Caesarean section delivery and its associated factors in Ghana: A multilevel analysis

BACKGROUND

Even if the ideal rate for caesarean section (CS) is considered 10-15%, worldwide CS rates have been steadily increasing, without significant additional benefit to women's health. Its overuse was associated with maternal and fetal complications. Therefore, this study aimed to determine the rate of CS delivery and associated factors among women delivered in health facilities in Ghana.

METHODS

A cross-sectional study was conducted using the 2022 DHS datasets from Ghana. A total of 5231 weighted samples were included. STATA.16 was used for analysis. A multilevel logistic regression was applied. An adjusted odds ratio with a 95% CI and a p-value <  0.05 was used to declare significantly associated factors.

RESULT

The prevalence of CS in Ghana was 20.29% [95% CI = 19.23-21.41%]. Age 25-34 [AOR = 1.32, CI: 1.04, 1.68] and 35 + [AOR = 1.57, CI: 1.16, 2.11], primary [AOR = 1.58, CI: 1.21, 2.07], secondary [AOR = 1.36, CI: 1.07, 1.73], and higher [AOR = 2.24, CI: 1.58, 3.17] education, richer [AOR = 1.45, CI: 1.06, 1.99] and richest [AOR = 2.35, CI: 1.63, 3.39] wealth index, employment [AOR = 0.77, CI: 0.64, 0.92], primiparous [AOR = 1.33, CI: 1.07, 1.67], giving first birth after the age of 35 [AOR = 4.58, CI: 1.88, 11.19], multiple pregnancy [AOR = 5.53, CI: 4.02, 7.62], large birth size [AOR = 1.25, CI: 1.06, 1.48], 4-6 kg birth weight [AOR = 2.13, CI: 1.55, 2.92], as well as residing in Volta [AOR = 1.98, 95% CI: 1.22, 3.22] and Bono East [AOR = 2.02, 95% CI: 1.28, 3.19] regions were significant factors associated with CS delivery in Ghana.

CONCLUSION

The rate of CS was higher than previous studies in Ghana and the WHO recommended level, making it a public health concern. Age, education, wealth, employment, parity, age at first birth, pregnancy type, birth size, birth weight, and region were significantly associated with CS. Therefore, strategies aimed at examining guidelines for proper indications and uses of CS may lead to an improvement CS rate.

Predicting Admission to Neonatal Care Unit at Mid-Pregnancy and Delivery Using Data from a General Obstetric Population

OBJECTIVES

Development and validation of risk prediction models at mid-pregnancy and delivery to predict admission to the neonatal care unit.

METHODS

We used data from all singleton deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019. Admission to the neonatal care unit was assumed if length of stay in the unit was > 24 h. Multivariable logistic regression with backward stepwise selection was used to develop the models. Discrimination was assessed using the ROC curve C-statistic, and internal validation was assessed using bootstrapping techniques. We conducted temporal external validation using data from all singleton deliveries at CUMH during 2020.

RESULTS

Out of 6,077 women, 5,809 (95.6%) with complete data were included in the analyses. A total of 612 infants (10.54%) were admitted to the neonatal care unit for > 24 hours. Six variables were informative at mid-pregnancy: male infants, maternal smoking, advancing maternal age, maternal overweight/obesity, nulliparity and history of gestational diabetes (C-statistic: 0.600, 95% CI: 0.567, 0.614). Seven variables were informative at delivery: male infants, nulliparity, public antenatal care, gestational age < 39 weeks', non-spontaneous vaginal delivery, premature rupture of membranes and time of birth between 17:01-07.59 h (C-statistic: 0.738, 95% CI: 0.715, 0.760). Using these predictors, we developed nomograms to calculate individualised risk of neonatal care unit admission. Bootstrapping indicated good internal performance and external validation suggested good reproducibility.

DISCUSSION

Our nomograms allow the user to quickly estimate individualised risk of neonatal care unit admission. Future research should aim to improve accuracy in early pregnancy to better assist counselling of parents.

Early-Life Exposure to PM2.5 and Sleep Disturbances in Preschoolers from 551 Cities of China

Rationale: Air pollution has been linked with sleep disturbance in adults, but the association in children remains unclear. Objectives: To examine the associations of prenatal and postnatal exposure to fine particulate matter (particulate matter ⩽2.5 μm in aerodynamic diameter; PM_2.5) with sleep quality and sleep disturbances among children in 551 Chinese cities. Methods: A total of 1,15,023 children aged 3-7 years from the Chinese National Cohort of Motor Development were included. Sleep quality was measured using the Children's Sleep Habits Questionnaire (CSHQ). PM_2.5 exposure was estimated using a satellite-based model. Generalized additive mixed models with Gaussian and binomial distributions were used to examine the associations of PM_2.5 exposure with CSHQ scores and risk of sleep disturbance, respectively, adjusting for demographic characteristics and temporal trends. Measurements and Main Results: Early-life PM_2.5 exposure was associated with higher total CSHQ score, and the association was stronger for exposure at age 0-3 years (change of CSHQ score per interquartile range increase of PM_2.5 = 0.46; 95% confidence interval [CI], 0.29-0.63) than during pregnancy (0.22; 95% CI, 0.12-0.32). The associations were more evident in sleep-disordered breathing and daytime sleepiness. Postnatal PM_2.5 exposure was associated with increased risk of sleep disturbance (adjusted odds ratio for per-interquartile range increase of PM_2.5 exposure at age 0-3 years, 1.10; 95% CI, 1.04-1.15), but no associations were found for prenatal exposure. Children who were exclusively breastfed for <6 months and had neonatal ICU admission may be more vulnerable to sleep disturbance related to PM_2.5 exposure. Conclusions: PM_2.5 exposure can impair sleep quality in preschool children.

Pregnancy and the risk of NICU admissions in Nandom Municipality of Ghana: A cross-sectional retrospective study

Background

Neonatal intensive care units (NICU) are specialized units that provide medical attention to neonates, and thus have become a vital aspect in the provision of critical care to infants who are faced with special challenges following birth.

Aim

To determine antepartum and intrapartum factors that predispose to NICU admissions in the Nandom Municipal of the Upper West Region of Ghana.

Method

This was a cross-sectional retrospective study, spanning from January 1, 2021 to December 31, 2021. Records covering 1777 women who were delivered or had their babies referred to the St. Theresa's Hospital in the Nandom Municipality were involved in the study. Descriptive statistics and multinomial logistic regression analysis were used to compare variables, and statistical significance was determined where the p-value was less than 0.05.

Results

From the study, the rate of NICU admission was 10.4%. There was a significant association between mothers who attended less than four antenatal sessions (p = 0.004) and admission to NICU. Nulliparous mothers (p = 0.027) and mothers who presented with multiple pregnancy (p < 0.001) were more likely to have their babies sent to NICU. Both preterm delivery (p < 0.001) and post-term delivery (p < 0.001) were prone to admission to NICU. Also, instrumental delivery (p < 0.001), cesarean section (p < 0.001), low birth weight (p < 0.001), and male infants (p = 0.003) had an increased risk of being admitted to NICU. Furthermore, severe (p < 0.001) and moderate (p < 0.001) birth asphyxia in the first minute following delivery were significantly associated with NICU admission whereas severely asphyxiated babies at 5 min (p < 0.001) were associated with NICU admission.

Conclusion

The study revealed a relatively high NICU admission rate in the study area, and the predictors are multifaceted. Tailored intervention programs aimed at curbing these predictors will be required to reduce the rate of NICU admissions in the Nandom Municipality of Ghana.

Determinants for perinatal adverse outcomes among pregnant women with preterm premature rupture of membrane: A prospective cohort study

Background

One of the most critical functions of the fetal membranes is to remain intact until the onset of labor to maintain the protective intrauterine fluid environment. In most pregnancies, spontaneous rupture usually occurs near the end of the first stage of labor. Preterm premature membrane rupture (PROM) occurs when the fetal membrane ruptures before 37 weeks of pregnancy, and it contributes to adverse maternal, fetal, and neonatal outcomes. Therefore, this study aimed to determine the association of determinant factors with adverse perinatal outcomes.

Methods

A prospective cohort study was conducted on pregnant women with preterm premature membrane rupture (n = 160) attending the teaching hospitals at Addis Ababa University. Socio-demographic and obstetric risk factors with adverse perinatal outcomes include the 5th minute Apgar score, neonatal intensive care unit (NICU) admission, early-onset neonatal sepsis (EONS), respiratory distress syndrome (RDS), perinatal mortality, Chorioamnionitis, and placental abruption were assessed. SPSS version 24, t-test, χ ² test, and logistic regression analysis were used. P-values <0.25 in the bivariate and p < 0.05 in the multiple logistic regression were considered statistically significant.

Results

The preterm (PROM) rate was 2.2% with perinatal mortality rate of 206/1,000. Gestational age (GA) at delivery was the determinate for low Apgar score at the 5th minute (AOR: 7.23; 95% CI, 1.10, 47.6; p = 0.04). Unable to use steroid (AOR: 8.23; 95% CI, 1.83, 37.0; p = 0.000), GA at membrane rupture (AOR: 4.61; 95% CI, 1.98, 31.8; p = 0.000) and delivery (AOR: 4.32; 95% CI, 1.99, 30.9; p = 0.000) were determinates for NICU admission. EONS was significantly affected by GA at membrane rupture (AOR: 5.9; 95% CI, 1.01, 37.0; p = 0.04). Placental abruption was significantly affected by GA at delivery (AOR: 7.52; 95% CI, 1.15, 48.96; p = 0.04).

Conclusion

GA at membrane rupture and delivery was the most critical predictors of adverse perinatal outcomes. Local guidelines on the approach and preterm PROM outcome management need to be prepared.

Racial variations of adverse perinatal outcomes: A population-based retrospective cohort study in Ontario, Canada

Introduction

Racial differences in adverse maternal and birth outcomes have been studied in other countries, however, there are few studies specific to the Canadian population. In this study, we sought to examine the inequities in adverse perinatal outcomes between Black and White pregnant people in Ontario, Canada.

Methods

We conducted a population-based retrospective cohort study that included all Black and White pregnant people who attended prenatal screening and had a singleton birth in any Ontario hospital (April 1^st, 2012-March 31^st, 2019). Poisson regression with robust error variance models were used to estimate the adjusted relative risks of adverse perinatal outcomes for Black people compared with White people while adjusting for covariates.

Results

Among 412,120 eligible pregnant people, 10.1% were Black people and 89.9% were White people. Black people were at an increased risk of gestational diabetes mellitus, preeclampsia, placental abruption, preterm birth (<37, <34, <32 weeks), spontaneous preterm birth, all caesarean sections, emergency caesarean section, low birth weight (<2500g, <1500g), small-for-gestational-age (<10th percentile, <3^rd percentile) neonates, 5-minute Apgar score <4 and <7, neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment but had lower risks of elective caesarean section, assisted vaginal delivery, episiotomy, 3rd and 4th degree perineal tears, macrosomia, large-for-gestational-age neonates, and arterial cord pH≤7.1, as compared with White people. No difference in risks of gestational hypertension and placenta previa were observed between Black and White people.

Conclusion

There are differences in several adverse perinatal outcomes between Black and White people within the Ontario health care system. Findings might have potential clinical and health policy implications, although more studies are needed to further understand the mechanisms.

Maternal and Neonatal Outcomes After Planned or Emergency Delivery for Placenta Accreta Spectrum: A Systematic Review and Meta-Analysis

Objective: To compare maternal and neonatal outcomes for women with placenta accreta syndrome (PAS) delivering via a planned or emergent approach.

Methods: A systematic search for relevant studies was conducted by screening the PubMed, Scopus, Web of Science, and Google Scholar electronic databases. Included studies should have been retrospective record-based or prospective in design. They must have compared maternal and/or neonatal outcomes for PAS patients delivering via planned and emergency procedures. Strength of association was presented as pooled adjusted relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Statistical analysis was done using STATA version 16.0.

Results: Nine articles were included in the meta-analysis. PAS patients undergoing planned deliveries had increased gestational ages, required fewer units of transfused blood, experienced shorter hospital stay durations, and presented reduced risks for maternal ICU admission and severe maternal morbidity. Neonates born to mothers undergoing planned deliveries had increased birth weights and decreased NICU admission risk.

Conclusion: These findings indicate a planned approach for delivery is better for maternal and neonatal outcomes compared to urgent/emergency delivery for PAS patients.

Clinicians' Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan

OBJECTIVE

To examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers.

DESIGN

A cross-sectional survey of neonatal nurses and physicians.

SETTING

Twenty-four NICUs in Jordan.

PARTICIPANTS

Participants included 213 nurses and 75 physicians who provided direct care for infants in NICUs.

METHODS

Using the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors.

RESULTS

In 83% of the recalled situations, the physicians in charge of the infants' care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants' primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses' perceived levels of involvement in decision making (χ²[4] = 23.140, p < .001).

CONCLUSION

Our results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.

Acute air pollution exposure and NICU admission: a case-crossover analysis

PURPOSE

Neonatal intensive care unit (NICU) admission rates have increased over time. Air pollution is associated with adverse pregnancy outcomes, but the relationship between prenatal air pollution exposure and NICU admission has not been investigated.

METHODS

In the Consortium on Safe Labor (2002-2008), 27,189 singletons were admitted to the NICU. Modified Community Multiscale Air Quality models estimated exposures for criteria air pollutants and constituents of particles less than or equal to 2.5 microns (PM_2.5). Case-crossover analyses calculated odds ratios and 95% confidence intervals for interquartile range increases in pollutant exposure, comparing exposures during the week of delivery to control periods before and after delivery.

RESULTS

In models that adjusted for PM_2.5, exposure to PM_2.5 constituents during the week before delivery was significantly associated with increased odds of NICU admission: elemental carbon (35%), ammonium ions (37%), nitrate compounds (16%), organic compounds (147%), and sulfate compounds (35%). Odds were also significantly increased by day of and day before delivery exposures to carbon monoxide (4%-5%), nitrogen dioxide (13%), nitrogen oxides (4%-8%), particles less than or equal to 10 microns (2%), particles less than or equal to 2.5 microns (2%), and sulfur dioxide (3%-6%). No associations were observed for ozone.

CONCLUSIONS

Acute exposures to PM_2.5 constituents and several traffic-related pollutants during the week before delivery, the day of delivery, and day before delivery appear to increase the odds of NICU admissions. These novel associations suggest infants exposed in utero to common air pollutants may require additional care during the newborn hospital admission.

Admission of term infants to the neonatal intensive care unit in a Saudi tertiary teaching hospital: cumulative incidence and risk factors

BACKGROUND

An increasing number of term infants of appropriate birthweight receive care in neonatal intensive care units (NICUs).

OBJECTIVES

This study assessed the prevalence, patterns, and risk factors for admission of term infants to a NICU to identify areas for quality improvement.

DESIGN

Cross-sectional analytical study.

SETTING

An academic and referral center in Jeddah, Saudi Arabia.

PATIENTS AND METHODS

The cases were all term infants (>=37 weeks gestational age) admitted to the NICU between 1 January and 31 December 2015. The controls were term infants who were not admitted to the NICU. Cases and controls were matched in a 1:1 ratio according to the date of birth (within one day).

MAIN OUTCOME MEASURES

Prevalence, pattern, and risk factors for admission of term infants to the NICU.

RESULTS

The rate of admission of term infants to the NICU during the study period was 4.1% (142 of 3314 live births in that year). Respiratory complications accounted for 36.6% (52/142) of admissions, followed by hypoglycemia (23/142, 16.2%) and jaundice (11/142, 7.7%). Premature membrane rupture and non-Saudi national status were the risk factors that remained significant after adjusting for confounders.

CONCLUSION

A growing number of term infants are admitted unexpectedly to the NICU. The risk factors and pattern of admission of term infants to the NICU should receive more attention in quality improvement and management agendas.

LIMITATIONS

This was a single-center study with limited access to information about unbooked mothers and details of the hospital stay of the admitted neonates.