Factors Associated with Caesarean Section Among Women Delivered at Kirehe District Hospital

Caesarean Section (CS) is a medical procedure which involves delivery of a baby through an incision made in the mother’s abdomen and uterus ¹. The frequency of CS has been steadily increasing globally in the past several decades where one in five women give birth by CS². The reasons that have been reported to contribute to CS increase include rise of pregnancy complications, emergence of pregnancies with multiple gestations, gestational obesity, twin pregnancy, previous CS, failure of progress in labor, breech presentation, increase in rate of labor induction and maternal request ³.

Globally, cesarean section (CS) rates increased from 12 % in 2000 to 15.5 % in 2012 ⁴. In developed countries birth by CS has been doubled in the last 20 years, for example in United Kingdom (UK) CS rate was 23% in 2007, which was almost twice compared to 1990s estimate⁵. In the united state (USA), the CS rate reached a level of 32% in 2007 ⁶. In China, the nationwide CS rate increased from 3.4% in 1988 to 39% in 2008, with a higher rate in urban areas ⁷. Current studies revealed that CS rate is ranged from 50 to 60% in most parts of China ^{8, 9, 10}.

The lowest rates of CS were observed in Africa with 7.3% and more specifically in Western Africa with only 3%. From 1990 to 2014, CS rates decreased in two countries: Guinea, from 3.3% to 2.4%; and Nigeria, from 2.9% to 2%. The highest rates of CS were reported in Latin American and the Caribbean (40.5%) and South America is the sub-region with the highest average CS rates in the world (42.9%) ¹¹. Results from a meta-analysis ranked the countries with the highest CS rates in each region. In Latin America and Caribbean, Brazil (55.6%) and Dominican Republic (56.4%) were on the top. In Africa, a Country with highest CS rates was Egypt (51.8%). Iran and Turkey in Asia (47.9% and 47.5%, respectively), Italy (38.1%) in Europe, United States (32.8%) in Northern America, and New Zealand (33.4%) in Oceania were the Countries with highest CS rates in their regions ¹¹.

Since 1985, the international healthcare community has considered the ideal rate for CS to be between 10% and 15% ¹². Since then, cesarean sections have become increasingly common in both developed and developing countries ¹³. Medically justified cesarean section can effectively prevent maternal and perinatal mortality and morbidity. Thus far, there is no evidence showing the tangible benefits of maternal request CS for women or infants ¹⁴. In many settings, women are increasingly undergoing cesarean sections without any medical indication which may contribute to the global increase of cesarean sections ^{15, 16}.

The results from Rwanda demographic health survey showed that 12% of women aged 15-49 years delivered their most recent birth by C-section (RDHS, 2015). Kigali city had the highest C-section delivery rates in both surveys (22% in 2014-15). The Eastern province region is composed by seven district hospitals whose average rate of CS was 23 % in the same period of five years. Despite this rate, Kirehe district is showing an increase CS in the past five years ranging from 24 -35 %. The overuse of cesareans is substantially rising in Rwanda both in rural and urban areas and is now considered as a public health problem. This study aims to determine the current prevalence of CS in Kirehe and its associated factors.

To date, the real reasons for the increase CS rate remains unclear, only a few studies have reported the actual medical indications for the rise CS rate, especially in Rwanda. There is need to determine the factors associated with this increase of C-section among the women delivered at Kirehe District Hospital located in rural area.

A retrospective study was conducted to identify factors associated with caesarean section among mother delivered at Kirehe District Hospital. This is a retrospective study which use quantitative research approach though database of mHealth of Kirehe Hospital. It used data collected for the period of two years (2018-2019).

Kirehe is a district in Eastern Province, Rwanda. Its capital is Kirehe town (which is usually known as Rusumo, being the major settlement of the former Rusumo district. It has a district hospital that serves the whole district and some neighbouring sectors. Data was collected among the mother’s delivered at Kirehe Hospital from January 2018 to December 2019.

Data were checked for completeness, cleaned, coded and entered into excel sheet, and then exported to SPSS version 22.0 for further analysis. Mean and standard deviation (SD) was used to describe continuous variables. Comparison of proportions was performed by Pearson chi- square (χ2) for categorical variables to determine associations between selected covariates and delivery mode.

Multivariable log-binomial regression models was used to estimate Risk for CS with 95% confidence intervals (CIs). A p-value of less than 5% (2-tailed) was considered statistically significant for univariate and multivariable analyses of risk factors for CS delivery.

The overall objective of this study was to determine the prevalence and factors associated with caesarean deliveries among women delivered at Kirehe District Hospital. Records of 1158 women delivered at Kirehe Hospital from January 2018 to December 2019 were retrieved.

Primary concerns in choosing a method for delivering a baby are the comfort of the mother and, specifically, the safety of both mother and baby. Recently, as safety has become more assured in most normal births in developed countries, health workers have focused on making the experience more pleasant and on meeting emotional needs by bringing the father and other family members into the process. Today, for a pregnancy without maternal complication, parents have the right to choose delivery mode for a new baby either vaginal or cesarean delivery. Normally, both cesarean and vaginal delivery is associated with well-known measurable short- and long-term maternal and neonatal complications and benefit ¹⁷.

Cesarean delivery is a surgical procedure to remove the baby from the uterus by cutting through the abdomen. Most cesarean births result in healthy babies and mothers. But CS is major surgery and carries risks. Healing also takes longer than with vaginal birth ¹⁸. The operation is commonly performed when labor does not progress as quickly as it should, when the fetus seems to be in trouble, or when the mother is bleeding vaginally. Often a cesarean is needed when the fetus is in breech position (feet first) or in the transverse position (lying crosswire in the uterus), or when its head is too big to pass through the mother pelvis. Surgical deliveries are more likely when the birth involves a first baby, a large baby, an older mother (35 years old and above), or a mother who has had an earlier cesarean delivery ¹⁹.

The prevalence of Caesarean delivery was 23.1% in at Kirehe District Hospital, which is above WHO recommendation. Previous studies on cesarean delivery rate and maternal or neonatal mortality have yielded inconsistent results. Current evidence showed that national cesarean delivery rates of up to approximately 19 % live births were associated with lower maternal or neonatal mortality among WHO member state ²⁰. In contrast, other studies reported that a higher cesarean delivery rate is associated with higher infant mortality rate in high-income industrialized countries ²¹. Similarly, Souza et al. observed that compared to spontaneous vaginal delivery, all other modes of delivery were associated with the increased risk of death, admission to intensive care unit (ICU), transfusion of blood and hysterectomy; this association was stronger in Africa, compared to Asia and Latin America ²². The increasing CS rate in rural health facilities in Rwanda could indicate increased access to EmONC services and the high utilization of skilled delivery.

A recent study conducted in Rwanda found that the rate of CS in Rwanda significantly increased from 2.2% (95% CI 1.8–2.6) in 2000 to 15.6% (95% CI 13.9–16.5) in 2019–20. Despite increasing in all health facilities over time, the rate of CS was about four times higher in private (60.6%) compared to public health facilities (15.4%) in 2019–20. The same study revealed that overall, there were varied associations between CS and maternal age, occupation, wealth, ANC attendance, parity, sex and size of the child, and region of residence over the years. Across the surveys, women with multiple pregnancies, with ≥4 ANC visits, and from the richest households had higher odds of CS, while multiparous women and women with female babies had lower odds of CS. Women with female babies had 19–27% lower odds of CS compared to male babies between 2005 and 2019–20 while those with 5 or more children has 65–85% lower odds of CS compared to those with one child between 2010 and 2019–20. Women with multiple pregnancies had 3.2 to 6.5 times higher odds of CS than singleton pregnancy between 2005 and 2019–20 ²³.

Sayinzoga et al. further attributed improved maternal health services including access to CS use to established network of follow up for pregnant women, infrastructural development and proper leadership in health service delivery ²⁴. However, the overuse of caesareans beyond WHO recommendations is substantially rising in Rwanda and is now considered as a public health problem.

In this study, no association observed between multiple pregnancies and CS this contrast many other studies that reported an association between multiple pregnancies and CS ^{23, 25}. In 2014, the rate of CS among women with multiple pregnancies was three times the average rate of CS in Rwanda, having doubled within the preceding five years. However, in 2019–20, the rate of CS among women with multiple pregnancies reduced by 10 percentage points while that of singleton significantly increased to 23.3%. Hence, there is a need to review the indication for CS among women with multiple and singleton pregnancies to guide clinicians on women who are likely to benefit from the procedure and avoid unnecessary CS in this group.

In this study the associated between eclampsia and CS was reported. Previous study revealed that there is a lack of robust evidence from randomised controlled trials that can inform practice regarding planned caesarean section versus planned vaginal birth for women with severe pre‐eclampsia. There is a need for high‐quality randomised controlled trials to assess the short‐ and long‐term effects of caesarean section and vaginal birth for these women and their babies ²⁶.

Pre‐eclampsia is a very frequent problem during pregnancy that affects up to one in 10 pregnant women. Pregnant women with pre‐eclampsia have symptoms such as high blood pressure, headache, problems with vision and swelling of hands, legs, or feet. If untreated, serious pre‐eclampsia may lead to poor health or even death both for pregnant women and for their babies. More women in low‐income countries and in difficult economic circumstances suffer and die from pre‐eclampsia. The only definitive treatment for this illness is the birth of the infant. It is therefore very common for doctors and pregnant women with serious pre‐eclampsia to discuss delivering the baby after 34 or 37 weeks of pregnancy, with the timing dependent upon the health of the mother and the baby.

This study adds to the evidence on CS in Rwanda by examining the hospital-based trends and factors associated with CS in rural district of Rwanda in the period of one year. The prevalence of CS has very high compared to WHO recommended rates. The use of private health insurance, had eclampsia and rupture of membrane were factors associated with CS increase in Kirehe District.

Women in rural area of Rwanda seem to have increased access to and use of CS. However, the significant increase in the rate of CS is of concern due to the potential of unnecessary CS. Therefore, there is a need to examine the guidelines for CS use in Rwanda to ensure proper indications for use of CS are adopted for beneficial outcomes.

Health education for women is an essential component of antenatal care. The following educational interventions and support programmes are recommended to reduce caesarean births only with targeted monitoring and evaluation.

For the sole purpose of reducing unnecessary caesarean sections, financial strategies (i.e. insurance reforms equalizing physician fees for vaginal births and caesarean sections) for health-care professionals or health-care organizations are recommended. Incentives given to health care professional who successful perform caesarean sections should be cancelled and focus more on women counseling.

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