Abstract

Worldwide rise in caesarean section rate during the last three decades, has been the cause of alarm and needs an in depth study. Caesarean section is one of the most common major surgical procedure performed now a days. The procedure is not benign and should be performed only when circumstances distinctly require it. Public perception of caesarean sections has seen a swing from a “failure of obstetric care” to being “safe for mother and child.” There have been occasions where an obstetrician has been manhandled for a poor outcome and blamed needlessly for not having performed a caesarean section. At the same time media glare has fallen unfavorably on the rise in rates of these procedures. Why have the rates increased and what are the strategies to reduce the rates of Caesarean sections? In this context, this study intends to find out the prevalence of caesarean section and also to identify the maternal, institutional and physician related determinants of caesarean section.

Objectives

• To find out prevalence of caesarean section in Trivandrum district during the year 2010.
• To find out maternal, hospital and physician related determinants of caesarean section in Trivandrum district

Materials and Methods: Our study was a Descriptive study from four maternity care hospitals in Trivandrum district. Duration of our study was 6 months and sample size was 800.

Results: Our study shows that the prevalence of caesarean section in private institutions in Trivandrum district is higher in private hospitals when compared to public sector. The primary caesarean sections in the public and private health institutions were found to be 38.50% and 47.90% respectively. The mean age of women who underwent caesarean section was found to be 27. Our study shows that there is an increasing trend for caesarean section as maternal age increases. The association between age and type of delivery was found to be significant. Analysis also shows that as level of education increases, the chance for caesarean section increases. The association between educational status and type of delivery was found to be highly significant. It was observed that 52.2% of the upper strata, which constitutes 50.4% of the study population, underwent caesarean section. Among the middle strata, 50.9% underwent caesarean section. In the lower socioeconomic strata, which constitutes 12% of the study population, only 37.5%) had a caesarean section. The results were statistically significant. Among the nulliparas, 55.1%) underwent caesarean section pointing to the increasing number of primary caesarean sections. The primary caesarean sections were 55.1% and repeat caesarean sections performed were 59.1%, in the population under study. The results were not statistically significant.85.1% of the caesarean sections were done at gestational age of 37 weeks or more. 13.6% of the caesarean sections were done preterm. The results were found to be statistically significant. It was observed that among those who underwent caesarean section, the most common medical complication seen associated was hypertensive disorders of pregnancy followed by gestational diabetes mellitus. When bivariate analysis was done to compare women with and without medical complications, it was found that the chance of women with medical complications to undergo caesarean section was 2.559 times when compared with women without any medical complications (Odd’s ratio = 2.559). About 59.5% and 54.5%> of women underwent caesarean section in private and public health institutions respectively. Among the public institutions, 58% and 51% of the women underwent caesarean sections in non teaching and teaching institutions respectively. In this study it was observed more caesarean sections performed in the study population, were emergency caesarean sections. The results showed that 52.1% of caesarean sections done in private sector were elective caesarean sections and majority (59.63%>) of caesarean sections performed in public institutions were emergency caesarean sections. The results were statistically significant. Majority of the caesarean sections were performed for previous caesarean section (39.8%), and irrespective of the type of health institution, it is the most common indication for a caesarean section..92.1%o of caesarean sections took place during day time in private institutions which may be due to the high number of elective caesarean sections in these institutions. The results were not statistically significant. Caesarean sections were performed mainly during day time, but 91.6% of caesarean sections performed in private institutions were during day time. The results were statistically significant. It was observed that in the health institution where there was no round the clock availability of ancillary services like pediatric, anaesthetic, and blood bank services, the caesarean section rate was higher. In a health institution where the physician practice followed was of solo type, a higher caesarean section rate was found.79.3% of the study population preferred vaginal delivery, whereas 20.8% preferred caesarean section. The results show that 60.1%> of the women who preferred caesarean section did so because they were advised by their obstetrician that undergoing vaginal delivery in the particular clinical situation would be risky for herself and/or her baby. 25.6% of them preferred caesarean section as they believed that it would be safer for their baby than a vaginal delivery. 12.5% were afraid and anxious of the pain they would have to experience during vaginal delivery. 1.8% of the women preferred caesarean section as they wanted their baby to deliver at an auspicious time. When the caesarean sections in the public health institution were analysed, it was observed that group V contributes most to the caesarean section rate (44.2%). This was followed by group II (30.16%). There were no cases under group IX.

Group V contributes most to the caesarean section rate (36.6%) in private health institutions. This is followed by group II (30.7%). It can be seen that 18.1% of the caesarean sections come under group I which is high when compared to the public institutions.

Conclusion: The prevalence of caesarean section in Trivandrum district during the year 2010 was 38.14%. The prevalence of caesarean section in Trivandrum district during the year 2010 in private hospitals (40.87%) was higher when compared to public health institutions (35.58%).

In the subset of population under study, the primary caesarean section rate was found to be high-31.82% and 41.3% in the public and private health institutions respectively. The maternal factors found significant were age, educational status, socioeconomic status, gestational age at delivery and presence of associated medical complications. The maternal factors like parity, number of antenatal visits done were found not to have significant association.

Irrespective of the type of institution, majority of the caesarean sections were found to be repeat sections. Majority of the caesarean sections performed were emergency caesarean sections in the public institutions under study, and in private institutions, majority were elective caesarean sections.

Irrespective of the type of institution, majority of caesarean sections were performed on weekdays and during day time. Caesarean section rate was higher in the health institution where there was no round the clock availability of ancillary services like paediatric and blood bank services and also where solo type of physician practice style was followed.

Majority of the women preferred vaginal delivery because it was the natural process of giving birth. Informed choice was not given to the patient. Most of the time, decision for the caesarean section was taken by the obstetricians themselves. Many of the women consider caesarean section to be safer for their baby and yet another few were afraid of the pain associated with normal labour.

The notable fact is that after Robson’s group V (which includes repeat caesarean sections), majority of caesarean sections come under group II (which includes induced labours and pre labour caesarean sections) in all the institutions under study, pointing to the high number of inductions in nulliparous women, which is of course an unhealthy trend.