Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania

Helena Litorp,Birgitta Essén,Lennarth Nystrom,Hussein L Kidanto,Elisabeth Darj

doi:10.1186/1471-2393-13-107

Helena Litorp, Birgitta Essén + Show 3 more

Open Access

https://doi.org/10.1186/1471-2393-13-107

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Abstract

BackgroundRising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country.MethodsWe conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age ≥ 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the χ2 test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance.ResultsWe included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031).ConclusionThe high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

Highlights

Rising caesarean section (CS) rates have been observed worldwide in recent decades
When private healthcare insurance was introduced at Muhimbili National Hospital (MNH) in 2004, the number of women with such insurance rose steadily reaching 20% in the last time period
We found a sharp increase in the total CS rate for all obstetric groups except transverse lie

Summary

Introduction

This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. Previous studies have explored rising CS rates in high-income [7] and in middle to lowermiddle income countries [8,9,10]. While maternal request [11], electronic fetal heart rate monitoring [12], and defensive obstetric practices [13] have been proposed as reasons for elevated CS rates in high- and middle-income countries, explanations for elevated CS rates in low-income countries are likely to be different. Few previous studies have explored a high CS rate in a low-income country [14,15,16]

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