04-1.7), and poor neonatal outcome (severe neonatal morbidity or death, AOR = 2.4, 95% CI: 1.03-5.6). A GWG rate above the recommendations was associated with higher odds of cesarean delivery (AOR = 1.7, 95% CI: 1.1-2.6), preterm birth (AOR = 2.2, 95% CI: 1.1-4.4), large-for-gestational-age newborns (AOR = 5.9, 95% CI: 1.5-23.1), and poor neonatal outcome (AOR = 2.7, 95% CI: 1.04-7.0). Our results suggest that the IOM 2009 recommendations on GWG rate during the second and third trimester may be suitable for guiding rural Bangladeshi women in the prenatal period, although the women should aim for rates near the lower bound of the range.

Marginal cord insertion among singleton births at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Umbilical cord may insert abnormally i.e. marginal insertion to a placenta which can cause different birth and perinatal complications. Despite the increased effort taken by different responsible bodies, the prevalence of birth and perinatal complications are still high, possibly due to anomalous cord insertion. So far, anomalous cord insertion lacks proper attention in different medical settings. Hence, the present study aims to assess the magnitude, risk factors, and adverse birth outcomes of marginal cord insertion among singleton births.

Methods

An institution-based cross-sectional study design was conducted. A systematic random sampling technique was used to select study participants. Data were collected by using a structured questionnaire and it was entered into epi-data version 3.1 then exported to SPSS version 20 for data cleansing and analysis. Bi-variable and multivariable logistic regressions were employed to identify risk factors and adverse outcomes associated with marginal cord insertions. Crude and adjusted odds ratio (P-value < 0.05) with a 95% confidence interval were calculated.

Result

The magnitude of marginal cord insertion was 6.4% (95% CI = 4.4–8.8%) in singleton pregnancies. Independent risk factors for marginal cord insertion were advanced maternal age (AOR = 2.24, 95% CI: 1.35–11.08), primiparity (AOR = 1.98, 95% CI: 1.37–8.69), maternal chronic hypertension (AOR = 3.07, 95% CI: 1.66–9.76), previous cesarean delivery (AOR = 2.51, 95% CI: 1.43–10.21), and use of intrauterine contraceptive device before pregnancy (AOR = 2.22, 95% CI: 1.36–12.30). Pregnancies complicated by marginal cord insertion are at higher risk to develop low birth weight (AOR = 2.89, 95% CI: 1.23–6.80), preterm birth (AOR = 4.00, 95% CI: 1.44–11.14), and emergency cesarean delivery (AOR = 3.68, 95% CI: 1.03–13.81).

Conclusion and recommendation

Marginal cord insertion is a mistreated potential risk for low birth weight, preterm birth, and emergency cesarean delivery. Routine screening of marginal cord insertion should be considered in pregnancies with advanced age, nulliparity, hypertensive disorder, history of cesarean section, and intrauterine contraceptive device usage before pregnancy.

Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study

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.

Indications and factors associated with cesarean section in Bhutan: A hospital-based study

OBJECTIVE

To investigate the factors associated with cesarean section (CS) in Bhutan.

METHODS

This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan.

RESULTS

The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS.

CONCLUSION

In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph.

Cesarean delivery and early childhood diseases in Bangladesh: An analysis of Demographic and Health Survey (BDHS) and Multiple Indicator Cluster Survey (MICS)

Introduction

The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.

Methods

We used four nationally representative data sets from multiple indicator cluster survey (MICS, 2012 and 2019) and Bangladesh Demographic and Health Survey (BDHS, 2011and 2014) and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases (fever, short or rapid breaths, cough, blood in stools, and diarrhea) as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.

Results

In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% [Risk Ratio (RR): 1.05, 95% CI: 0.95, 1.17, p = 0.33]. However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [(2011 BDHS RR: 1.22, 95% CI: 1.08, 1.38) and (2019 MICS RR: 1.21, 95% CI: 1.08, 1.35)] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.

Conclusion

Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh.

Magnitude of Cesarean Section Delivery and Its Associated Factors Among Mothers Who Gave Birth at Public Hospitals in Northern Ethiopia: Institution-Based Cross-Sectional Study

Background

Cesarean section is one of the most common surgeries around the world performed whenever abnormal conditions complicate labour and vaginal delivery, threatening the life or health of the mother or the baby. Although the cesarean section is a safe operation, when it is performed without medical need, it puts mothers and their babies at risk of short- and long-term health problems. However, the factors are not persistent and there is limited information concerning the levels of cesarean section delivery and its associated factors in public hospitals of North Wollo Zone. Therefore, this study aimed to assess the magnitude of cesarean section and associated factors in hospitals of North Wollo Zone, Northern Ethiopia.

Methods and Materials

An institution-based cross-sectional study design was employed among 433 mothers who gave birth in public hospitals of North Wollo Zone, Northern Ethiopia, from March 01 to 30, 2019. A systematic random sampling method was used to select the study participants. A structured questionnaire was used to collect data. Bivariable and multivariable analyses were carried out to identify independent predictors of cesarean section.

Results

The magnitude of cesarean section delivery was 30.9% (95% CI, 26.8–35.3). Being urban resident (AOR=4.04, 95% CI: 2.19–7.45), malpresentation (AOR=2.56, 95% CI: 1.29–5.05), having a previous cesarean section (AOR=9.11, 95% CI: 3.77–22.01) and antepartum haemorrhage (AOR=8.65, 95% CI: 3.82–19.56) were statistically and positively associated with cesarean section delivery.

Conclusion

The magnitude of cesarean section delivery among mothers who gave birth at North Wollo Zone public hospitals was high. Residence, antepartum haemorrhage, having a previous cesarean section, and malpresentation were factors associated with cesarean section. Therefore, health education and giving a clear picture regarding the risks and benefits of cesarean section as well as avoiding unjustified cesarean section delivery should be encouraged.

The association of maternal age with adverse neonatal outcomes in Lusaka, Zambia: a prospective cohort study

Background

Pregnancy among adolescents, whether intended or not, is a public health concern as it is generally considered high risk for both mothers and their newborns. In Zambia, where many women engage in early sexual behaviour or marry at a young age, 28.5% of girls aged 15–19 years were pregnant with their first child in the year 2013–2014. This study sought to explore associations between maternal age and neonatal outcomes among pregnant women in Lusaka, Zambia.

Methods

This was a secondary analysis of data nested within a larger population-based prospective cohort study which was implemented in three government health facilities-two first level hospitals and one clinic in Lusaka, Zambia. Women presenting to the study sites for antenatal care were enrolled into the study and followed up for collection of maternal and neonatal outcomes at 7, 28 and 42 days postpartum. The study’s primary outcomes were the incidence of maternal and newborn complications and factors associated with adverse neonatal outcomes. Statistical significance was evaluated at a significance level of P < 0.05.

Results

The study included 11,501 women, 15.6% of whom were adolescents aged 10–19 years. Generally, adolescence did not have statistically significant associations with poor maternal health outcomes. However, the risk of experiencing obstructed labour, premature rupture of membranes and postpartum hemorrhage was higher among adolescents than women aged 20–24 years while the risk of severe infection was lower and non-significant. Adolescents also had 1.36 times the odds of having a low birthweight baby (95% CI 1.12, 1.66) and were at risk of preterm birth (aOR = 1.40, 95% CI 1.06, 1.84). Their newborns were in need of bag and mask resuscitation at birth (aOR = 0.62, 95% CI 0.41, 0.93). Advanced maternal age was significantly associated with increased odds of hypertension/ pre-eclampsia (95% CI 1.54, 5.89) and preterm labour (aOR = 2.78, 95% CI 1.24, 6.21).

Conclusions

Adolescence is a risk factor for selected pregnancy outcomes in urban health facilities in Lusaka, Zambia. Health care workers should intensify the provision of targeted services to improve neonatal health outcomes.

Trial registration

Clinical trial number and URL: NCT03923023 (Retrospectively registered). Clinical trial registration date: April 22, 2019.

Factors Associated with Cesarean Section among Primiparous Women in Georgia: A Registry-based Study

Cesarean section rates remain high in Georgia. As a cesarean section in the first pregnancy generally lead to a cesarean section in subsequent pregnancies, primiparous women should be targeted for prevention strategies. The aim of the study was to assess factors associated with cesarean section among primiparous women. The study comprised 17,065 primiparous women with singleton, cephalic deliveries at 37–43 weeks of gestation registered in the Georgian Birth Registry in 2017. The main outcome was cesarean section. Descriptive statistics and logistic regression analysis were used to identify factors associated with cesarean section. The proportion of cesarean section was 37.1% with regional variations from 14.2% to 57.4%. Increased maternal age, obesity and having a baby weighing ≥4000 g were all associated with higher odds of cesarean section. Of serious concern for newborn well-being is the high proportion of cesarean section at 37–38 weeks of gestation. Further research should focus on organizational and economical aspects of maternity care to uncover the underlying causes of the high cesarean section rate in Georgia.

Emergency peripartum hysterectomy at Jordan University hospital - a teaching hospital experience

Introduction

Emergency peripartum hysterectomy (EPH) is a foremost operation and is perpetually implemented in the presence of life intimidating hemorrhage during or immediately after abdominal or vaginal deliveries. The aim of this study was to review cases managed at the Department of Gynecology and Obstetrics at Jordan University Hospital (JUH).

Material and methods

All women who underwent EPH due to any cause in the period from January 2010, to December 2017 were included in the study. Data were collected retrospectively using the patients’ files namelessly. Main measures: age, gravidity, parity, number of previous cesarean sections, previous uterine surgeries, indication for hysterectomy, complications, antepartum bleeding and the need for blood transfusion.

Results

In total, 74 cases of EPH were managed during the study period. The incidence of EPH ranged from 0.24 to 8.7 per 1000 deliveries. EPH was found to be more common following cesarean sections than vaginal deliveries. The prime indication was abnormal placentation, uterine atony, and uterine rupture. The risk factors included previous cesarean sections, scarred uteruses, multiparity, older age group. Maternal morbidity ranged from 26.5 to 31.5% and mortality from 0 to 12.5% with a mean of 4.8%.

Conclusions

EPH is the most demanding obstetric surgery performed in very tiresome circumstances of life threatening hemorrhage. The indication for EPH in recent years has changed from outdated uterine atony to abnormal placentation. Antenatal eagerness of the risk factors, engrossment of proficient obstetricians at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in tumbling morbidity and mortality.

Maternal and neonatal outcomes following a prolonged second stage of labor: A meta-analysis of observational studies

Several articles investigated the impact of prolonged second stage of labor on maternal and neonatal outcomes; however, strict consensus is still lacking. The purpose of the present meta-analysis is to investigate risk factors that contribute to the pathophysiology of prolonged labor as well as effect sizes of maternal and neonatal morbidity. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar database. Observational studies (prospective and retrospective) were considered eligible for inclusion in the present meta-analysis. To minimize the possibility of article losses we avoided language, country and date restrictions. Meta-analysis was performed with the RevMan 5.3 and secondary analysis with Rstudio. Overall, 13 studies were included in the present systematic review that comprised 337.845 parturient. Prolonged second stage was associated with higher odds of postpartum hemorrhage, chorioamnionitis, endometritis, postpartum fever and obstetric anal sphincter injury. Persistent occiput posterior position and shoulder dystocia were also more prevalent compared to women with normal duration of the second stage. The need for admission to the neonatal intensive care unit was higher as well as the risk of developing neonatal sepsis. On the other hand, the odds of perinatal death were comparable among cases with prolonged and normal duration of the second stage. The results of the present meta-analysis clearly indicate that deliveries following a prolonged second stage of labor are at increased risk of maternal and neonatal complications. The presented effect estimates can be used in current clinical practice during patient counseling.

Prevalence and factors associated with caesarean section in four Hard-to-Reach areas of Bangladesh: Findings from a cross-sectional survey

BACKGROUND

Caesarean section (C-section) is a major obstetric life-saving intervention for the prevention of pregnancy and childbirth related complications. Globally C-section is increasing, as well as in Bangladesh. This study identifies the prevalence of C-section and socio-economic and health care seeking related determinants of C-section among women living in hard-to-reach (HtR) areas in Bangladesh.

METHODS

A cross-sectional survey was conducted using a structured questionnaire between August and December 2017 at four distinct types of HtR areas of Bangladesh, namely coastal, hilly, haor (wetland), and char areas (shallow land-mass rising out of a river). Total 2,768 women of 15-49 years of age and who had delivery within one year prior to data collection were interviewed. For the analysis of determinants of C- section, the explanatory variables were maternal age, educational status of women and their husbands, women's religion, employment status and access to mobile phone, wealth index of the household, distance to the nearest health facility from the household, the number of ANC visits and presence of complications during pregnancy and the last childbirth. Logistic regression model was run among 850 women, who had facility delivery. Variables found significantly associated with the outcome (C-section) in bivariate analysis were included in the multivariable logistic model. A p-value <0.05 was considered as statistically significant in the analyses.

RESULTS

Of the 2,768 women included in the study, 13% had C-sections. The mean (±SD) age of respondents was 25.4 (± 0.1) years. The adjusted prevalence of C-section was 13.1 times higher among women who had their delivery in private facilities than women who delivered in public facilities (Adjusted Odds Ratio, AOR: 13.1; 95% CI 8.6-19.9; p-value: <0.001). Women from haor area and coastal area had 4.7 times (AOR: 4.7; 95% CI 2.4-9.4; p value: <0.001) and 6.8 times (AOR: 6.8; 95% CI 3.6-12.8; p value: <0.001) more chance of having C-section, respectively, than women living in char area. Among women who reported complications during the last childbirth, the AOR of C-section was 3.6 times higher than those who did not report any complication (AOR: 3.6; 95% CI 2.4-5.4; p value: <0.001).

CONCLUSIONS

The study identifies that the prevalence of C-sections in four HtR areas of Bangladesh in substantially below the national average, although, the prevalence was higher in coastal areas than three other HtR regions. Both public and private health services for C-section should be made available and accessible in remote HtR areas for women with pregnancy complications. Establishment of an accreditation system for regulating private hospitals are needed to ensure rational use of the procedure.

Reducing caesarean rates in a public maternity hospital by implementing a plan of action: a quality improvement report

BACKGROUND

Caesarean rates increased in different parts of the world, rising from 20% to 33% in the USA and from 40% to 55% in Brazil between 1996 and 2011; however, there was no reduction in morbimortality rates. Several factors have been suggested as responsible for this increase, such as health judicialisation, fear of the painful process on the patients' part and reduction of medical training in vaginal delivery and labour complications. It is urgent to reverse this process and, therefore, a model of actions was created with the intention of engaging the team in order to reduce caesarean rates in a Brazilian hospital.

METHODOLOGY

The model was based on the following actions: encouragement of labour analgesia; execution of written reports of any cardiotocographic examination; plan-do-study-act cycles for nursing orientations about the positions that favour pregnant women during labour; creation of a birth induction form; monthly feedback with physicians and nurses on caesarean rates achieved; verification of the caesarean rate by medical staff with individual feedback; daily round of medical coordination for case discussions; disclosure of caesarean rates on hospital posters; and constant dissemination of literature with strategies to reduce caesarean delivery. This plan of action started in January 2016. The mean caesarean section rate in the 31 months preceding the interventions (period A) was then compared with the 31 subsequent months (period B).

RESULTS

Both periods presented caesarean rates with normal distribution. The mean caesarean rate was 29.24% (range: 38.69%-23.89%, SD 3.24%) vs 25.84% (range: 17.96%-34.97%, SD 3.92%, p<0.05), respectively, for periods A and B.

CONCLUSION

After the implementation of the plan of action, there was a reduction in caesarean rates in this hospital.

Not just numbers: beyond counting caesarean deliveries to understanding their determinants in Ghana using a population based cross-sectional study

BACKGROUND

The increasing rate of caesarean deliveries (CD) has become a serious concern for public health experts globally. Despite this health concern, research on factors associated CD in many low- and -middle countries like Ghana is sparse. This study, therefore, assessed the prevalence and determinants of CD among child-bearing women aged 15-49  in Ghana.

METHODS

The study used data from the 2014 Ghana Demographic and Health Survey. The analysis was limited to mothers (n = 2742) aged 15-49 , who had given birth in health facilities 5 years preceding the survey. Association between CD and its determinants was assessed by calculating adjusted odds ratios (AOR) with their respective 95% confidence intervals using a binary logistic regression.

RESULTS

The percentage of mothers who delivered their babies through caesarean section (CS) was 18.5%. Using multivariable logistic regression, the results showed that women aged 45-49 (AOR = 10.5; 95% CI: 3.0-37.4), and women from a household that are headed by a female (AOR = 1.3; 95% CI = 1.1-1.7) had higher odds to deliver through CS. Women from the Upper East (AOR =0.4; 95% CI = 0.2-0.7) and Upper West (AOR = 0.4; 95% CI = 0.2-0.8) regions had lower odds to deliver their children through CS. Women with parity 4 or more (AOR = 0.3; 95% CI = 0.2-0.5) had lower odds of CD compared to those with parity 1. Women with female babies had lower odds (AOR = 0.8; CI = 0.7-0.9) of delivering them through CS compared to those with male children.

CONCLUSION

The percentage of women delivering babies through the CS in Ghana is high. The high rates of CD noted do not essentially indicate good quality care or services. Hence, health facilities offering this medical protocol need to adopt comprehensive and strict measures to ensure detailed medical justifications by doctors for performing these caesarean surgeries.