Abstract
Prenatal care (PNC) and counseling about delivery method is an important strategy to prevent delivery complications among women with multiple prior Cesarean sections (CS). In low income countries, an elective CS is recommended for this population. This cross-sectional study examined factors associated with counseling about delivery method and its influence on the likelihood of an elective CS delivery. A total of 422 women with ≥2 prior CS who delivered across five hospitals in Democratic Republic of Congo (DRC) were interviewed about PNC and counseling. Descriptive statistics and multivariate regression were completed to ascertain factors associated with counseling. Only 33.6% delivered via planned CS; 60.7% required an emergency CS. One-quarter completed four PNC visits; 64.5% received counseling. Number of PNC visits and number of prior CS were significant predictors of receipt of counseling. Women who received ≥2 PNC visits were 2.2 times more likely to have received counseling (p = 0.000). Among women who received counseling, 38.6% had a planned CS compared with 24.7% in the non-counseled group. Counseling was associated with mode of delivery; emergency CS and vaginal delivery were more frequent among women who did not receive counseling (p = 0.008). These findings highlight the importance of counseling during PNC visits. This study also highlights the poor coverage and quality of counseling in this high-risk population and the need for improvements in PNC. Less than 40% of counseled women followed provider recommendations for a planned delivery via CS. The majority labored at home and later delivered emergently. The significant number of women who trial labor without medical supervision despite their high-risk status sheds light on the influence of patient perceptions about CS and acceptance of medical intervention during birth.
Highlights
Access to Cesarean section (CS) is an important component of obstetric care, in an emergency context, and is associated with reduction in maternal and neonatal mortality and morbidity [1]
A CS rate of 5–15% of births is considered optimal to achieve gains in maternal and child health indicators. This percentage remains low in many low- and middle-income countries (LMICs) and is disparate according to sociodemographic factors within countries, reflecting barriers to access, such as lack of health facilities in rural areas and low population health literacy [2]
A recent review reports on CS-associated maternal deaths in LMICs, citing a high mortality rate that remains unchanged over time and linking emergent CS and those performed during second stage labor with significantly increased mortality and morbidity [3]
Summary
Access to Cesarean section (CS) is an important component of obstetric care, in an emergency context, and is associated with reduction in maternal and neonatal mortality and morbidity [1]. A CS rate of 5–15% of births is considered optimal to achieve gains in maternal and child health indicators. This percentage remains low in many low- and middle-income countries (LMICs) and is disparate according to sociodemographic factors within countries, reflecting barriers to access, such as lack of health facilities in rural areas and low population health literacy [2]. A recent review reports on CS-associated maternal deaths in LMICs, citing a high mortality rate that remains unchanged over time and linking emergent CS and those performed during second stage labor with significantly increased mortality and morbidity [3]. In the absence of adequate obstetric monitoring and care provision, it remains a recommendation for elective repeat CS, in the context of a history of multiple CS
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