Proportion of caesarean section delivery
In this study, the proportion of women who had CS was 38.3%. This proportion is higher than the national average of 11% in Uganda (Atuheire et al., 2019). In addition, this proportion is also higher than the 25% CS rates reported in Kabarole District, western Uganda (Dusabe et al., 2018). The WHO recommends an acceptable CS range of 10-15% so as to achieve optimum maternal and neonatal benefits (WHO, 2015). The rural hospital is a not for profit private hospital with general and specialized health care services and serves the surrounding population of Rukungiri District and neighboring districts. The results of this study may be explained by the fact that the rural hospital is known in the western region for offering high quality, affordable obstetric services, which may attract many women to deliver from there either as self-referrals or as referrals from other public and private facilities within Rukungiri district and beyond.
The other reason for the high proportion of CS in this study, maybe attributed to the fact that most of the rural health centres have inadequate resources and the shortage of healthcare staff such including midwives, nurses, general doctors and obstetricians (Dusabe et al., 2018), and this may lead to women preferring to deliver from this rural hospital compared to other health facilities within the region. This is because the study rural hospital has 2 obstetricians, 5 medical officers, 2 intern doctors and 33 midwives and this staffing, in particular, which may contribute to the high proportion of CS, put other studies related (Hospital records, 2018). High level of staffing being associated with increased CS is also found in other studies done in other countries (Can, Catak, SÜTLÜ, & Kilinc, 2016; Gholami et al., 2014).
Currently, the study rural hospital has staff from the United Kingdom supporting the Obstetrics &Gynaecology Department as part of the Uganda Maternity and Newborn Hub program and this may attribute to the high CS rates in this hospital compared to other rural hospitals without such programs. This study, in particular, enrolled only eligible immediate postnatal women within 72 hours and this could have resulted into the missing out of women who delivered by SVD and got discharged within 24- 48 hours, thus by time the researcher and her team came to the postnatal ward the next day, they may have ended up finding the majority of the admissions as post-operative CS clients as their main study participants. This may have contributed to the high proportion of CS in the rural hospital.
The high proportion CS in this study is almost similar to the findings of a study done in Kenya where the proportion of CS was 32.6% (Juma, Nyambati, Karama, Githuku, & Gura, 2017). These findings almost coincide with those of another study done in Bangladesh (35.0%), Ethiopia (34.3%) and Northern America (32.3%) (Betrán et al., 2016). Despite the high proportion of CS found in this study, other studies that were done in the private hospitals of Tehran Iran, Brazil and two public hospitals of Shanghai found much higher CS rates of 86.2%, 62.0% and 58.1% respectively (Amini, Mohammadi, Omani-Samani, Almasi-Hashiani, & Maroufizadeh, 2018; Ji et al., 2015; Vieira et al., 2015). The high proportion of CS in these studies may be attributed to higher preferences for CS among women in developed countries.
On the other hand, a study conducted in Ghana found a much lower proportion of CS (6.59%) (Manyeh et al., 2018). This is similar in developing countries like Somalia where health services remain a challenge, CS rates were low and women resisted CS due to some cultural and social economic reasons for their refusal to consent for CS (Borkan, 2010). In addition, in Ethiopia, CS rates were also low and many deliveries were not attended by skilled health care workers and the government attempted to improve access to care by training non-physician clinicians to perform CS (CSA, 2012). Another study conducted in Cameroon found CS rate was 5.69% in semi-urban and 6.22% in rural areas (Vieira et al., 2015).
Out of the 123 participants who had CS delivery in this study, 110 (89.4%) of them were emergencies and 13 (10.6%) were elective or planned CS deliveries. The common indications for CS in this study were fetal distress at the percentage of 28.5, history of previous CS scar (18.7%), poor progress of labour (11.4%) and CPD (6.5%). This is not surprising as the majority of the literature sources indicate the same common indications for CS (Alden et al., 2013; Marshall & Raynor, 2014; Mehrabian & Mehdizadeh, 2019). The high percentage of fetal distress maybe attributed to over-diagnosis since the FHR was determined subjectively using a fetoscope.
The high proportion of CS may be attributed to the poor quality of the ANC services that could be provided to women, with medical staff missing out to detect early the pregnancy deviations, so as to prepare women for delivery. The high rates of emergency CS maybe are attributed to the poor monitoring of labour by midwives, nurses and doctors hence having a large percentage of women go for CS. The indications of CS in this study are similar to those from other studies done in Fort portal Uganda, South Africa, Nepal, Bangladesh and Brazil (Begum et al., 2017; Inyang-Otu, 2014; Khanal, Karkee, Lee, & Binns, 2016; Nelson, 2017; Vieira et al., 2015). Similar indications of CS including failure of progress of labour and history of the previous scar were also found in a systematic review and meta-analysis done in LMICs (Sobhy et al., 2019).
Factors associated with caesarean section delivery
In this study, the number of ANC visits was associated with CS delivery. Women who had attended ≥4 ANC visits were more likely to have CS compared to their counterparts who had attended <4 ANC visits. This finding may be attributed to the poor quality of ANC services offered to women by the healthcare providers, where the pregnancy deviations may not be detected early. The finding in this study is coherent with similar studies done in Uganda, Kenya and Bangladesh where attendance of ≥4 ANC visits was associated with increased CS (Dusabe et al., 2018; Oweya, 2010; Shiblee, 2017). Another study done in public hospitals in Brazil found that having ≥6 consultations during ANC visits was associated with increased CS (Vieira et al., 2015). These findings are contrary to those of a study done in Southwestern Ethiopia which found that respondents who had attended one ANC visit were more likely to have CS compared to their counterparts who had attended more than one ANC visit (Dadi & Mihrete, 2018).
Findings in this study show that women who had parity of ≤4 were more likely to have CS compared to their counterparts who had parity of ≥5. This is not surprising as information from literature resources identify primigravida as a risk factor for CS (Alden et al., 2013; Marshall & Raynor, 2014). Although parity was not associated with CS in this study, other studies were done in South Africa, Brazil and Bangladesh have found a relationship of less parity with increased CS (Begum et al., 2017; Inyang-Otu, 2014; Vieira et al., 2015). Similar findings from other studies done in Japan and Brazil found that CS was more common among nulliparous women (D'orsi et al., 2006; Suzuki & Nakata, 2013). On the contrary, a study conducted in Ghana found that the odds for CS decreased with increasing parity (Manyeh et al., 2018). This discrepancy may be explained by the information in different textbooks and literature sources which consider both categories as risk factors for CS (Alden et al., 2013; Marshall & Raynor, 2014).
In this study, respondents with the secondary and above level of education were more likely to have CS compared to their counterparts who had primary and below level of education. This finding may be explained by the frequent ANC visits attended by such women with high education level at the hospital, as this study found attendance of ≥4 ANC visits is associated with increased CS. Although education was not significantly associated with CS in this study, other studies done in Bangladesh and Kenya have found a relationship between secondary education and above with increased CS (Begum et al., 2017; Oweya, 2010). On the contrary, a study done in Ghana found primary education and junior schooling was associated with increased CS (Manyeh et al., 2018). This discrepancy in these studies may be associated with the difference in a study setting, sample size, study time and the percentage of people with secondary education and above within the sample size.
Findings in this study show that women aged ≥35 years were 19.2% less likely to have CS compared to their counterparts aged <18 years. This may not make sense in this study due to the low numbers found where both age groups are at a risk of having CS as mentioned by different literature sources and textbooks. Although age of ≥35 years was not significantly associated with CS in this study, surprisingly, studies in Ghana, Bangladesh, Brazil and Denmark found that advanced maternal age ≥35 years was positively associated with CS (Begum et al., 2017; Manyeh et al., 2018; Rydahl, Declercq, Juhl, & Maimburg, 2019; Shiblee, 2017; Vieira et al., 2015). The higher odds for CS among women with advanced maternal age in these studies are explained by the increased risk of maternal obstetric complications develop with advanced maternal age as evidenced by written literature from textbooks (Alden et al., 2013; Marshall & Raynor, 2014). On the contrary, a study done in Ethiopia and Ghana found that the odds of CS were lower among women aged 15-19 years compared to women aged ≥35 years (Abebe et al., 2015; Manyeh et al., 2018). In this study, women who were employed were more likely to have CS compared to their counterparts who were peasants. This may be attributed to the fact that employed women have some finances with them thus are empowered to attend more ANC visits, thus early detection of pregnancy complications increasing the likelihood of CS. Although occupation was not statistically significant with CS in this study, other studies done in Kenya, Ethiopia, Bangladesh and Pakistan established a statistically significant relationship between occupation and CS (Amjad et al., 2018; Begum et al., 2017; Betrán et al., 2016; Oweya, 2010).
Women who were referred were more likely to have CS compared to the non-referrals in this study. This is not surprising because they already had delivery complication as explained by the high percentages of indications of CS in this study. Although referral status was not significantly associated with CS in this study, a study conducted in the Democratic Republic of Congo found that referral status was associated with CS delivery (Philémon et al., 2017). Similarly, in another study conducted in Tanzania, the level of CS among medically referred women was higher (Sørbye et al., 2011).
Findings in this study show that women who were on community-based insurance were more likely to have CS compared to their counterparts who were not insured. This may be due to the frequent ANC visits attended by women on insurance, as they have already planned costs and attendance of more ANC visits is found associated with CS in this study. Although there was no statistical significance between health system factors such as community-based insurance, referral status, and level of the referring health facility with CS in this study, previous studies done in the Democratic Republic of Congo, Kenya and Tanzania identified a relationship between some of these factors and having CS (Oweya, 2010; Philémon et al., 2017; Sørbye et al., 2011). On the other hand, a systematic review and meta-analysis found that women with private insurance were more likely to have CS compared to their counterparts with public insurance (Hoxha, Braha, Syrogiannouli, Goodman, & Jüni, 2019).
There were inadequate numbers of some variables during analysis for the different categorizes. This was a cross-sectional study and therefore it cannot derive the causal relationship from the cross-sectional analysis. Consecutive sampling was used and thus introduced a form of bias.