A cross sectional study of current trends and indicators of caesarean section as a mode of delivery in an urban slum of metropolitan city

 

Sanjay N Sid^1*, Ranjit Mankeshwar²

 

¹Assistant Professor, Department of Community Medicine, Government Medical College, Miraj, Maharashtra, INDIA.

²Associate Professor, Department of Community Medicine, Grant Government Medical College, Byculla, Mumbai, INDIA.

Email: sanjaysid1986@gmail.com

 

Abstract               Background: The increasing Caesarean section rate has become a major public health issue. This is mainly due to the fact that more and more women are being delivered by caesarean sections for not well defined medical reasons. Method: The present study was community based cross sectional study, carried out in an urban slum area of a Metropolitan city. Study population comprises of women who have delivered a child in last five years (2009-2013) in an urban slum of metropolitan city. Questionnaire was prepared and 400 women were interviewed using structured questionnaire. Results: In the current study the prevalence of caesarean section was 24.5%. Elective caesarean sections deliveries were 41.83% and 58.87% were emergency caesarean sections deliveries. Current study has shown caesarean section rate is approximately constant over this period of five year. Proportion of caesarean section delivery was increased from 2009 to 2013, but this increase was not found statistically associated. Common indication observed in this study for caesarean sections were baby was in distress (31.6%), previous caesarean section (25.5%), cephalopelvic disproportion (21.4%), nonprogression of labour (19.4%) and complicated position (18.3%). Conclusion: Percentage of caesarean section performed was increased over a period of a time.

Key Words: Caesarean Section, Trend, Indicators, Community based.

 

 

 

INTRODUCTION

Increasing caesarean section rates are a trend observed worldwide.¹ The concern for the caesarean rates is due to its rapid increase over the period.² The caesarean section rate rose from 4% in the 1970s to 21.5% in 2001 in the United Kingdom, from 30.3% in 1978-1979 to 50.8% in 1994 in Brazil, from 11.1% in 1988 to 38.1% in 2000 in South Korea, and from 4.7 to 22.5% over the past three decades in Shanghai.³ A report published by the Centers for Disease Control and Prevention, National Center for health statistics, USA showed that the caesarean section rate rose by 53% from 1996 to 2007.29 According to NFHS-2 data Goa (15.3%) and Kerala (13.7%) were the two states with higher rate of caesarean section in country.⁴ Based on DLHS-3 data, the caesarean section delivery rate in India was 9.2%. Population-based cross sectional study by S. Sreevidya et al. at Madras in 1997-99 found caesarean section rate of 32.6%.⁵ Similar study conducted at Delhi by SK Bhasin et al. in 2003-04 found caesarean section rate of 34.4%.⁶ Indications for Caesarean Section are classified under two heading, absolute indications and relative indications.⁷ There are other important factors which play important role in increasing trend of caesarean section. These factors are related to patients, physicians and social, economic and cultural composition of society.⁸ There are many factors, such as better operative techniques, trained staff, improvement in anaesthesia, facilities for blood transfusion and invention of newer antibiotics. The indications and incidence of caesarean section is increasing.⁹ In the United Kingdom ‘Patients demand’ was the third commonest indication for elective Caesarean section in 1992. Fear of the pain of labour and avoiding injury to the perineum, which may lead to sexual dysfunction, are some of the reasons quoted for it. In India astrological reasons play the same role.¹⁰ Researchers found a strong correlation between increasing caesarean section delivery and socio-economic and cultural factors. Studies showed that in case of developed countries, doctor’s preference for this surgical procedure, coupled with women’s demands are responsible for the increasing trend¹¹ An increase in the caesarean section rates over the recent years can be explained by obstetricians "playing safe" (i.e., conducting caesarean for even minor complications and avoiding litigation problems).^12,13 This study aims to assess current trends and indicators in caesarean section as a mode of delivery in women who have delivered a child in the last five years, in a metropolitan city.

 

MATERIAL AND METHODS

Present study was Community based cross sectional study. It was carried out in an urban slum area of a Metropolitan city, over a period of December 2013 - November 2015. Sample Size for this study was calculated by using following formula.

where,

n = Size of the sample

Z 1- α/2 = Standard normal deviate for α

p = Anticipated population prevalence

d = Absolute precision required on either side of the proportion

In the current study,

Z 1- α/2 = 1.96 (for α = 0.05)

p = 35 %

d = 5 %

n = 350

Computed sample size works out to be 350. This study sample size is 400. Women fulfilling inclusion criteria were included in the study. Inclusion criteria for this study was

1. Women who have delivered a child in last five years i.e. after 1st Jan 2009.
2. Women who are willing to participate in the study.

Purposive sampling technique has been used to select the study area of urban slum. A slum area adjacent to Urban Health Training Centre of Grant Government Medical College, Mumbai was selected. A questionnaire was designed to collect information about mode of delivery in each study participant. As a researcher himself interviewed all the subjects, the final questionnaire was prepared in English language without any translation. It emphasised on acquiring information of caesarean section as the mode of delivery and its associated factors by literature search and consultations with guide and a experts in their respective field. Data collection tool was tested by conducting a pilot study on 40 women, who met the inclusion criteria. After the pilot study; required changes were carried out in the questionnaire. The pilot sample was not included in the study. Before the interview, the individuals were informed about the scope and nature of study. It was explained to all mothers that the information would be kept confidential.

Statistical Analysis

Stata SE 13.1 was used to analyse data. SPSS 16.0 was used to enter and code data.

Ethical approval: Details of the study were presented to the Institutional Ethical Committee of the Grant Government medical college, Mumbai where the researcher was registered, in January 2013.Various aspects involved in the study were discussed and ethical clearance was granted for the study.

OBSERVATION AND RESULTS

This study has included 400 women as study sample. The present study included women who had delivered in last five years. In this study sample 316 (79%) were in the age group of 20-30 years while 36 (9%) and 48 (12%) were in the age group of <20 years and >30 years respectively. Table no.1 mentions Sociodemographic and other details of the mothers.

 

Table 1: Sociodemographic and other details of the mothers. Values are given as in percentage

Current study has found the prevalence of caesarean section in this study sample was 24.5%. Of this all caesarean section deliveries 41.83% were elective caesarean sections deliveries, and 58.87% were emergency caesarean sections deliveries. The table No.2 shows number of deliveries occurred in the respective year and percentage of caesarean section in that year. The percentage of total delivery increased from 17.5% in 2009 to 23% in 2013. The proportion of caesarean section was 21.4% in 2009, which has increased to 27.2% in year 2013. To test whether this association was statistically significant, Pearson’s Chi-square test was used. Chi-square value was 1.37, which at 4 degree of freedom was not significant (p = 0.84). This shows that there was no increasing trend of caesarean section was observed during the study period.

 

Table 2: Caesarean and all deliveries by year

In this study mothers were asked about indication of caesarean section. Many mothers had reported two or more indications for caesarean section. In the current study fear of birth pain was also reported by mother as an indication for caesarean section. These reported indications except fear of birth pain were cross verified from hospital record file available with them. In 43.9% cases it was seen that mothers were fearful of birth pain. Common indication for caesarean section were baby was in distress (31.6%), previous caesarean section (25.5%), cephalopelvic disproportion (21.4%), non-progression of labour (19.4%) and complicated position (18.3%).

 

Figure 1: Indications for Caesarean Section

Mothers were asked about advantages of caesarean section delivery over vaginal delivery, to assess these women’s viewpoint about caesarean section. About 64% of women said that short duration is its advantage and 57.7% said that less pain the major advantage. This finding underlines the fact that many women have fear of birth pain in their mind and not willing to bear pain of vaginal delivery for long. About 37.5% women said it can save life in emergency. This underlines the fact that many women see it as life saving procedure and do not hesitate to opt for it. 16% said that it does not cause local injury. In the current study 13.7% of women said that caesarean section has no advantage at all. In 25.5% previous caesarean section was indication for current caesarean section procedure.

 

Figure 2: Perceived advantages of Caesarean Section

 

DISCUSSION

This study analysed data of mode of a delivery over a period of five year from 2009-2013 by interviewing study participants and studying hospital records available with them. This study observed increase in the rate of a caesarean section over this period. This increase was not found statistically significant. A hospital-based retrospective study carried out by Unnikrishnan B et al. at Karnataka, that study included all deliveries from 2005 to 2009. An increasing trend of caesarean section was noted in that study. Caesarean section rate of 20.2% have increased to 23.3% in 2009.¹⁴ A study by the Indian Council of Medical Research (ICMR) in 33 tertiary care institutions noted that the average caesarean section rate increased from 21.8 % in 1993-1994 to 25.4 per cent in 1998-1999.¹⁵ Study conducted at the Nowrosjee Wadia Maternity Hospital, Mumbai, showed that during 1957-1998, the caesarean section rates in this hospital increased from 1.9% to 16%.¹⁶ Present study also observed that there different indicators for this caesarean section. A cross sectional study conducted by S.K. Bhasin et al at east Delhi found that the main indications of caesarean section were fetal distress (22.9%), followed by post caesarean pregnancies (21.5%) and the failure of progression in labour (11.8%).⁶ P.Sudha Kumari et al. conducted a cross sectional study at Hyderabad which shows that of the 255 caesarean sections in their study, (21.9%) were repeat sections, (18.4%) due to obstructed labour, (16.1%) due to fetal distress, (12.5%) due to failure to progress, (7.8%) due to breech presentation, (11.8%) due to hypertensive disorders, (4.7%) due to Ante partum haemorrhage and (6.7%) because of post dated pregnancy.¹⁷ Prashant Bade et al have found that commonest indication for caesarean section was previous caesarean section (24.8%) followed by cephalopelvic disproportion (17.6%), failure to progress (16.6%), and fetal distress (11.7%).¹⁸ Study carried out by Emma L. Barber et al. have found relative contributions of each indication to the total increase in primary caesarean rate as non-reassuring fetal status (32%), labor arrest disorders (18%), multiple gestation (16%), suspected macrosomia (10%), pre-eclampsia (10%), maternal request (8%), maternal-fetal conditions (5%), and other obstetric conditions (1%).¹⁹ A study was conducted by Selina MW Pang et al.at Hong Kong. Mothers were asked the reasons for choosing caesarean section as the mode of delivery. About 35.3% said caesarean section is safer for the baby.23% were having fear of vaginal birth.18% said caesarean section has less pain.13.7% said it doesn’t cause local trauma.³ Present study also observed similar kind of indicators for this caesarean section as found in these various study. Present study found that previous caesarean section was indication for caesarean section in 25.5%. This is a vicious cycle that needs to be put to a stop which is possible only if trial for vaginal delivery after caesarean section is promoted. Present study also added afraid of birth pain as one of the indicator for caesarean section as this was mentioned by maximum number of women. While studying reference material it was observed that this indication played major role in ‘Patients demand’ for caesarean section. Fear of birth pain in mind of mother may have accelerated their decision when asked for it by doctor. In this study mothers were asked about advantages of caesarean section delivery over vaginal delivery to know about their own perceptions. These are their perceived advantages. Many reported one or other advantage of caesarean section over vaginal delivery. Only 13.7% said that caesarean section has no advantage over vaginal delivery. This may be matter of concern. In KAP study conducted by Saoji Ajeet et al 47.3% favoured caesarean section.²⁰ About 64% of women said that short duration is its advantage and 57.7% said that less pain the major advantage. This highlights that most of the time mother are not willing to bear birth pain for longer time. This also underlies the important role of indication ‘Afraid of Birth Pain’ in deciding mode of delivery. In study conducted by Saoji Ajeet et al 68.5% women believed that caesarean section is less painful.²⁰ About 37.5% women said it can save life in emergency. This underlines the fact that many women see it as life saving procedure and do not hesitate to opt for it.

CONCLUSIONS

Present study as well as many other studies quoted above indicates that it is necessary to conduct population-based surveys to estimate current trends of caesarean section which can improve the understanding of indicators of caesarean section. In order to understand and improve the health care system‘s response to increasing trend of caesarean section, consistent information regarding demographic data of women and their preferences to mode of delivery are important to be recorded at different type of health facility. Efforts should be made to promote awareness of women regarding risk associated with caesarean section procedures that will help to bring down the rate of caesarean section. This will reduce economical, physical, psychological burden from mother and her family. This study has certain limitations that it was a cross sectional study conducted in an urban slum of a metropolitan city, with a sample size of 400, therefore generalizability of the study findings could be a concern. A multi-centric study, would address this concern. The study was cross-sectional, and therefore only able to suggest associations rather than causal relationships.

 

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