Caesarean Sections in a National Referral Hospital in Addis Ababa, Ethiopia: Trends, Predictors and Outcomes Open Access
- Other title
- Type of item
- Degree grantor
University of Alberta
- Author or creator
Kuzma, Tamara O.M.
- Supervisor and department
Saunders, L. Duncan (School of Public Health)
- Examining committee member and department
Turnell, Roger (Obstetrics and Gynecology)
Khadaroo, Rachel (General Surgery)
Jhangri, Gian (School of Public Health)
Voaklander, Don (School of Public Health)
School of Public Health
- Date accepted
- Graduation date
Master of Science
- Degree level
Background Globally, maternal mortality remains a significant public health problem. In order to reduce maternal mortality, emergency obstetric care (EmOC) must be available and accessible to all women. EmOC refers to the services used for the treatment of complications that arise during pregnancy and childbirth. One EmOC indicator, as per the WHO, is that Caesarean sections (CS) as a proportion of all births should be between 5% and 15%; morbidity and mortality rates rise significantly beyond this range in many countries in the world. Worldwide, CS rates have been rising in the last several decades in developed and developing countries. The Ethiopian national CS rate is low at 1.5%, while in Addis Ababa, the capital city, the CS rate is 21.8%. The difficulty with instituting interventions to modify CS rates is that more information is required concerning both the indications and the appropriateness of surgical delivery. The WHO has concluded that the Robson classification system is the most appropriate classification system of indications for CS for international use. A major limitation of the Robson system is that it does not account for the urgency of the CS. Combining the Robson criteria with urgency criteria provides a more useful tool to analyze and compare CS performed globally. Objective The objective of this study was to analyze Caesarean section rate trends and maternal and perinatal outcomes in a specialized hospital in Ethiopia, a low-income country. Methods This was a retrospective cohort study of deliveries at an Ethiopian national specialized hospital in the Ethiopian calendar years 2002-2006 (between Meskerem 1, 2002 and Pagume 5, 2006; the equivalent period in the Gregorian calendar is September 11, 2009 to September 10, 2014). Cluster sampling of all deliveries of gestational age ≥ 28 weeks in this period was used (N=4,816). Women were categorized into one of 10 Robson groups. All mothers who delivered by CS were assigned into one of four urgency groups: Emergent, Urgent, Scheduled, Elective. Maternal morbidity rate was used to characterize maternal outcomes. The perinatal mortality and perinatal distress rates were used to characterize perinatal outcomes. Results The total CS rate rose from 24.5% in 2002 to 32.8% in 2006 (p= 0.001). An increase in the rate of referral by health care workers and a decrease in hospital instrument deliveries can partially explain the increase in CS rate. Within Robson groups, the only group which had a statistically significant change in CS rate in the 5-year time period was Robson group 1 (Nulliparous women with a single cephalic pregnancy, at greater than or equal to 37 weeks gestation in spontaneous labour) (15.9% in 2002 to 24.1% in 2006; p= 0.02). For nine of ten Robson groups, the largest urgency subgroup was the Scheduled group. The overall maternal morbidity rate increased from 3.5% in 2002 to 4.1% in 2006, with higher morbidity rates in the middle years (p= 0.02). The perinatal mortality and perinatal distress rates did not significantly change over time. Conclusions The overall CS rate at SPHMMC significantly increased. Low-risk nulliparous women are the most significant contributors towards the overall CS rate at SPHMMC, followed by women who had a previous CS. The majority of CS performed were done for women requiring an early delivery, and not on an ‘emergent’ basis. The maternal morbidity rate increased slightly over time, but perinatal outcomes did not significantly change from 2002 to 2006. Despite little evidence of increased complications, increased use of CS without medical indications can result in harm as well as unnecessary drain on limited health care resources. Evidence-informed interventions to reduce both primary and repeat CS need to be studied and implemented at this Ethiopian hospital.
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