Prevalence of Cesarean Section in Urban Health Facilities and Associated Factors in Eastern Ethiopia: Hospital Based Cross Sectional Study

Fikirte Tsega; Bezatu Mengistie; Yadeta Dessie; Melkamu Merid Mengesha

doi:10.4172/2376-127X.1000169

ISSN: 2376-127X

Journal of Pregnancy and Child Health

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Prevalence of Cesarean Section in Urban Health Facilities and Associated Factors in Eastern Ethiopia: Hospital Based Cross Sectional Study

Fikirte Tsega¹, Bezatu Mengistie², Yadeta Dessie² and Melkamu Merid Mengesha^2*
¹Department of Pediatrics and child health, Hiwot Fana Specialized University Hospital, Ethiopia
²School of Public Health, College of Health and Medical sciences, Haramaya University, Ethiopia
Corresponding Author :	Melkamu Merid Mengesha School of Public Health College of Health and Medical sciences Haramaya University, Ethiopia Tel: 251912094941 E-mail: survivalepi@gmail.com
Received April 09, 2015; Accepted May 25, 2015; Published May 27, 2015
Citation: Tsega F, Mengistie B, Dessie Y, Mengesha MM (2015) Prevalence of Cesarean Section in Urban Health Facilities and Associated Factors in Eastern Ethiopia: Hospital Based Cross Sectional Study. J Preg Child Health 2:169. doi: 10.4172/2376-127X.1000169
Copyright: © 2015 Tsega F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Cesarean section (CS) is an operative technique by which a fetus is delivered through an abdominal and uterine incision. When adequately indicated, it can prevent poor obstetric outcomes and be a life-saving procedure for both the mother and the fetus. The rate of CS is increasing in developing countries despite the World Health Organization recommendation of 5% to 15% as an optimum range.

Objective: This study aimed to assess the prevalence of CS in urban health facilities and associated factors in Harar, eastern Ethiopia.

Methods: A cross-sectional study was conducted in private and government hospitals in Harar town from February 1 to March 30, 2013. A face to face interview was used to collect data by structured questionnaire. Data were entered in to computer using Epi-Info version 6 and exported to SPSS version 16 for analysis. The dependent outcome variable was delivery by CS. Multivariate logistic regression analysis was carried out to control confounding variables to identify factors associated with CS. P value <0.05 was used to declare statistical significance.

Result: The overall prevalence of CS in Hospitals in Harar was 34.3%. The prevalence of CS in private hospitals was 58.7% compared to the 26.6% prevalence in public hospitals. Higher monthly family income (AOR=3.09, 95% CI (1.42, 6.71)), big baby (AOR=3.58, 95% CI (1.11, 11.55)), previous CS delivery (AOR=50.00, 95% CI (17.76, 144.00)), and private hospital delivery (AOR=3.00, 95% CI (1.6, 5.61)) were positively and significantly associated with CS delivery.

Conclusion: Measures like interventions on prevention of unnecessary primary CS including health education for pregnant mothers on the risk of cesarean section during antenatal care visits and advocating vaginal delivery would be important to halt decrease the high prevalence in CS.

Keywords

Cesarean section; Prevalence; Associated factors; Hospital; Eastern Ethiopia

Abbreviations

NC: Antenatal Care; AOR: Adjusted Odds Ratio; CI: Confidence Interval; COR: Crude Odds Ratio; CS: Cesarean Section; EDHS: Ethiopian Demographic and Health Survey; ETB: Ethiopian Birr; IRB: Institutional Review Board; USD: US Dollar; WHO: World Health Organization

Background

Cesarean section is an operative technique by which a fetus is delivered through an abdominal and uterine incision [1]. When adequately indicated it can prevent poor obstetric outcomes and be a lifesaving procedure for both the mother and the fetus [2]. However, there is a growing concern about unnecessary CSs; the increased risk of maternal morbidity, neonatal death and neonatal admission to an intensive care unit [3].

Optimal range of CS is debatable, however, in 1985 the World Health Organization (WHO) suggested that the rates of CS should not exceed 15%, since no additional benefit for the newborns or for the mothers is obtained beyond this level [4]. On the other hand, a rate of less than 5% would reflect difficulty in access to adequate treatment [5]. Despite this recommendation, evidences suggest that the rates of CS are high in developing countries and are increasing, with wide variation between countries and between regions of the same country [6-8].

The national CS delivery rate in Ethiopia was 0.6%, with regional rates varying from 0.2% to 9% [9]. However, according to the 2011 EDHS (Ethiopian demographic and health survey) the regional variations of CS delivery rate range from 0.5% in Oromia to 21.8% in Addis Ababa [10]. A few studies conducted in Addis Ababa compared the rate of CS in public and private for profit hospitals. According to these studies the CS rate ranged from15% to 31.1% in public hospitals and from 41.7% to 48.3% in private hospitals [8-11]. A trend analysis of the CS rate in Addis Ababa (1995 to 2010) showed a significant increase with a 2.6 fold increase in 2011 compared to the figure in 2000 [8]. When looking at the rate of CS in the Eastern part of the country including the Ethiopian Somali region, Dire Dawa admintrative council and Harari region it was 0.7%, 6.2 % and 7%, respectively [10].

The percentage of CS delivery among the lowest wealth quintile was 0.1 % compared to 7.2 % among the highest wealth quintile [10]. CS rate due to maternal request without medical indication contributed to 7.5 % in private hospitals in Addis Ababa compared to none in public/ teaching hospitals [11].

Findings from previous studies indicated medical and nonmedical factors that are likely to be associated with the rising rate of CS including previous cesarean section, maternal income, parity, maternal educational status, induction of labor, and hypertension [8,10,12,13]. However, given only few studies are conducted in assessing the rate CS in Ethiopia [8,9,11], there is limited information concerning the rate CS in public and private hospitals and the associated factors. Therefore, this study was aimed to assess the prevalence of cesarean section in urban health facilities and associated factors in eastern Ethiopia. The finding of this study will benefit policy makers, service providers and clients by providing important information for decision making on service provision and utilization.

Materials and Methods

Study area and period

Harar is located 526 km away from Addis Ababa, the capital city of Ethioppia. Based on the 2007 Census, the total population of Harari regional state was 183,415 out of which females account 91, 099 [19]. Harar city has 19 kebeles (lowest administrative unit) which are divided in to six districts. In the region, there are six hospitals (2 public, 2 private and 2 military), 8 health centers and 26 health posts. This study was conducted in two private and two public hospitals where basic and comprehensive obstetric services were being provided.

The study was conducted from February 1 to March 30, 2013.

Study design: A hospital based cross-sectional study was used to assess the rate of CS and associated factors in selected private and government hospitals in Harar town

Population: All mothers who delivered in the selected hospitals and consented to participate and were conscious in the study period were eligible to participate in this study.

Sample size calculation

The sample size was calculated using single population proportion formula by assuming the previous unknown magnitude of CS to be 50% in the region, 95% confidence level, 4% margin of error. Accordingly, the sample size calculated for the study was 600 mothers. Adding 5% none response rate to the calculated sample size, the final sample size obtained was 630. The sample size was proportionally allocated for each hospital depending on the previous year monthly average number of client flow to each hospital.

Sampling technique: Taking in to account the short duration of study period and low institutional delivery we decided to include all mothers who delivered in the selected hospitals in the study.

Instrument, data collection and quality control

A structured questionnaire was used to collect the data through a face to face interview. The questionnaire was initially prepared in English and then translated to Amharic and Oromifa. The Amharic and the Oromifa version of the questionnaire were used for data collection. Both the Amharic and the Oromifa versions of the questionnaire were pretested on 5 % of study subjects in Army and Police hospitals to check that the tools were actually measuring what the study wanted to measure. The questionnaire assessed variables including sociodemographic characteristics of the respondents, previous and current pregnancy history, and pregnancy outcome. The data was collected by trained nurses and midwives working in obstetric wards of the respective hospitals during the study period. They were provided with two days of training on how to fill the questionnaire, on the objective of the study, content of the questionnaire and how to keep confidentiality and privacy of the study. The data collection was supervised by BSc holder senior staffs working in the obstetric department of the selected hospitals. Completed questionnaires is collected every day by the supervisors and checked for completeness and consistency for timely feedback. The participants were interviewed after they gave birth and stable to communicate. 29 of the participants were refused to participate in this study.

Data management

Data were entered in to computer using Epi-Info version 6 and exported to SPSS for windows version 16 (Chicago, SPSS Inc. 2007) for analysis. The dependent outcome variable was delivery by cesarean section. Bivariate logistic regression was carried out to identify individual variables associated with the outcome variable. Finally, the multivariate logistic regression analysis was carried out to control confounding variables to identify the predictors of CS. Enter method was used for the regression. Vaginal delivery in this study included both spontaneous vaginal delivery and instrumental delivery. Duration of labor was the time between the onset of labor and arrival to service delivery point (hospital) as reported by the respondent. Big baby (macrosomia) refers to fetal birth weight more than or equal to 4000 g. Co-linearity was checked for the covariates in the final model and no multicollinearity was observed. Variables with P value < 0.2 in the bivariate analysis were selected and entered into the multivariate analysis. P value <0.05 was considered statistically significant.

Ethical consideration

Ethical clearance was obtained from Institutional Health Research Review Committee (IHRERCB) of the College of Health and Medical Sciences, Haramaya University. Official permission was granted from each hospital administration. Individual verbal informed consent was obtained from each of the respondent before starting the study. Individual participants verbal informed consent was documented as whether they agreed to participate or not and the verbal consent form was approved by the IHRERCB of the College of Health and Medical Sciences, Haramaya University. Confidentiality was assured throughout the study.

Results

Socio demographic characteristics of women

This study had a response rate of 95.4 %( 601/630). Of the women who participated in this study 61.1% (367/600) were in the age range of 20-29 years. Only 7% (42/600) of women were above 35 years of age. 58.8% (353/600) of the women were admitted from the neighboring rural areas of Oromia region. Economically most of the women, 78.5% (472/601), were unemployed house wives and 50.7% (282/556) had monthly family income of 1000 ETB (50 USD) or low. Educationally, only 10.8% (65/601) of women attended college (Table 1).

Basic obstetric service utilization and prevalence of cesarean section delivery

ANC follow up during pregnancy of current delivery was 77.5% (465/600). Among women who had ANC follow up 37.5% (163/435) and 37.2% (162/435) had completed their 3^rd and 4^th ANC visits respectively. Similarly 4.8 % (21/435) and 20.5% (89/435) of women had only the first and second ANC visit respectively. ANC follow up by facility type was 51.8% (241/465) in government health center, 18.7% (87/465) in public hospital and 29.5% (137/465) in private clinic. Of women who had their ANC visit in health center 26.6% (64/241) delivered by CS. Women who had their ANC visit in private clinic/hospital had a 47.4% (65/137) prevalence of CS delivery. Similarly, of women who had their ANC visit in a government hospital 27.6% (24/87) delivered by CS.

For 65.7% (395/601) of women the current mode of delivery was vaginal delivery. The overall prevalence of CS in the study setting was 34.3% (206/601). Place of current delivery for 76.2 % (458/601) of women was in public hospitals while for 23.8% (143/601) it was in private hospitals. The prevalence of CS in private hospitals was 58.7% (84/143) which was higher compared to 26.6% (122/458) in public hospitals in the study setting. Of 600 women for whom information on parity was obtained 37.2% (223/600) were nulliparous and 19.6% (118/600) had four or more deliveries. Similarly 24% (144/600), 11.7% (70/600), and 7.5% (45/600) of women had only one, two, and three deliveries respectively. Prevalence of CS delivery among nulliparous women, women with parity one, women with parity two, women with parity three, and women with parity four and above was 29.1% (65/223), 31.4% (22/70), 34.7% (50/144), 51.1% (23/45), and 39% (46/118) respectively.

Information on duration of labour was obtained only for 498 of the women. The duration of labor was calculated based on patient report. Accordingly, duration of labour on arrival to hospital was within 12 hours for 57.8% (288/498) of women followed by 31.3% (156/498) between 12 and 24 hours. Duration of labour lasted more than 24 hours for 10.8% (54/498) of the women. Of women who had duration of labour within 12 hours 24.3% (70/288) had CS delivery. similarly, for those who had duration of labour between 12 and 24 hours and beyond 24 hours the rate of CS delivery was 31.4% (49/156) and 25.9% (14/54), respectively.

Previous mode of delivery for 88% (455/517) of women was vaginal delivery while for 12% (62/517) of women it was CS. Out of 62 women who delivered by CS previously, 90.3% (56) delivered by CS on the current delivery.

Birth weight for 83.5% (466/558) of newborns was in the normal range (i.e. 2500-4000 g) while 7.2% (40/558) and 9.3% (52/558) of newborns had low birth weight and birth weight above 4000 g respectively. Out of the total women who delivered a big baby, 67.3% (35/52) women had CS delivery.

Factors associated with cesarean section delivery in the bivariate logistic regression model

Being rural resident (COR=1.64, 95% CI (1.15, 2.33)), having a monthly family income of 4000 ETB (200 USD) or more (COR=2.63, 95% CI (1.61, 4.29)), previous CS delivery (COR=38.31, 95% CI (15.98, 91.84)), parity of three or more (COR=1.61, 95% CI (1.11, 2.33)), fetal birth weight of greater than 4000 g (COR=5.43, 95% CI (2.20, 13.41)), private hospital delivery (COR=3.92, 95% CI (2.65, 5.80)), and private clinic/hospital ANC visit (COR=2.50, 95% CI (1.61, 3.88)) were found significantly associated to cesarean section delivery in the bivariate logistic regression. Being a self-employed by occupation in the bivariate logistic regression model was protective against CS delivery (COR=0.47, 95% CI (0.25, 0.88)) (Table 2).

Factors associated with cesarean section delivery in the multivariate logistic regression model

We entered the variables found significant in the bivariate model in to the multivariate logistic regression model except the independent variable ‘place of ANC visit’ as it had more missing values. Even though not significant in the bivariate logistic regression model, we included age in the final model for biological importance. Regression diagnostic was done to assess multi-collinearity and there was no evidence showing multi-collinearity among the independent variables in the model.

In the multivariate logistic regression model, independent of other factors, monthly family income of 4000 Ethiopian Birr (200 US Dollar) or more (AOR=3.09, 95% CI (1.42, 6.71)), birth weight of more than 4000 g (AOR=3.58, 95% CI (1.11, 11.55)), previous CS delivery (AOR=50.00, 95% CI (17.76, 144.00)), and private hospital delivery (AOR=3.00, 95% CI (1.6, 5.61)) were positively and significantly associated with cesarean section delivery (Table 3).

Discussion

The prevalence of cesarean section in Ethiopia at a national level is far below the minimum recommended level of 5% [4,9-10]. However, this should not underestimate variations in the prevalence across geographical areas within the country. In this study the overall prevalence of cesarean section in public and private hospitals in Harar was 34.3%. It was relatively higher compared to the WHO recommended maximum limit of 15% cesarean section for any geographic area [4]. Different studies suggested that there is no additional benefit beyond 10% prevalence of cesarean section [14,15].

Compared to the study finding based on three Ethiopian demographic and health survey (EDHS) data in Addis Ababa [8], the prevalence of cesarean section in this study setting was also relatively higher. In the Addis Ababa study the prevalence of cesarean section in 2009/2010 was 24.4% [8]. When compared to other hospital based studies in middle and low income countries, the prevalence of cesarean section in the study setting was relatively consistent with the value of 35.1% in Argentina, 29.3% in Brazil, 30.7% in Sri Lanka [2]. The prevalence of cesarean section was higher in private hospitals (58.7% (84/143)) compared to public hospitals (26.6% (122/458)) in the study setting. High prevalence of cesarean section in private hospitals was consistent with studies conducted somewhere else [8,9,11,16]. But the reason for the increased prevalence of cesarean section in private hospitals in the study context needs further investigation. This study didn’t assess whether the increase is due to an influence from the physician/institution for the procedure to be done or it is due to client preference.

Higher family income in the study setting was associated with cesarean section delivery which was supported by findings from different studies reported from different settings [2,8,17]. Previous cesarean section was also associated with current cesarean section delivery in the study setting. This finding was supported by studies in different settings [11,12,18].

Other important factors identified in the multivariate logistic regression to be significantly associated with current cesarean section in the study setting include birth weight and private hospital delivery. This finding was also consistent with study done somewhere else [8,13].

This study tried to assess an important issue, the rate of CS in private and public hospitals and identified some of the factors related to its increase. However, patient card as a source of information was not reviewed and hence the study did not access maternal and fetal indications. The study also did not access if the CS was conducted based on maternal request or based on an appropriate medical ground. Therefore, the limitation of missing to include these important variables may have confounded some of the results observed in the study.

Conclusion

The overall institutional (public/private hospitals) prevalence of cesarean section in Harar was 34.3%. It is high compared to the WHO recommended optimum upper limit of 15% prevalence. The prevalence of cesarean section in private hospitals was twice as high as that of public hospitals. In the multivariate logistic regression factors identified to be significantly associated with cesarean section delivery in this study were previous cesarean section, private hospital delivery, higher monthly family income, and birth weight of greater than or equal to 4000 g. Therefore we recommend the following based on our finding: interventions on prevention of unnecessary primary cesarean section to avoid repeat cesarean section, advocating vaginal delivery for a woman who had previous cesarean section if medically appropriate, and health education for pregnant mothers on the risk of unnecessary cesarean section during antenatal care visits will also be important in gaining clients rational decision on the mode of delivery. Finally we recommend further investigation on the reasons for increased prevalence of cesarean section in private hospitals.

Acknowledgements

The authors like to thank the obstetrics and gynecology department of Hiwot Fana Specialized University Hospital, Jegol Hospital, Yimage and Harar General Hospital. We also like to extend our appreciation to the data collectors and respondents participated in this study.