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Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell kvinno- & mödrahälsovård och migration/Essén)
Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell sexuell och reproduktiv hälsa/Larsson)
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2013 (English)In: BMC Pregnancy and Childbirth, 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.

Place, publisher, year, edition, pages
2013. Vol. 13, 107- p.
Keyword [en]
Caesarean section, Robson classification, Low-income countries
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-202372DOI: 10.1186/1471-2393-13-107ISI: 000319062400001OAI: oai:DiVA.org:uu-202372DiVA: diva2:631916
Available from: 2013-06-24 Created: 2013-06-24 Last updated: 2015-03-09Bibliographically approved
In thesis
1. 'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting
Open this publication in new window or tab >>'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting
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.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1063
caesarean section, complications, attitudes, women, caregivers, low-income countries, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medical Science
urn:nbn:se:uu:diva-238626 (URN)978-91-554-9134-5 (ISBN)
Public defence
2015-02-19, Rosénsalen, Kvinnokliniken, Ing. 95/96, Akademiska sjukhuset, Uppsala, 13:15 (English)
Available from: 2015-01-29 Created: 2014-12-15 Last updated: 2015-03-09

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