Ram et al. Pacific Journal of Reproductive Health 2018;1(7):384-389
CLINICAL AUDIT
DOI: 10.18313/pjrh.2018.906
OPEN ACCESS
Prevalence and characteristics of caesarean section among pregnant women who delivered at the Colonial War Memorial Hospital in Suva, Fiji, 2016. Nitik RAM1, James FONG2, Pushpa NUSAIR3, Masoud MOHAMMADNEZHAD4, Sari ANDAJANI5 1
Senior registrar, 2Head of Department, Obstetrics and Gynaecology, Colonial War Memorial Hospital. 3Assistant Professor in Gynaecology, School of Heath Sciences, Fiji National University. 4Associate Professor in health promotion, School of Public Health and Primary Care, Fiji National University. 5 Head of Discipline, School of Public Health and Psychosocial Studies, Auckland University of Technology, New Zealand.
ABSTRACT: Background: In recent decades there has been a marked increase in caesarean section rates in both developed and developing countries. Institutional data indicate a rise in caesarean section rates in Fiji however published data in this regard is lacking. This study aims to estimate the prevalence and identify the characteristics of caesarean sections at Colonial War Memorial Hospital (CWMH) in 2016. Methods: This is a retrospective audit of 1625 women who underwent caesarean section at CWMH from 1st January 2016 to 31st December 2016. A data collection form was developed to collect data from the birth register book. The data collected included patients’ demographic characteristics, indication for caesarean section, surgeon hierarchy, and wound check review. Data was analysed using SPS and the results were presented in tables and graphs. Findings: Of the 1625 caesarean sections included, the majority were I-Taukei (indigenous Fijians) (77%; n=1148) and 20-34 years old (60%; 887) and primigravida (46%, 739). Most caesarean delivery was performed by a senior registrar (62%; 1002). Of the 1,625 caesarean sections, 88% (1409) were emergency caesarean sections and 13% (216) were elective procedures. Fetal distress was noted as the indication for 56% (911) of all caesarean section deliveries followed by obstructed labour (16%) and fetal malpresentation (13%). Conclusion: In 2016, CWMH recorded the highest rate of caesarean section births adding to the rising trend in caesarean section rates observed in CWMH over the past years. There is a concern in the rise of caesarean sections in first time mothers. There is a need to define fetal distress and obstructed labour that may assist in reducing unnecessary caesarean sections. Further studies are needed to explore the indications for caesarean sections and whether the increase in rate has improved perinatal outcomes versus an impact on health resources. Key words: prevalence, caesarean section, pregnant women, Fiji BACKGROUND In recent decades a marked increase in caesarean section (CS) rates have been noted in both developed and developing countries. The real cause of this increase is not certain. Although the World Health Organisation (WHO) recommends an average of no more than 10-15% of births by CS for optimal maternal and neonatal outcomes, global
Corresponding author: Nitik Ram.
[email protected] Received: 10.04.2018; Published: 20.08.2018 Citation: Ram et al. Prevalence and characteristics of caesarean section (CS) among pregnant women who delivered at the Colonial War Memorial Hospital (CWMH) in Suva, Fiji, 2016. Pacific Journal of Reproductive Health 2018;1(7)384-389. DOI: 10.18313/pjrh.2018.906 Copyright: © 2018 Ram et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Ram et al. Pacific Journal of Reproductive Health 2018;1(7):384-389
rates of CS delivery vary widely from country to country, ranging from 0.6% in South Sudan to 55.5% in Brazil.1,2,3,4 When medically indicated, CS effectively prevents adverse birth outcomes. However, caesarean delivery incurs surgical risks and can complicate future pregnancies. More longer term adverse outcomes were reported in two meta-analyses involving 23 and 20 observational studies which indicated that delivery by CS was associated with a 20% increase in subsequent risk of respiratory disease and diabetes in the newborn.5,6,7,8 According to WHO, Fiji has the second largest population of all South Pacific islands with an estimated population of 881,000. The average annual population growth rate stands at 0.8%. Fiji had 18 live births per thousand population in 2015 with an average maternal mortality of 30 per 100,000 live births.9 The Colonial War Memorial Hospital (CWMH) located in Suva, serves as the national referral hospital for Fiji and is accessible to other countries in the region, as it provides other specialised services including renal, cardiac and cancer services.10 CWMH delivers approximately 8500 babies annually accounting for more than 50% of total live births in Fiji.11 The CS rate at CWMH has considerably escalated from 6.3% in 1970 to 18.4% in 2012, and 19% in 2015.11 This rise in CS is also experienced nationally and in the Pacific.3 Unfortunately, within facilities in the South Pacific region, there is limited data regarding CS rates, the characteristics of women who have had CS and factors associated with CS delivery. The purpose of this study was to estimate the prevalence of CS and the characteristics of women who had CS at CWMH in 2016. This paper serves as a baseline reference to future interested parties in regard to changing CS rates and indications at CWMH, in Fiji and the Pacific. It may also help demonstrate variation in rate, demography, indications and clinician caseloads across various training hierarchy. METHODS This is a retrospective descriptive audit of all CS procedures at the CWMH from 1st January 2016 to 31st December 2016. All women who had a CS in 2016 at CWMH were included and women and incomplete case records were excluded. All applicable data was collected by the lead
DOI: 10.18313/pjrh.2018.906
investigator from the birth register book located in the CWMH labour ward. A data collection form was made and the information such as mothers’ age, ethnicity, education level, indication for CS, surgeon hierarchy, and wound check review were transferred to it. In this study indication for CS was divided to two broad categories; maternal and fetal indicators. The three main indications stipulated were: fetal distress (abnormal cardiotocograph, category 2 and 3 or moderate/ thick meconiumstained liquor), obstructed labour, and malpresentation. Surgeon hierarchy was categorised into three groups including consultant, senior registrar and junior registrar. Wound check review was classified as no wound infection and wound infection (superficial, moderate, and severe). The data was transferred to an Excel spreadsheet, cleaning and a descriptive analysis was generated using SPSS (IBM version 22, Chicago, IL, USA). The results were presented in the form of table and graph. Ethical approval was obtained from The Department Research Committee in the School of Medicine and Nursing at the Fiji National University (FNU); the College Human Research Ethics Committee CHREC of FNU and the Fiji National Human Ethic Research Committee FNHREC 2017.41 CEN. RESULTS Overall in 2016, 8038 women delivered their babies at the CWMH; 80% had a normal birth (n=6143) and 20% (1625) underwent a CS delivery. Of the 1625 women who had CS, 9% (147) were patients of private consultants. As reported in Table 1 the majority of women with CS were ITaukei (77%; 1148) and 60% (887) were 20-34 years of age. In addition, half of the women were educated in secondary school and 49% were married. Nearly half of the women were primigravida (46%; 894) and about 10% were women 19 years and younger. Most CS were performed by senior registrars (62%, 1002), followed by their junior peers (25%) with one to three years of experience, and then consultants who performed 13%. Of 1625 caesarean delivery, 216 (13%) were elective caesarean while 88% (1409) were emergency procedures. Indications for emergency CS include fetal distress, fetus malpresentation and obstructed labour. Fetal distress was found in 56%
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Ram et al. Pacific Journal of Reproductive Health 2018;1(7):384-389
(911) of all CS, followed by obstructed labour (16%) and fetal malpresentation (13%) (Figure 2). Table 1: Characteristics of women who underwent caesarean delivery at CWMH (N=1625). Characteristics Frequency Ethnicity I-taukei 1148 Indo-Fijian 334 Others 143 Ethnicity-specific CS rates I-taukei Indo-Fijian Others Education level Primary 130 Secondary 813 Tertiary 682 Marital status Single 222 De facto 532 Married 724 Mother’s age at birth (years)
