Our study demonstrates high rate of CS delivery exceeding half of all the deliveries at our institution. Almost one third of the delivered neonates were admitted to the NICU. This high rate could be related to the fact that KAUH is a referral tertiary center with a high rate of high-risk pregnancy referrals and the presence of IVF center.
Globally, there has been an uptrend in the rate of CS deliveries over the past two decades. A recent report published in 2016 showed an increase in CS rate from 20 to 42% in Latin America and 14 to 25% in Europe (3).
In the US, the CDC reports about CS delivery have shown a national increase in CS rate over the past few years reaching as high as 38% in the southern states (16).
Among the factors that could have contributed to this global increase in the rate of CS procedure are patient expectations regarding the safety of labor, improved maternal education and economic status increasing maternal demand for CS delivery, the fear of malpractice claims, and the limitations or lack of experience in technology in assessing the risk of vaginal delivery (17).
In Jordan, a national study published in 2017 reported a CS rate of 29% among different Jordanian hospitals (15). In their study, Batieha et al reported a higher rate of CS in teaching and private hospitals, they also reported higher rate of CS with previously scarred uterus and fetal distress. The neonatal mortality rate was also higher compared with vaginal births. Ten years earlier, the rate of CS was about 18% as reported by Department of Statistics (Jordan) and Macro International Inc. 2008 (18). Factors that could possibly explain the higher rate in teaching and private hospitals include performing unindicated operations for the purpose of training the resident doctors or strictly for better financial gain (14).
The indications for CS deliveries among our patients are consistent with other international reports (3,14,19). The main reported indication of CS in our study is a scared uterus. This was the main medically approved indication in the majority of other studies. This factor should draw the attention of all decision makers to review the indication of the first time CS and make sure it is medically indicated since this is the main determinant for repeat sections in the future especially in places where large family size is preferred and could be potentially limited with repeated CS deliveries.
The increase in maternal request for elective CS in the absence of any medical or obstetric indications has added to the rising rate of CS in multiple centers (20). In our study, maternal request accounted for about 15% of the CS procedures. On the contrary, this has not been of a great concern in Canada and Switzerland where the obstetricians stick to the local guidelines and don’t perform CS solely upon maternal request (21). More detailed counselling should be provided to expectant mothers about the short and long-term consequences of this procedure, obstetricians need to focus on medical indications during their discussion and guide the pregnant women in making the decision.
The increasing rate of IVF procedures and other reproductive interventions resulting in multiple gestations has also contributed to higher CS rate in tertiary centers(21)
Although emergency CS procedures are intended to lower maternal and neonatal mortality and morbidities, it is clear that CS delivery might be associated with negative short-term and long-term consequences. This has been reported in several studies across the world with prolonging postpartum pain, analgesic intake, and hospital stay as well as increasing rate of NICU admissions with all resulting social and financial burdens. (21–23).
Our study showed the rate of NICU admission to be about 30% for all groups and 19% among term births. Of the NICU admissions, nearly 45% were born by a planned CS delivery after 35-week gestation. Term babies constitute about half of NICU admissions, of whom two-thirds (234/346) were born between 37 and 38.6 weeks. The main indication for admission of term babies is for respiratory support secondary to delayed transitioning and the median length of stay among this group of babies is 4 days (IQR 2, 8 days).
Regarding neonatal outcomes, our findings are consistent with several other studies reporting an increase in respiratory morbidity among term babies born by planned CS (24,25). This can be explained by the fact that fetal lung fluid clearance is delayed or impaired after planned CS deliveries without going through labor first (26). In our cohort, almost one third of the neonates admitted to the NICU were given a 2 to 3-hour chance of transitioning in the newborn nursery before getting transferred to the NICU for respiratory support.
The respiratory outcomes of term neonates are not only reported to be worse after CS delivery when compared to vaginal birth. Rather, the exact gestational age plays an important role on the outcome of these babies. Studies have reported a better outcome for neonates delivered by elective CS if the procedure is performed after completed 39-week gestation (27,28).
Our study showed that about one out of 4 babies delivered by a planned scheduled CS after 35 weeks’ gestation was admitted to the NICU. We have also noticed that 63% (988/1557) of planned CS deliveries among term babes were performed between 37-38.6 weeks and the rate of NICU admission among this group in particular was 16% (159/988). Same finding of high rate of NICU admission among early term CS deliveries was reported by Wilmink from Netherlands (29) which emphasizes the importance of avoiding elective CS before 39 weeks.
Salemi et al found that the outcome of early term delivery is significantly worse among neonates born by elective CS when compared to those born after labor induction (30). This concludes that adverse neonatal respiratory outcomes could be potentially decreased not only by avoiding CS delivery but also by the advancing GA even in the full term category. The compliance with the ACOG recommendations regarding avoiding early term delivery should be strongly encouraged to avoid such unwanted complications (31). Although delayed transitioning and TTN are considered benign, the social and financial burdens of having babies admitted to the NICU for few days should not be underestimated (27,28).
Another downside of CS delivery that is not focused on by most studies is the decline in breastfeeding rate in those neonates compared with vaginal birth. In 2017, we have published a study about predictors and barriers to exclusive breastfeeding in Jordan and found a strong negative association between breastfeeding trends and CS delivery (32).
The main limitation of our study is the retrospective chart review nature which makes it difficult to accurately infer conclusions. Also, the reasons for performing CS procedures were primarily provided by the obstetrician who is likely to provide reasonable justifications for performing CS although this may not reflect the actual indications.