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'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In recent decades, there has been a seemingly inexhaustible rise in the use of caesarean section (CS) worldwide. The overall aim with this thesis is to explore the effects of and reasons for an increase in the CS rate at a university hospital in Dar es Salaam, Tanzania.

In Study I, we analysed time trends in CS rates and maternal and perinatal outcomes between 2000 and 2011 among different obstetric groups. In Study II, we documented the occurrence and panorama of maternal ‘near-miss’ morbidity and death, and analysed their association with CS complications. We also strived to determine if women with previous CS scars had an increased risk of maternal near-miss, death, or adverse perinatal outcomes in subsequent pregnancies. Studies III and IV explored women’s and caregivers’ in-depth perspectives on CS and caregivers’ rationales for their hospital’s high CS rate.

During the study period, the CS rate increased from 19% to 49%. The rise was accompanied by an increased maternal mortality ratio (odds ratio [OR] 1.5, 95% Confidence Interval [CI] 1.2–1.8) and improved perinatal outcomes. CS complications accounted for 7.9% (95% CI 5.6–11) of the maternal near-miss events and 13% (95% CI 6.4–23) of the maternal deaths. Multipara with previous CS scars had no increased risk of maternal near-miss or death compared with multipara with previous vaginal deliveries, and a lower risk of adverse perinatal outcomes (adjusted OR 0.51, 95% CI 0.33–0.80). Both women and caregivers stated they preferred vaginal birth, but caregivers also had a favourable attitude towards CS. Both groups justified maternal risks with CS by the need to ‘secure’ a healthy baby. Caregivers stated that they sometimes performed CSs on doubtful indications, partly due to dysfunctional team-work and a fear of being blamed by colleagues. 

This thesis raises a concern that maternal health, interests, and voices are overlooked through the CS decision for the benefit of perinatal outcomes and caregivers’ liability. An overuse of CS should be seen as a sign of substandard care and preventing such overuse needs to be among the key actions when formulating new targets for the post-2015 era.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 114 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1063
Keyword [en]
caesarean section, complications, attitudes, women, caregivers, low-income countries, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-238626ISBN: 978-91-554-9134-5 (print)OAI: oai:DiVA.org:uu-238626DiVA: diva2:772232
Public defence
2015-02-19, Rosénsalen, Kvinnokliniken, Ing. 95/96, Akademiska sjukhuset, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2015-01-29 Created: 2014-12-15 Last updated: 2015-03-09
List of papers
1. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania
Open this publication in new window or tab >>Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania
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2013 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, 107- p.Article in journal (Refereed) Published
Abstract [en]

Background: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. Methods: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age >= 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the chi(2) test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. Results: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). Conclusion: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

Keyword
Caesarean section, Robson classification, Low-income countries
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-202372 (URN)10.1186/1471-2393-13-107 (DOI)000319062400001 ()
Available from: 2013-06-24 Created: 2013-06-24 Last updated: 2017-12-06Bibliographically approved
2. Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania
Open this publication in new window or tab >>Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania
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2014 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, 244- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

METHODS:

We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.

RESULTS:

We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).

CONCLUSIONS:

The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-229946 (URN)10.1186/1471-2393-14-244 (DOI)000340799000001 ()25056517 (PubMedID)
Available from: 2014-08-18 Created: 2014-08-18 Last updated: 2017-12-05Bibliographically approved
3. "What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates
Open this publication in new window or tab >>"What about the mother?": Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates
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2015 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 7, 713-720 p.Article in journal (Refereed) Published
Abstract [en]

Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision makers Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-238473 (URN)10.1016/j.midw.2015.03.008 (DOI)000356237500010 ()25886967 (PubMedID)
Funder
Swedish Research Council
Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
4. Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
Open this publication in new window or tab >>Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
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2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, 232-240 p.Article in journal (Refereed) Published
Abstract [en]

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

Keyword
Tanzania; Caesarean section; Low-resource setting; Attitudes; Caregivers; Transparency
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-238477 (URN)10.1016/j.socscimed.2015.09.003 (DOI)000364245600027 ()26364010 (PubMedID)
Funder
Swedish Research Council
Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved

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  • modern-language-association-8th-edition
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