SIR 1206 015 Non Caesarean Developing Countries

8/11/2019 SIR 1206 015 Non Caesarean Developing Countries

1/5

Canadian Journal on Scientific and Industrial Research Vol. 3 No. 4, May 2012

179

Non-medical factors affect caesarean sectionrates among developing countries

*Maha M., Atout

*Lecturer of Maternity and Newborn nursing, Isra UniversityE.mail: [email protected] , Tel: 00962799114502

Abstract_ Presently, the Caesarian section (C/S)has become widely used in developing countrieswhere it can be a life-saving procedure for motheror baby. It may carry severe health problem for themother and newborn. Cesarean section ratecontinues to rise in many countries with routineaccess to medical services, yet this increase is notassociated with improvement in perinatal mortalityor morbidity. This raises a range of concerns aboutthe use of caesarean section for non- medicalindications. The next review addresses factors thataffect the increase in C/S rate in the developingcountries without medical indications.

Key Words: Caesarian section, prenatal mortality,non- medical indications, developing countries

I. INTRODUCTION

Recently the rate of cesarean section (C/S) hasgrown rapidly. Not only in the developingcountries, but also the developed countries haveshowed a significant increase [1] .

As a surgical procedure, it's the most frequentlyperformed in the united state. Approximately oneout of four women will have cesarean delivery inher reproductive years [2]. This increase has raisedthe concern about the unnecessary C/S withoutmedical reasons.

In 2007 the rate of C/S rate in the United Statearrived 29.1%, which considered the highest amongthe developed countries. About one third of the C/Soperations were repeated procedures. [3]

Among developing countries, the rate of C/S inthe majority of them was between 5%-15 % asshown in the next table. Around 4%- 18% of themwere performed on maternal request [1]. Althoughthe disparities that found between these countries,especially poor and rich, they had an enormousincrease in the rate of cesarean section in the lastcentury [4]

Compared with normal vaginal delivery, C/Sdelivery may carry severe health problems for bothnewborn and mother. For newborn it may lead torespiratory complication and neurological deficits,for mother it may increase the long-term morbiditythat may happen postpartum [5]. Furthermore, there

is an elevated risk of unexplained stillbirth insubsequent pregnancies among women withprevious multiple caesarean section .[6] Caesareansection may require more healthcare resources,which consider a real burden on the health caresystems, especially with limited budgets . [7]

On the other hand C/S help reduce maternal andperinatal mortality when contraindication of normalvaginal delivery is present, or when the progressionof labor is thought to be unsafe [6] , because of thedebate emerged about the risks and benefits for theC/S operation, World health organization (WHO)states that it is not justified in any place of the

world to perform C/S operation in a rate greaterthan 10%-15%.

II. IM OF THE REVIEW

The aim of this review is to explore the non-medical factors associated with caesarean sectionrate in the developing countries

Rate ofC/S

Less than 5%

Between(5-15) %

More than15 %

Name ofcountry

Yemen,Mauritania,Sudan,Algeria

Oman,Morocco,Libya,Tunisia,

SaudiArabia,UAE,Egypt,kuwiat,Jordan,Syria

Lebanon,Qatar,Bahrain


2/5


180

III. LITERATURE REVIEW

This section addresses non- medical factorsassociate rates of C/S in developing countries.Literature has revealed three major non-medical

factors affected C/S rates:

1. Physician -related factors:Physicians are generally thought to play the

dominant role in the medical care decisions. Somepatients may leave the health-care related decisionto the physician, because they trust his knowledgeand expertise. There are many non- medicalfactors affect physicians' opinions toward the routeof delivery as they mentioned below:

a. Lack of second opinion consultation

Lack of second opinion consultation was foundto affect physicians' decision toward route ofdelivery. As it was found in the qualitative studyconducted to determine factors affect obstetricians'decision on the route of delivery among 19 boardscertified obstetricians working in four Jordanianhospitals. The findings of the study showed that100% of those obstetricians claimed that absence ofsecond opinion consultation especially in the high-risk deliveries plays a significant role in theincrease in the C/S rate [8]

b. Fear of professional liability:Legal claim against obstetricians for negligence

was found to affect C/S rates. Physicians tend tomove toward safer practice with low level ofprofessional liability. This was supported by theJordanian study that was conducted to explorefactors affect physicians' decision on the route ofdelivery in high- risk pregnancies. It was found thatthe fear of professional liability for the physicianhad an impact on delivery decision, especially withhigh-risk pregnancies such as assisted birth thatcould affect the life and health of the neonate andmother. [8]

In addition, a study conducted in Ireland toestimate proportion of obstetricians who would agreewith elective C/S on maternal request. The resultshowed that there was a positive relationship betweenfear from professional litigation and the tendencytoward C/S operation. [9]

c. Age and clinical experience

Older and more experienced physicians werefound to perform lower C/S rate than younger andless experienced as it found in a study that wasconducted to assess factors affecting theobstetrician decision toward the route of delivery inhigh- risk pregnancies. [8]

Another study was conducted to determine theimpact of demographical factors such as age,working environment and personal birth experienceof the physician on the attitude towards electiveC/S without medical indication. Results showedthat younger physicians approved C/S on demandgreater than physicians between 50 and 60 years of

age, which may be due to working experience. [10]

d. Gender of physician:In the Jordanian study that was conducted to

address physicians' characteristics and their effects ontype of delivery decision [8]. Male physicians werefound to prefer C/S mode of delivery. That genderdifference remains not understood. However, theresearcher explained reason for this difference couldbe the deep understanding of the female physician forthe female body system.

However, opposite results were found related to

the physician gender and C/S route of delivery. As itwas found in the follow-up study that showed that(31) % of female obstetricians would choose cesareansection operation for themselves without medicalreasons [8]. This study was the background foranother study in 2002 where female obstetricianswere asked about their personal choice for mode ofbirth. The findings showed that (15.5) % wouldchoose an elective caesarean [11].

In conclusion, there is a debate related to thephysician's gender effects on the route of delivery,therefore more studies should be conducted to explorehow gender differences among physicians affect theirdecision of delivery type.

2. Women- related factors:The preference of women to perform C/S

instead of normal vaginal delivery is one of themost important factors for the increasing rate ofC/S in the developing counties. Literatures haveexplored many factors that affect women'sdecision toward route of delivery:

a. Lack of informationA qualitative study that was conducted in

Lebanon in 2007 to investigate the environmentalfactors that affect the C/S option among differentstockholders. Results showed that lack ofinformation about the post-partum periodfollowing the C/S operations affect womendecisions of the route of delivery. In the previousstudy the result emerged that the painless idea ofC/S compared with pain received during normalvaginal delivery affect their decision when theyplanned to get birth. [6]

a. Fear of childbirthIt is common for women to feel fearful about

childbirth. Childbirth is known to be


3/5


181

unpredictable and painful and accomplished withsmall risks of morbidity or even death for motherand fetus. Fear from childbirth may vary amongwomen. Some women would overcome and copewell with her fear, while others may have anextreme fear or anxiety; this may leads her tocope with her fear by request for cesarean section

without medical indications. [12]

A qualitative study was conducted to describeAustralian womens request for caesarean sectionin the absence of medical indicators. Resultsshowed that the most important reason forrequesting C/S operations was fear of giving birthvaginally especially in the first pregnancy. Theanalysis suggested that fear of giving birthvaginally for some women was reinforced bydifficult birth experience that was shown by themother of pregnant woman [13]

b. Women age

Trends in cesarean section rate with maternalage have been of interest in the last 10 years.. As itwas shown in the retrospective study whichconducted to assess the effect of maternal age onC/S rate among 11.815 patient. Results revealed anincrease in C/S rate with increasing maternal age.[12]

Another study found that women age at firstpregnancy is another factor that could affectwomen choice for type of delivery. The researcherfound that older age women at first pregnancyprefer C/S delivery more than younger. This wasdiscussed that the underlying cause for C/S choicefor older women at first time pregnancy was theirbelieves that it's the safer way to get a child . [13]

c. Level of educationLevel of education was found to affect C/S rate.

This was supported by the Chinese studythat was conducted to explore the effect ofeducational levels and the employment of themother on the route of delivery among Chinesewomen. Results showed that there was anassociation between high educational level and theemployment of the mother on the increasing C/Srate. The researcher explained that better- educatedwomen were more likely to have babies atrelatively late age. [14]

d. Previous infertilityPrevious infertility was found to increase C/S

rates as some people think that C/S is the saferway to get child. In a study that was conducted inNigeria in 2006 to assess women reasons forrequesting C/S operations among 27 women whorequested C/S without medical indications. Oralquestionnaire was administered previous deliveryand after 6 week postnatal. Results showed thatthe major reasons among Nigerian women to

request C/S operations were previous infertility(40.7) %. The underlying aim of this choice wasthe desire of having a live birth to beat theproblem of infertility. They believed that C/Soffered them the best chance of fulfilling theirdesire [15]

e. Community factors: (social interaction,

urbanization level) Social interaction

Community factors have an impact on therising in the number of C/S in developingcountries. Depends on a study that was conductedto analyse the community factors that affect therate of C/S among six developing countries.Results showed that women, who have a highsocial interaction, were associated with lowerincidence of C/S choice. because women whoshare information with others social sourceswould be more likely to be informed about thepotential harms that may result from C/S, such as

hospitalization, recovery time, pain fromoperation, and breastfeeding problems [16]

Level of urbanizationIn the developing countries the trend for

urbanization is another factor that affects the routeof delivery, depends on the results of a study thatwas conducted to examine the associationbetween urbanization and the risk for C/S amongEgyptian women. It was found that the increasethe urbanization level was associated with theincrease of C/S rate. One possible explanation forthis association was that the higher level ofurbanization would correspond with lowerfertility rate [1]

The explanation of that was cleared in anotherstudy which conducted in Taiwan to explorepossible explanations for the higher C/S rateamong urban areas. lower fertility rate in theurban areas in comparison with those in ruralareas, raised the focus for people live in urbanplaces to focus more attention on the safety of thebaby, therefore choosing the safer way to getchild (in their opinion C/S safer than normalvaginal delivery). As a result increase C/S rate [9]

In conclusion, C/S rate was shown to increasein urban areas more than rural places. Because thelower fertility rates that were seen in the urbanareas.

3. Management factors:

Management factors have been shown to play asignificant role in explaining C/S rates for nonclinical indications. It has been classified into fourcategories: hospital characteristics, lack of midwife


4/5


182

type of health insurance coverage, and the diversityof health care centers among some countries.

a. Hospital characteristicsHospital characteristics were appeared to

influence C/S rate as it was found in the Jordanianstudy that aimed to study factors affect the

obstetrician decision on the route of deliveryamong two groups of military hospitals. It wasfound that the presence of full-time obstetricanesthesiology, teaching institution, large deliveryunit capacity, urban location of the hospital, and thepresence of qualified medical staff and neonatalintensive care unit, all of these hospitalcharacteristics factors may decrease the rate ofcaesarean section operations [2]

b. Lack of midwifes in the labor unitsThere is a relationship between the presence of

an enough number of midwifes, and the mode ofdelivery. Depends on the previous Jordanian study,the presence of qualified midwifes would decreasethe rate of C/S. [2] This study was supported byanother study that concluded that the presence ofqualified midwifes in the labor settings had aneffects on numbers of C/S operations. Forexample, a country like Egypt characterized by lackof trained midwifes has a high proportion of C/S. Incontrast to Syria and Palestine which had asignificant proportion of qualified midwifes, havemoderate C/S rate. [1]

c. Type of Health insurance coverageIt was found that C/S decisions were affected

by type of health insurance that carried by womenwho seek the health institution as it will emergefrom the next studies.

In one study that conducted in 2007 todifferentiate between private and public hospitals interm of their relation to increase C/S rate amongnulliparous women. It was found that with privateinsurance women had more tendencies to decideC/S delivery rather than those who hadn't privateinsurance. [17]

Furthermore, some countries have healthinsurance systems that don't cover analgesia relatedto normal vaginal delivery, such as epiduralanalgesia, in contrast to total financial coverage forC/S analgesia such as (spinal or epidural includedin C/S).These systems encouraged women to movetoward the cost- effective route of delivery, whichmeans C/S deliveries .[6]

d. The diversity of health care centersMaldistribution of health care centers was

found to affect C/S rates as it was found in theretrospective study that conducted to look for thesocioeconomic differences in C/S rates in 13

developing countries. Results showed that lessthan 1% of the population in the poorest countriessuch as Sub-Saharan Africa could apply C/S, evenin the life-saving cesarean, which had negativeeffects on the pregnant women and fetus healthoutcome. This has been explained for thisproblem: the health care services might not exist

because of poverty, or it can't be reached becauseof the misdistribution of health centers [18]

Data from Latin America suggested that thesurgical services were available to cover a largenumber of population, but the distribution of theseservices was not optimal that would deprive largeareas from these services. As a result the distanceneeded to reach the hospital to perform surgicalprocedure would make time and financial barrier.

On the other hand, countries such asNicaragua and Bolivia which are consideredhighly-incomed, had high proportion of C/Sarrived to 44 %. This improper distribution had asignificant effect on the health on mother andinfants [18]

In conclusion, many studies reported thatmaldistribution of health care facilities in somecountries may affect C/S rate among them. Since,the large distances that could be passed to arrivethe health centers will create a time and financialbarriers. This may prevent pregnant women fromseeking any surgical interventions. Even with life-saving cesarean section. As a result decrease C/Srates.

IV. CONCLUSION

Several studies suggested that there were non-medical indications that may influence the decisionof use caesarean section as a method of delivery.

There are three non medical factors that affectcesarean section rate; physician related factors,women related factors, and management relatedfactors. Physician related factors may include: lackof second opinion consultation, fear from litigation,and physician characteristics (age, clinicalexperience, and gender), Women related factorsmay include: lack of information, previousinfertility, fear from childbirth, economical status,and women characteristics. Management relatedfactors were: type of health insurance, lack ofmidwifes in labor units, diversity of health services,and hospital characteristics.

Further studies are needed to provide theliterature with an updating statistics that give a newand accurate figure to the decision maker, alsomore financial support should be offered for theresearcher to support their studies on this importanthealth topic, toward natural delivery, this is the newinternational trend to improve health of the mother


5/5


183

and fetus, and this is the main goal that we seek toarrive in the maternal and newborn health nursing.

V. REFERENCES

1.

Jurdi R, Khawaja M. caesarean sectionrates in the Arab regions: cross-nationalstudy, Health policy plan. 2004; 9(2):101-110.

2. Amarin Z, Alchalabi H, Khader Y.Variation in repeat caesarean sectioncomplication rates among 3 hospitals innorthern Jordan, Eastern MediterraneanHealth Journal, 2006;12(5): 610-618

3. Chen C , Lin H ,Liu T et al. Urbanizationand the likelihood of a cesarean section,Eur J Obstet Gynecol and Reprod Biol,2008: 141 : 104110.

4. Al-Mazrou Y. HIV/AIDS epidemicfeatures and trends in Saudi Arabia.Annal of Saudi Medicine. 2005;52(2):100-104

5. Jain L, Golde G, Dudell M. Respiratorytransition in infants delivered by cesareansection, SeminPerinatol, 2006; 30:296-304.

6. Khasholian T, Kaddour A, DeJong J. Thepolicy environment encouraging C-section in Lebanon, Health Policy, 2007;83(12), 3749.

7. Minkoff H. The ethics of Cesareansection by Choice, Semin perinatol, 2006;30: 309-312.

8. Qublan H, El-qudah M, Al-Taani M.Factors affecting the obstetrician decisionon the route of delivery in high riskpregnancies, JRMS, 2003; 10(2), 32-37.

9. Chen C, Lin H, Liu T. Urbanization andthe likelihood of a cesarean section . Eur JObstet Gynecol and Reprod Biol, . 2004;141(3), 104110.

10. Ben-Meir A, Goseph G, Ezra Y. Cesareansection upon request: is it appropriate foreverybody? J. Perinat.Med, 2005; 33:106-111.

11. Bruce L, Flamm M, Donald M, BerwickM, Kabcenell A . Reducing cesareansection rates safely: lessons from A"breakthrough series" collaborative.Birth.1998; 5(2):117-123

12. Al-Mazrou Y. HIV/AIDS epidemicfeatures and trends in Saudi Arabia.Annal of Saudi Medicine.2005;52(2):100-104

13. Fenwick J, Staff M, Gamble J, Debra K,Bayes S. Why do women requestcaesarean section in a normal, healthy

first pregnancy? Midwifery, 2008;10(101): 1-7

14. HONG X. Factors Related to the HighCesarean Section Rate and Their Effectson the Price Transparency Policy inBeijing, China, Tohoku J. Exp. Med,2007; 212: 283-29

15.

Chigbu C, Ezenyeaku C.Women'sopinions and experiences with inductionof labor and cesarean delivery on requestin south eastern Nigeria, BJOG ,2008;103(3), 158 161.

16. Leone T, Padmadas S, Matthews.Community factors affecting risingcaesarean section rates in developingcountries: An analysis of six countries,Soc Sci Med, 2008; 67(3), 12361246.

17. Stafford RS. Cesarean section use andsource of payment: analysis of Californiahospital discharge abstracts. American

Journal of Public Health 2002;80(3):3135.

18. Ronsmans C, Holtz S, Stanton C.Socioeconomic differentials in caesareanrates in developing countries: aretrospective analysis, Lancet, 2006;368(4) 15161523.

VI. BIOGRAPHIES

Maha Mohd Wahpi Atout,Lecturer at Nursing Faculty/ IsraUniversity. Birth date and place:November 15 th 1984, Amman,Jordan, B.Sc. Nursing science,Faculty of Nursing, Jordan

University, Amman, 2006. M.S.N: Maternity andNewborn, Jordan University for Science andTechnology, 2009

SIR 1206 015 Non Caesarean Developing Countries

Documents

Transcript of SIR 1206 015 Non Caesarean Developing Countries