'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)
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
Obstetrics, Gynecology and Reproductive Medicine
Research subject Medical Science
IdentifiersURN: urn:nbn:se:uu:diva-238626ISBN: 978-91-554-9134-5OAI: oai:DiVA.org:uu-238626DiVA: diva2:772232
2015-02-19, Rosénsalen, Kvinnokliniken, Ing. 95/96, Akademiska sjukhuset, Uppsala, 13:15 (English)
Stones, William, Professor
Essén, Birgitta, Senior lecturerKidanto, Hussein L., PhDDarj, Elisabeth, Professor
List of papers