Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey

Valérie Briand,Mamadou Traore,Alexandre Dumont,Pierre Fournier,Michal Abrahamowicz,Laurence Watier

doi:10.1186/1471-2393-12-114

Abstract

BackgroundTwo years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.MethodsWe conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007–10/01/2008). Data were collected regarding women’s characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.ResultsAmong 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).ConclusionsWe confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Highlights

Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali
CS accounted for 19.8% of all deliveries, with a higher rate in Senegal (20.9%, 95% CI: 20.5–21.3) than in Mali (18.5%, 95% CI: 18.1–18.8)
*Chronic hypertension, gestational hypertension, pre-eclampsia, eclampsia or HELLP syndrome. **Suspected cephalopelvic-disproportion reported as “excessive fundal-height” or “pathologic pelvis”. £CS accounted for 19.8% of all deliveries, with a higher rate in Senegal (20.9%, 95% CI: 20.5–21.3) than in Mali (18.5%, 95% CI: 18.1–18.8)

Summary

Introduction

Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali. In sub-Saharan Africa (SSA), In order to improve access to emergency obstetric care (EmOC), national free-CS policies are being trialled in several SSA countries [5]. In Senegal, exemption of CS fees was introduced in 2005 in all referral hospitals of the five poorest areas. In Mali, the free-CS policy was adopted on a national basis in 2006. In both countries, government funded schemes provide CS kits with basic supplies to district hospitals and reimburse regional hospitals for lost caesarean revenues. In Mali, fee exemption is for surgery, CS supplies, drugs and hospitalization, whereas only supplies are free in Senegal

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Conclusion