Factors Associated with the Type of Cesarean Section and the Risk of Postoperative Complications in Greek Women

Factors Associated with the Type of Cesarean Section and the Risk of Postoperative Complications in Greek Women. Abstract Background: Cesarean Section was historically performed to save the lives of mothers and infants. Ηowever, in the past decades, a significant increase in Cesarean Section rates have been observed in Greece and worldwide. The purpose of this research was to investigate the contributing factors to the increase in the Cesarean Section rate (emergency and elective) and postoperative complications. Methods: A total of births in 6 months (August 2019-February 2020) at the University Hospital of Larisa in Greece was collected. The performed analysis included the available socio-demographic and medical information in the medical records and a socio-demographic and medical questionnaire for women with cesarean deliveries. We also analyzed the impor-tance of the variables in cesarean deliveries compared to vaginal deliveries and postoperative complications. Results: Out of the total number of the included 633 births, the vaginal delivery rate was 42% (n = 268), previous Cesarean Section and women with in vitro fertilization showed higher percentages for Elective Cesarean Section (46%) compared to women who underwent an Emergency Cesarean Section for the same reasons (42.2%). Besides, a higher percentage of Emergency Cesarean Sections was observed in women living in urban centers (OR = 4.044, p = 0.002) and those diagnosed with stress disorders (OR = 7.048, p = 0.004). Furthermore, Cesarean Section complications were more common among women having undergone Emergency Cesarean Section (OR = 10.357, p < 0.001). Conclusions: The overall high rates of Cesarean Section in Greece demonstrate the lack of national strategies and prevention mechanisms from iatrogenic interventions and lack of promoting good midwifery practices. More specifically, a decrease in iatrogenic factors leading to the primary Cesarean Section will decrease Cesarean Section rates in Greece.


Background
Cesarean Section (CS) rates have been increasing in recent decades worldwide, and this is a global problem because of the negative effect on maternal and neonatal health [1]. Although CS is a very common surgery, it is associated with an increased risk of hemorrhage, uterine bladder and bowel injury, postoperative sepsis, postoperative ileus [2] and thromboembolic events [3,4]. Some studies on neonatal complications have shown that CS is associated with an increased risk for the infant's obesity, diabetes, respiratory morbidity, and atopic dermatitis in childhood [5,6]. Furthermore, women having undergone a CS face an increased risk of placenta previa in a subsequent pregnancy, especially if the second pregnancy occurs within a year after the first CS [7].
Since 1985, the World Health Organization (WHO) has considered that the ideal CS rate ranges from 10-15%. It has also emphasized that a CS rate higher than 10% is not associated with a reduction in maternalneonatal mortality [8]. In 2009, WHO indicated that both very low and very high CS rates could be dangerous; the ideal CS rate was 5-15% [9]. However, at least 1.4 million cesarean sections were performed in Europe in 2017. In Greece, according to WHO, over half of the deliveries in 2016 were cesarean deliveries, putting Greece among the countries with the highest CS rates [10]. In addition to Greece, CS rates were very high in Cyprus, 54.8%, Romania, 44.1%, Bulgaria, 43.1%, Poland, 39.3%, Hungary, 37.3%, Estonia and Lithuania, (both) 19.4%, France, 19.7% and Finland, 16.5% [11].
Furthermore, there is evidence that there has been an increase in CS rates in middle and high-income countries resulting in the financial burden of health services [12]. indications, such as maternal characteristics (age and high educational level, high-income level, and social class) maternal request and scientific-technological advances [13,14]. Another significant factor is a previous CS. It has been observed that a previous CS has become a major driver of increasing total CS rates,

Methods
The aim of the study was to analyze the factors that lead to EMCS or ELCS, as well as the factors that lead to postoperative complications in a University Hospital of a large Health region state.

Study population
This cross-sectional study took place from August 2019 to February 2020 at the maternity unit of the

Study design
The data were collected from the women's medical records, (which are paper-based in Greece) and from a researcher's questionnaire (with the written consent of the women), following an interview onthe 3rd postpartumday. Socio-demographic and financial data of women and information about the health of the mothers before, during, and after the surgery were collected. More specifically, the medical, gynecological, mental history and the pathology of gestation was recorded, as well as the number of previous births, the type of conception, and the causes that led to EMCS or ELCS and any postoperative complications.
The combination of questionnaire and medical record was used to detect information better about the women's socioeconomic status and health level.

Statistical analysis
Quantitative variables were presentedas mean values (SD) or as median values (interquartile range = IQR).
Qualitative variables areexpressed as absolute and relative frequency. For the comparisons of proportions, chi-square and Fisher's exact tests were used.
Logistic regression analyses were applied to explore the factors likely to be related to the type of c-section.

Demographic characteristics of participants
365 women who had a cesarean section were recruited and evaluated. As shown in Cesarean Section were more likely to live in rural areas or had a previous delivery and less likely to be of another nationality than Greek. Figure    Interval, *p < 0.05 Table 2: Results of logistic regression model for the factors associated with the type of Cesarean section.

Discussion
The subject of the present research was the identi- More specifically, the results show that for the 6month period, the CS rate was 58% of total births; 36% ELCS and 22% EMCS (Figure 1). The current study revealed that the key factor affecting the mode of birth is the woman's place of residence. Although in several studies which investigated the CS sociodemographic factors have shown the maternal age, the educational and the financial level as key factors [22], in this research living in rural areas seems to be a determining factor for ELCS. A possible explanation for this phenomenon could be the obstacles in accessing organized obstetrical health care services for women living in rural areas that creates a sense of insecurity in women and physicians and, therefore, leads to a planned CS delivery, compared to women living in urban areas. The findings show that the increased CS rates are mainly due to a change in the risk profile of the mothers and babies. More specifically, although a previous CS does not necessarily mean a scheduled CS in next pregnancy [16,23]

Conclusion
The present study identified the iatrogenic and non-

Declarations
Ethical approval