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Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

ABSTRACT: Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007-10/01/2008). Data were collected regarding women's characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

SUBMITTER: Briand V

PROVIDER: S-EPMC3534628 | biostudies-literature | 2012 Oct

REPOSITORIES: biostudies-literature

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Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

Briand Valérie V Dumont Alexandre A Abrahamowicz Michal M Traore Mamadou M Watier Laurence L Fournier Pierre P

BMC pregnancy and childbirth 20121022

<h4>Background</h4>Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.<h4>Methods</h4>We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007-10/01/2008). Data were collected regarding women's characteristics and on available institutional resources. Individual and institutional facto ...[more]

PMID: 23088501

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Project description:BackgroundGlobally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines.MethodsA qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section.ResultsThe results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations.ConclusionSeveral institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Project description:Caesarean sections (CS) is the most common lifesaving surgeries for obstructed labour and other emergency obstetrical conditions. The WHO had recommended ideal rate for CS to be between 5% and 15%. The rate higher than 15% indicates overused other than lifesaving. Bangladesh has experienced a dramatic increase in CS delivery from 4% in 2004 to 23% in 2014. This increase is elevated by the several factors including maternal education, maternal request or elective CS, and by the urban richest population. However, little is known about the use CS by the urban poorest population. Therefore, the study aimed to examine and identify the factors associated with CS among the urban disadvantaged section of the population. A total of 1063 randomly chosen women aged 15-49 years from the population of 121,912 residing five-different slums were interviewed during November-December 2016. CS delivery was considered as outcome variable. Both bivariate and multivariable statistical analyses were carried-out. We performed logistic regression analyses to examine the net-effect of independent variables on outcome variable. Over 25% of total deliveries and 50% of facility-based deliveries were CS. The odds of CS delivery was 3.4-fold greater among better-off women than poorest. Women who had 4 + ANC checks-up during pregnancy had a 2-fold higher odds of CS delivery than women of ANC check-up. In private facilities, 76% of births were delivered as CS, followed by 51% in public facilities and 24% in NGO facilities. The likelihood of CS delivery in private facilities was 9.2-fold greater than NGO facilities after controlling for women socio-demographic, pregnancy and delivery characteristics. Thus, the high use of CS is largely associated with private facility, ANC visits and household wealth. Therefore, the Government of Bangladesh should take immediate actions by designing new policies and regulations to ensure CS for the lifesaving condition, not for financial gain.

Project description:BACKGROUND:Caesarean section is considered a relatively preferable and safe method of delivery as compared to normal delivery. Since the last decade, its prevalence has increased in both developed and developing countries. In the context of developing countries viz., South Asia (the highest populated region) and South-East Asia (the third-highest populated region), where a significant proportion of home deliveries were reported,however, the preference for, caesarean delivery and its associated factors are not well understood. OBJECTIVE:To study the caesarean delivery in the South and South-East Asian countries and to determine the factors associated with the preference for caesarean delivery. METHODOLOGY:Demographic and Health Survey Data on from ever-married women of nine developing countries of South and South-East Asia viz., Vietnam, India, Maldives, Timor-Leste, Nepal, Indonesia, Pakistan, Bangladesh, and Cambodia have been considered. Both bivariate and binary logistic regression models were used to estimate the propensity of a woman undergoing for caesarean delivery and to assess the influence of maternal socioeconomic characteristics towards the preference for caesarean delivery. RESULTS:Obtained results have shown an inclination of caesarean delivery among urban than rural women and are quite conspicuous, but is found to be underestimated mostly among rural women. Caesarean delivery in general is mostly predisposed among women whose baby sizes are either very large or smaller than average, have a higher level of education and place of delivery is private medical institutions. The logistic regression also revealed the influence of maternal socioeconomic characteristics towards the preference for caesarean delivery. Based on nine South and South-East Asian countries an overall C-section prevalence of 13%, but based on institutional births its increase to 19%. The forest plot demonstrated that a significant inclination of C-section among urban than rural regions. In Meta-Analysis, very high and significant heterogeneity among countries is observed, but confirms that in terms of prevalence of C-section all of the countries follow independent pattern. CONCLUSION:Study of seven urban and four rural regions of nine South and South- East Asian countries showed, a significant inclination towards the caesarean delivery above the more recent outdated WHO recommended an optimal range of 10-15%and are associated maternal socioeconomic characteristics. In order to control unwanted caesarean delivery, the government needs to develop better healthcare infrastructure and along with more antenatal care related schemes to reduce the risks associated with increased caesarean delivery.

Project description:ObjectiveIn the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal.Study designCross-sectional survey nested in a randomised cluster trial (1/10/2007-1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women's, newborn's and hospitals' characteristics.ResultsAmong the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16-0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07-1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66-2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery.ConclusionsIn referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed.

Project description:The onchocerciasis transmission models EPIONCHO and ONCHOSIM have been independently developed and used to explore the feasibility of eliminating onchocerciasis from Africa with mass (annual or biannual) distribution of ivermectin within the timeframes proposed by the World Health Organization (WHO) and endorsed by the 2012 London Declaration on Neglected Tropical Diseases (i.e. by 2020/2025). Based on the findings of our previous model comparison, we implemented technical refinements and tested the projections of EPIONCHO and ONCHOSIM against long-term epidemiological data from two West African transmission foci in Mali and Senegal where the observed prevalence of infection was brought to zero circa 2007-2009 after 15-17 years of mass ivermectin treatment. We simulated these interventions using programmatic information on the frequency and coverage of mass treatments and trained the model projections using longitudinal parasitological data from 27 communities, evaluating the projected outcome of elimination (local parasite extinction) or resurgence. We found that EPIONCHO and ONCHOSIM captured adequately the epidemiological trends during mass treatment but that resurgence, while never predicted by ONCHOSIM, was predicted by EPIONCHO in some communities with the highest (inferred) vector biting rates and associated pre-intervention endemicities. Resurgence can be extremely protracted such that low (microfilarial) prevalence between 1% and 5% can be maintained for 3-5 years before manifesting more prominently. We highlight that post-treatment and post-elimination surveillance protocols must be implemented for long enough and with high enough sensitivity to detect possible residual latent infections potentially indicative of resurgence. We also discuss uncertainty and differences between EPIONCHO and ONCHOSIM projections, the potential importance of vector control in high-transmission settings as a complementary intervention strategy, and the short remaining timeline for African countries to be ready to stop treatment safely and begin surveillance in order to meet the impending 2020/2025 elimination targets.

Project description:Introduction Caesarean sections (CS) feature prominently in obstetric care and have impacted positively on maternal / neonatal outcomes globally including Ghana. However, in spite of documented increasing CS rates in the country, there are no studies assessing the adequacy of post-CS pain control. This study assessed the adequacy of post-CS pain management as well as factors influencing this outcome. Additionally, post-CS analgesia prescription and serving habits of doctors and nurses were also described to help fill existing knowledge gaps. Methods Pain scores of 400 randomly selected and consenting post-CS women at a tertiary facility in Ghana were assessed at 6–12 hours post-CS at rest and with movement and at 24–36 hours post-CS with movement using a validated visual analog scale (VAS) from February 1, 2015 to April 8, 2015. Participant characteristics including age, marital status and duration of CS were obtained using pretested questionnaires and patient records review. Descriptive statistics were presented as frequencies and proportions. Associations between background characteristics and the outcome variables of adequacy of pain control at 6–12 hours post-CS at rest and with movement and at 24–36 hours post-CS with movement were analysed using Chi-square and Fisher’s exact tests and logistic regression methods. Adequate pain control was defined as VAS scores ≤5. Results At 6–12 hours post-CS (at rest), equal proportions of participants had adequate and inadequate pain control (50.1% vrs 49.9%). Over the same time period but with movement, pain control was deemed inadequate in 93% of respondents (369/396). Women who had one previous surgery [OR 0.47 95%CI 0.27, 0.82; p = 0.008] and those whose CS lasted longer than 45 mins [OR 0.39 95% CI 0.24, 0.62; p<0.001] had lower odds of reporting adequate pain control. Women prescribed 12-hourly and 8-hourly doses of pethidine had only 23.5% (12/51) and 10.3% (3/29) served as prescribed respectively. At 24–36 hours post CS, adequate pain control was reported by 85.3% (326/382) of participants. Conclusions Pain management was deemed inadequate within the first 12 hours post-CS with potential implications for early mother-child interaction. Appreciable numbers of participants did not have their analgesics served as prescribed. Adjunct pain control measures should be explored and healthcare workers must be encouraged to pay more attention to patients’ pain relief needs.

Dataset Information

Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

Publications

Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.

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