UKRAINE’S EXPERIENCE WITH CAESAREAN SECTIONS: RATES AND INDICATIONS

ccording to official statistics the Table 1. Contribution of each C/S indicator to the overall C/S rate in the Donetsk caesarean section (C/S) rate in Region, Ukraine, 2010 and 2012 (aggregated data from 44 maternities). Ukraine increased from 9.2% A Indications for C/S C/S rate by different indications in 1998 to 16.5% in 2012 (1), although according to per total number of deliveries and total C/S this varies across maternities and regions nationally agreed of the country. The Donetsk Region of protocol 2010 (n=41 253) 2012 (n=43 071) Ukraine, with a population of 4.7 million, % of all % of % of all % of has a C/S rate that is higher than the rest N deliveries all C/S N deliveries all C/S of the country. In 2010 there were 41235 deliveries in the Region, with a C/S rate Obstruction for vaginal 486 1.18 6.80 123 0.29 1.61 delivery (pelvic, tissue, of 17.3% and in 2012 there were 43071 tumor) deliveries and the CS rate was 17.7%. Although this C/S rate does not greatly Uterine scar 1559 3.78 21.80 1932 4.49 25.41 exceed the rates recommended by the (previous C/S) WHO of 10-15% (2), we felt that it was Placenta previa/ 595 1.44 8.32 542 1.26 7.13 important to understand the factors as- ­Placenta abruption sociated with C/S in the Region. Severe preeclampsia 388 0.95 5.43 322 0.75 4.23 Our study had 2 parts. The first com­ ponent collected and analyzed aggregated Common diseases 79 0.19 1.10 98 0.23 1.29 data from 44 maternities in the Donetsk (according to National Protocol) Region, in the south eastern part of Ukraine, for 2010 and 2012. A specially Common diseases 466 1.13 6.52 268 0.62 3.52 developed and approved form was dis- (not according to ­National Protocol) tributed at the maternities and completed by each hospital’s administrative personal. Increase infection trans- 94 0.23 1.31 184 0.43 2.42 Indication for C/S and urgency of the mission risk (HIV, HSV) need for the C/S were used to analyze the Breech presentation 602 1.46 8.42 826 1.92 10.86 data. The urgency of the need for C/S was documented using the following stand- Foetal abnormalities 3 0.01 0.04 5 0.01 0.07 (requires C/S according ardized scheme: to National Protocol) • Category 1 - Immediate threat to the life of the woman or foetus; High perinatal risk 553 1.34 7.73 505 1.17 6.64 • Category 2 - Maternal or foetal com- (not according to ­National Protocol) promise which is not immediately life-threatening; Abnormal progress of 551 1.34 7.70 554 1.29 7.29 • Category 3 - No maternal or foetal labour compromise but needs early delivery; Obstructed labour 745 1.81 10.42 858 1.99 11.28 • Category 4 - Delivery timed to suit Foetal distress 696 1.69 9.73 1078 2.50 14.18 28 woman or staff. This categorization was based on updated Cord prolapse 87 0.21 1.22 82 0.19 1.08 evidence-based C/S national ­guidelines Multiple pregnancy 70 0.17 0.98 226 0.52 2.97 accepted in Ukraine in 2011 and intro­ duced at all maternities since 2012. Clinical death of mother 2 0.005 0.03 1 0.002 0.01 Descriptive statistics and odds ratios Missing information 176 0.43 2.46 N/A N/A N/A (OR 95%CI) were applied. The second aspect of our study col- Total number of C/S 7152 17.34 100 7604 17.65 100 lected data from 2 maternities with similar preterm delivery rates. Hospital 1 is a third level hospital where data were Robson’s classification for C/S was used women into one of 10 groups, is easily collected for January-June 2010 (total to analyze the data. This classification replicable and subject to the least bias. births=1845) and Hospital 2 is a second system uses 4 obstetric characteristics Data were retrieved from archival Paper level hospital where data were collected­ (parity, labour type, gestational age and Registers officially approved and used in for all of 2012 (total births=1917). foetal presentation/number) to classify Ukraine and computed.

Iryna Inna Oleg Svetlana Mogilev­ Kukuruza­ Belousov­ Makarova kina

Results immediate action. Thirty three percent Indication based methods provide infor- Data on contribution of each indicator to of C/Ss were performed electively and mation on why the C/S was done, urgency the overall C/S rate are presented in the an additional 20% had been scheduled based methods provide information Table 1. on an elective basis but were performed on when it was done and woman based The most common indication for C/S emergently prior to the scheduled date methods provide information on who was that of previous C/S (uterine scar), due to unexpected indications (i.e. onset is having C/S. Combined these methods accounting for 3.78% of all deliveries of labour or premature rupture of the can better help us determine if the right and 21.79% of all C/S in 2010 and 4.49% membranes). This resulted in additional women at the right time is undergo- of all deliveries and 25.41% of all C/S in urgency both for the patient and for the ing C/S. Our analysis in Ukraine has 2010. Interestingly, its rate increased 1.2 staff. helped to identify groups and indications times (95% CI 1.1 – 1.3) from 2010 to Results from analysis of C/S rates that require further analysis to better 2012, despite the acceptance and imple- using Robson’s classification of the 2 understand the client, practice and policy mentation of national evidence based hospitals revealed differing overall C/S aspects that contribute to C/S rates and guidelines to support vaginal birth after rates (28.45% at Hospital 1 and 16.48% identify potential areas for modification. C/S in the country in 2011. Whether at Hospital 2). While the data collected this is client choice or provider driven were from different years (2010 and 2012 Iryna Mogilevkina, MD, PhD, is unclear. Breech presentation as an respectively) given the relatively short Professor, indication for C/S also increased during interval between the data collection it is Dept Obs & Gyn, this time frame (OR 1.3, 95% CI 1.1-1.6) reasonable to assume that C/S rates at Odessa National Medical University, Odessa, Ukraine as well as foetal distress (OR 1.5, 95% CI each hospital did not change significantly 1.4 – 1.6), multiple pregnancies (OR 3.1, over this period. Further evaluation as Inna Kukuruza, MD, 95% CI 2.4 – 4.1) and risk of infection to whether this is due to different patient Chief Obstetrician & Gynaecologist, transmission (OR 1.9, 95%CI 1.5 – 2.4). populations, practice patterns or both Vinnytsia Oblast State In 2010 roughly 14% and 2012 roughly would be useful. Application of this ­Administration, 10% of all C/S were done for indications system also identified similar groups of Department of Health and Resorts, that were not agreed upon or indicated women who were most likely to be deliv- Deputy Chief of Childbirth, Vinnytsia in the national guidelines (under the ered by C/S. At both hospitals these were Regional Hospital, categories of common disease of mother Group 1 (nulliparous women with single Vinnitsa, Ukraine and perinatal risks). As C/S for maternal cephalic pregnancy, >37 weeks gestation request was not approved as an indica- in spontaneous labour) accounting for Oleg Belousov, MD, Candidate of Medical Science, tion for C/S in the national guidelines, 5.96% of all deliveries at Hospital 1 and Head of Department, we surmise that these 2 categories may in 6.15% of all deliveries at Hospital 2 and Donetsk Regional Center for Mother fact reflect maternal requests for C/S. The Group 5 (all multiparous women with at and Child Care, high rate of C/S due to foetal distress is least one previous uterine scar, with single Donetsk, Ukraine also of particular interest, as this may be cephalic pregnancy, >37 weeks gestation) an area that could be decreased with im- contributing to 6.94% of all deliveries at Svetlana Makarova, MD, plementation of additional foetal surveil- Hospital 1 and 4.01% of all deliveries at Chief Obstetrician & Gynaecologist, lance techniques. At present the capacity Hospital 2. Group 2 (nulliparous women Department of Health, for fetal monitoring in Ukraine is limited with single cephalic pregnancy, >37 Mariupol City Council, 29 and we rely primarily on intermittent weeks gestation who either had labour Head of Women’s Clinic, auscultation. Electronic fetal cardiotoco­ induced or were delivered by CS before Mariupol City Hospital 2, Mariupol, Ukraine graphy (CTG) is rarely used due to lack of labour) was also identified as being more expendable materials (recording paper) likely to be delivered by C/S at Hospital Corresponding author: imogilevkina@ and shortage of personnel CTG interpre- 1 accounting for 5.14% of all deliveries. gmail.com tation skills. Unfortunately, as only ag- These specific groups are deserving of gregated data were collected for our study more detailed analysis to understand the purposes we are unable to correlate the underlying factors associated with their Reference indication of foetal distress for C/S with contribution to the overall C/S rate. 1. Golubchikov N, Rudenko M. Health neonatal status. state of womens’ population of Ukraine When we analyzed C/S categories based Conclusion in 2012. Kiev, 2013. on degrees of urgency we found that Multiple methods can be utilized to try 2. World Health Organization: Appro- 47% of all cases fell into the 1st and 2nd and understand the factors associated priate technology for birth. Lancet categories of urgency and thus required with the C/S rate in Donetsk, Ukraine. 1985, 326(8452):436-7.

No.73No.81 - 20112015