Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 33  |  Issue : 2  |  Page : 458--463

Comparative study of cesarean section in secondary and tertiary healthcare levels


Mohamed M Fahmy1, Alaa F Al Halaby1, Hala M Gabr2, Heba F Salama1, Abdullah G Arafat3,  
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Obstetrics and Gynecology at Ministry of Health, Menoufia, Egypt

Correspondence Address:
Abdullah G Arafat
Obstetrics and Gynecology at Ministry of Health, Menoufia
Egypt

Abstract

Objective To clarify the prevalence of cesarean section (CS) in Menoufia University Hospital and Menouf General Hospital regarding the rate, indications, and complications of CS. Background CS rate is rising worldwide with increasing concern especially in developed countries. It is associated with higher maternal and neonatal morbidity. Patients and methods This was a retrospective analytical study. The rates of CS in both Menoufia University Hospital and Menouf General Hospital were reviewed from 2013 to 2017, and detailed patient records in both hospitals were reviewed from January 2017 to December 2017. Robson Ten Group Classification System was applied to categorize the different indications of CS. Results There was a significant rise in CS rate in both hospitals every year. In Menoufia University Hospital, it increased from 48.50% in 2013 to 59.43% in 2017, and in Menouf General Hospital, it increased from 45.95% in 2013 to 53.50% in 2017. The most common indication in both hospitals was a previous CS. According to Robson Ten Group Classification System, the most common group in both hospitals was group five. The most common maternal complication in both hospitals was postpartum hemorrhage, but the rate of cesarean hysterectomy was more common in Menoufia University Hospital. Wound sepsis was more common in Menouf General Hospital than Menoufia University Hospital. Conclusion Rate of CS in Menoufia University Hospital is higher than Menouf General Hospital owing to its nature as a tertiary care and referral hospital for difficult and complicated cases.



How to cite this article:
Fahmy MM, Al Halaby AF, Gabr HM, Salama HF, Arafat AG. Comparative study of cesarean section in secondary and tertiary healthcare levels.Menoufia Med J 2020;33:458-463


How to cite this URL:
Fahmy MM, Al Halaby AF, Gabr HM, Salama HF, Arafat AG. Comparative study of cesarean section in secondary and tertiary healthcare levels. Menoufia Med J [serial online] 2020 [cited 2020 Aug 13 ];33:458-463
Available from: http://www.mmj.eg.net/text.asp?2020/33/2/458/287746


Full Text



 Introduction



Cesarean section (CS) is a major obstetric intervention for saving the lives of women and their newborns from pregnancy-related and childbirth-related complications. Unnecessary CS may have an adverse effect on maternal and neonatal outcomes[1]. Rising CS rate is a worldwide concern, particularly in developed countries[2]. CS rates continue to increase around the world, without a clear understanding of the main drivers. The CS rate in Brazil (51.9%) represents one of the highest rates in the world along with China (52.5%), Cyprus (52.2%), the Dominican Republic (56.4%), and Egypt (51.8%)[3]. Following the rate of cesarean birth in Turkey from 1993 till 2013, there was a rapid growth rate from 14.3% in 1993 to 51.9% in 2013[4]. There is considerable evidence to show that CS puts women at increased risk for obstetric hemorrhage, infection, and deep vein thrombosis[5]. Many factors have contributed to the increasing rates of CSs, including increases in maternal age, BMI, and changes in obstetric practices and technologies. CSs requested by the mother and fear of litigation among caregivers have now became one of the most common indications of CS[6]. A recent systematic review of ∼27 different classification system suggested that the Robson Ten-Group Classification System (RTGCS) of CS gives us a chance to look at CS rates in specific groups to help identify possible reasons for this rising rate[7]. Cases of cesarean delivery were categorized into ten groups according to their basic obstetric characteristics of parity, previous CS, gestational age, mode of onset of labor, fetal presentation, and number of fetuses. The Ten-Group Robson classification has been praised for its simplicity, robustness, reproducibility, and flexibility[8]. RTGCS has been recommended by both the WHO in 2014 and the International Federation of Obstetrics and Gynaecology[9] for the evaluation of CS rates over time. The aim of this study is to clarify the prevalence of CS in tertiary healthcare level and secondary healthcare level, comparing both levels regarding prevalence rate, indications, and complications of CS.

 Patients and Methods



This retrospective analytical study was conducted at the Department of Obstetrics and Gynaecology and in Patient Affairs and Statistics Unit of Menouf General Hospital and Menoufia University Hospital after approval from Ethics Committee for Human Research of Menoufia University. We had chosen Menouf General Hospital and Menoufia University Hospital as they are the largest secondary and tertiary care hospitals in Menoufia Governorate, respectively. The records of patients were reviewed after permission of the ethical committee of Menoufia University and the general manager of Menouf General Hospital with assurance of privacy and recording details about patients and doctors. Menouf General Hospital serves the city of Menouf, some of surrounding cities, and a part of Beheira Governorate. It has 18 beds for patients with Obstetrics and Gynecology problems. There was no cardiotocography device at this time in the hospital. It has obstetrician staff consisting of eight consultants, 34 specialists, and 15 resident doctors. It has two operative rooms for elective CS and all emergency cases of all the specialties in the hospital. The Blood bank of Menouf Hospital has available packed red blood cells and plasma only, but no platelets available. It has 15 ICU beds. Menoufia University Hospital serves the population of nine provinces and also a part of Beheira Governorate. It is a tertiary healthcare hospital and referral hospital for many small hospitals in Menoufia Governorate for any complicated cases or difficult cases. It has 50 beds for patients with obstetrics and gynecology problems; it has four operative rooms well equipped for Obstetrics and Gynecology operations only. It has 32 ICU beds for all the specialties, not for obstetrics and gynecology only. It has two cardiotocography devices. It serves patients with minimal fees and sometimes free of charges. It has a medical staff consisting of 42 consultants, 18 assistant lecturers, and 10 resident doctors. It has a blood bank containing blood and all its derivatives including platelets. CS incidence rate only, without any details, from 2013 to 2017 in both hospitals was obtained from the statistics department of both hospitals and mentioned in the study. Then complete records of CS patients had been reviewed from 1 January 2017 to 31 December 2017 in both hospitals for rate of CS, age, parity, gravidity, gestational age at delivery, previous delivery mode, fetal presentation, past history of medical importance, CS indications, neonatal outcome regarding Apgar score, Neonatal ICU (NICU) admission, number of babies, whether single or multiple, and maternal complications, for example, postpartum hemorrhage (PPH), blood transfusion, bladder injury, cesarean hysterectomy, and septic wound. This study compared between both hospitals regarding the number of CS, indications of CS, and complications. The indications of CS were divided into maternal and fetal indications. Maternal indications, included cephalopelvic disproportion, failed a trial of labor, scarred uterus owing to either previous CS or myomectomy, precious baby, CS on maternal request, accidental hemorrhage, placenta praevia, oligohydramnios, old primigravida, and medical disorders as diabetes mellitus and hypertensive disorders of pregnancy. Fetal indications included malpresentation, multiple pregnancies, fetal distress, intrauterine growth retardation (IUGR), post-term pregnancy, cord prolapse, macrosomia, and congenital fetal anomalies. The indications of CS owing to breech malpresentation had been separated from other malpresentation, and also the twin's pregnancy had been separated from patients with high-order multiple pregnancies, and this had been done to be more determined in the indications of CS. Incomplete files were excluded from the study in both hospitals.

Statistical analysis

Data were collected, analyzed, and tabulated using SPSS (version 22; SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: descriptive statistics in the form of number and percent for qualitative data and mean and SD for quantitative data, and analytical statistics in the form of χ2 and Fisher exact test for comparison between qualitative data, Z test for comparison between two proportions, and Student t-test for comparison between normally distributed quantitative data. Statistical significance was set at P value up to 0.05 (two-tailed).

 Results



In Menoufia university hospital, CS rate was 48.50% (1277/2629) in 2013, 46.4% (1264/2724) in 2014, 43.99% (1134/2578) in 2015, 55.91% (1093/1955) in 2016, and 59.43% (1076/1798) in 2017. In Menouf General Hospital, it was 45.95% (1700/3700) in 2013, 45.41% (1662/3660) in 2014, 46.81% (1824/3897) in 2015, 45.37% (1367/3013) in 2016, and 53.50% (1327/2470) in 2017 [Table 1]. After exclusion of incomplete records in 2017, it was 1324 CS cases in Menouf General Hospital and 1076 in Menoufia University Hospital. Regarding CS indications [Table 2], the most common indication in Menoufia University Hospital in 2017 was previous CS. The second largest contribution of the indications of CS was oligohydramnios, severe pre-eclampsia, breech malpresentation, placenta praevia and accreta, cephalopelvic disproportion, post-term pregnancy, failed trial of labor, twins pregnancy, accidental hemorrhage, IUGR, and fetal distress. In Menouf General Hospital, previous CS also was the most common indication, and the second common causes contributing toward CS indications were oligohydramnios, post-term pregnancy, failed a trial of labor, severe pre-eclampsia, IUGR, breech malpresentation, twins, cephalopelvic disproportion, placenta praevia and placenta accrete, and accidental hemorrhage. After application of RTGCS on indications of CS in both hospitals [Table 3], we found that group five was the most common group in both hospitals. Group ten was the second most common group subjected to CS at Menoufia University Hospital. Group two is the second most common group subjected to CS in Menouf General Hospital. There was a statistically significant difference regarding Apgar score between Menouf General Hospital and Menoufia University Hospital CS cases (P < 0.001), being higher in Menouf General Hospital. There was a statistically significant difference regarding NICU admission between Menouf General Hospital and Menoufia University Hospital CS cases (P < 0.001), being higher in Menouf General Hospital [Table 4]. Regarding CS complications [Table 5], there was no statistically significant difference regarding CS complications among Menouf General Hospital (8.91%) and Menoufia University Hospital (9.68%) (P = 0.867), as shown in [Table 5]. However, there was a statistically significant difference regarding the type of complication between secondary and tertiary care hospitals in CS cases (P < 0.001). Postpartum hemorrhage and blood transfusion were the most common complications in both hospitals. The second common complication in Menoufia University Hospital was a cesarean hysterectomy. Wound sepsis was the second common complication in Menouf General Hospital.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

 Discussion



CS rate is rising worldwide, and Egypt is a part of that. In this study, the CS rate was in rising every year in both secondary and tertiary healthcare levels. There was a statistically significant difference regarding CS rates between Menoufia University Hospital and Menouf General Hospital (P < 0.001), being higher in Menoufia University Hospital [Table 1], owing to its nature as a tertiary care level and referral hospital. This study was in agreement with previous studies, for example, Dawood et al.[10], who studied the CS rate in Tanta University Hospital, which is tertiary care hospital, and found that CS rate was rising from 41% in 2013 to 45% in 2014 up to 46% in 2015. Another study performed by El Khayat et al.[11] measured CS rate at Cairo University Hospitals and concluded that CS rate was gradually increasing from 38.84% in 2008 to 41.17% in 2012. The Egyptian ministry of health and population reported that 50.8% of all deliveries were by CS[12]. In this study, we found that the most common indication in both hospitals was previous CS. CSs owing to medical disorders were more common at Menoufia University Hospital than Menouf General Hospital. Menoufia University Hospital had the upper hand in the management of cases of placenta praevia and severe pre-eclampsia with a higher rate of them in it than secondary care. Moreover, CS cases owing to ruptured uterus represented in Menoufia University Hospital, and this indication was not represented in Menouf General Hospital. So Menoufia University Hospital deals with more difficult and complicated cases than Menouf General Hospital, and this reflects why the rate of CS was higher in it than Menouf General Hospital. CS on maternal request was more in Menouf General Hospital than Menoufia University Hospital. When Robson criteria were applied to Menoufia University Hospital to determine the indications of CS, we noticed that group five was the most common group subjected to CS. Group ten was the second most common group subjected to CS, as it has more advanced postnatal care and NICU, so the number of preterm births was higher. Group one is the third most common group. Moreover, after application of RTGCS to Menouf General Hospital, we noticed that group five was the most common group subjected to CS. Group two was the second most common group subjected to CS. Group ten was the third most common group. There were no cases of induced labor in both hospitals. The results of our study were in agreement with Ebrashy et al.[13] and El Khayat et al.[11], who reported that repeated CS was the main indication, and a large proportion of patients had a previous CS, with an incidence of ∼43.5% in the past 5 years. Moreover, Dawood et al.[10] determined that group five was the most common group, group two was the second common, and group eight was the third common group. Marcos et al.[3] reported that group two, group five, and group ten had the highest effect on Brazil's CS rate in both public and private health sector, which measured more than 70% of CS rate. The most relevant complication in both hospitals was the PPH. PPH was higher in Menouf General Hospital (7.47%) than Menoufia University Hospital (7.25%). The second most common complication in Menoufia University Hospital was cesarean hysterectomy (1.15%) owing to an increased rate of placenta praevia, placenta accreta, and rupture uterus than in Menouf General Hospital, along with increased number of referred, difficult, and complicated cases. In Menouf General Hospital, the second common complication was wound sepsis (0.60%). This agrees with a previous study which revealed that incidence rate of bladder injury during CS was 0.28%, and patients with previous caesarean delivery were 4.22 times as likely to have a bladder injury at delivery versus those who did not have a previous caesarean delivery[14]. In similar studies, Infection was the most common complication, and breaking of Pfannenstiel incision the second most common. Postpartum psychosis and abdominal organ injury other than the urinary system are very rare[10]. Moreover, Kabel and Weeber[15], in their study, reported that postpartum hemorrhage was the most common cause of maternal morbidity. Its incidence after CS was 8.6–13%. Our study has some limitations. CS rate was not accurately measured because it neglected the private hospitals which had many fake indications for CS and depended only on these public hospitals in their serving areas. The incidence of CS wound infection was not accurately identified, because most cases are recognized after discharge and most cases did not return for follow-up. This suggests the necessity to perform postdischarge surveillance to obtain a more accurate rate of wound infection. In addition, this study neglected the rate of vaginal birth after caesarean. These Robson criteria prevent the analysis of CS on maternal request[16]. Moreover, they neglect the analysis of obstetric morbidities such as placenta praevia, some medical disorders, the method used for labor induction, and cause of prematurity. We observed a higher rate of documentation of neonatal consultation in Menouf General Hospital than Menoufia University Hospital. This is a point of strength in Menouf General Hospital.

 Conclusion



The rate of CS is rising annually in both hospitals, but it is comparable to other hospitals in Egypt. This increased rate is more in tertiary care than secondary care owing to its nature as a referral hospital and higher center of healthcare. Several strategies must be implicated to face this increasing rate, such as an introduction of vaginal birth after caesarean protocols, induction of labor, and operative vaginal delivery. We must focus on the health education and counselling of the mothers about their wrong thoughts for vaginal delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Begum T, Rahman A, Nababan H, Hoque DM, Khan AF, Ali T, et al. Indications and determinants of caesarean section delivery: evidence from a population-based study in Matlab, Bangladesh. PLoS One 2017; 12 :e0188074.
2Vinograd A, Weinstock T, Mazor M, Mastrolia SA, Beer-Weisel Vogel JP, Betrán AP, et al. Use of the Robson classification to assess caesarean section trends in countries: a secondary analysis of two WHO multi-country surveys. Lancet Glob Health 2015; 3 :e260–e270.
3Marcos NP, Mariado CL, Ana Paula EP, Rosa MS, Jacqueline AT, Marcos AB, et al. Use of Robson classification to assess caesarean section rate in Brazil: the role of the source of payment for childbirth. Reprod Health 2016; 13 :128.
4Santas G, Santas F. Trends of caesarean section rates in Turkey. J Obstet Gynaecol 2018; 38 :658–662.
5Chong C, Su LL, Biswas A. Changing trends of caesarean section births by the Robson Ten Group Classification in a tertiary teaching hospital. Acta Obstet Gynecol Scand 2012; 91 :1422–1427.
6Tollånes MC Increased rate of caesarean sections – causes and consequences. Tidsskr Nor Laegeforen 2009; 129 :1329–1331.
7Torloni MR, Betran AP, Souza JP. Classifications for caesarean section: a systematic review. PLoS One 2011; 6 :e14566.
8Betran AP, Vindevoghel N, Souza JP, Ulmezoglu AMG, Torloni MR. A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it. PLoS One 2014; 9 :e97769.
9FIGO Working Group on Challenges in Care of Mothers and Infants during Labor and Delivery. Best practice advice on the 10-Group Classification System for caesarean deliveries. Int J Gynecol Obstet 2016; 135 :232–233.
10Dawood AS, Dawood AS, El-Shwaikh SL. A three year retrospective study of caesarean section rate at Tanta University Hospitals. J Gynecol Obstet 2017; 5 :25–30.
11El-Khayat W, Adel D, El-Bar MA, Waly M. Cesarean Section Rate at a Tertiary University Hospital in Egypt in Five Years Period (2008-2012). KAJOG 2013; 4 :66–74.
12Ministry of Health and Populations [Egypt], El-Zanaty Associates [Egypt], ICF International. The 2014 Egypt Demographic and Health Survey (2014 EDHS). Cairo, Egypt: Main Findings; 2015.
13Dawood AS, Dawood AG, El-Shwaikh SL. A three year retrospective study of Caesarean section rate at Tanta University Hospitals. Journal of Gynecology and Obstetrics. 2017; 5 :25–30.
14Christopher MT. Bladder injury during caesarean delivery. Curr Womens Health Rev 2013; 9 :70–76.
15Kabel KT, Weeber TA. Measuring and communicating blood loss during obstetric haemorrhage. J Obstet Gynecol Neonatal Nurs 2012; 41 :551–558.
16Gossman GL, Hoesch JM, Tanfer K. Trends in maternal request caesarean delivery from 1991 to 2005. Obstet Gynecol 2006; 108 :1506–1516.