Final Thesis of ZILLO ZIDDA

Joint MPH Program Arba Minch University and Addis Continental Institute of Public Health

MATERNAL COMPLICATION AND ASSOCIATED FACTORS AMONG WOMEN WHO GAVE BIRTH BY CAESARIAN SECTION DELIVERY AT GAMO GOFFA ZONE AND BASKETO SPECIAL WOREDA, SOUTHERN ETHIOPIA

BY: ZILLO ZIDDA (BSC)

A THESIS SUBMITTED TO COLLEGE OF MEDICINE & HEALTH SCIENCES, ARBAMINCH UNIVERSITY, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER’S IN PUBLIC HEALTH

ARBA MINCH, ETHIOPIA June 2015

JOINT MPH PROGRAM ARBA MINCH UNIVERSITY AND ADDIS CONTINENTAL INSTITUTE OF PUBLIC HEALTH

MATERNAL COMPLICATION AND ASSOCIATED FACTORS AMONG WOMEN WHO GAVE BIRTH BY CAESARIAN SECTION DELIVERY AT GAMO GOFFA ZONE AND BASKETO SPECIAL WOREDA, SOUTHERN ETHIOPIA

BY: ZILLO ZIDDA (BSC) ADVISOR: HONELIGN NAHUSENAY, HO, MPH

A THESIS SUBMITTED TO COLLEGE OF MEDICINE & HEALTH SCIENCES, ARBAMINCH UNIVERSITY, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER’S IN PUBLIC HEALTH

ARBA MINCH, ETHIOPIA June 2015

Acknowledgment I would like to express my deepest gratitude and appreciation to my advisor M/r Honelgn Nahusenay for his unreserved, continuous support, generous assistance, constructive criticism, guidance, and valuable comments in each & every steps of this thesis work. Without his support this work has been impossible.

I am greatly thankful to Norwegian Lutheran Mission-Reduction of Maternal Mortality Project for providing me with financial support to conduct this research. And also, I extend my deepest gratitude and appreciation to Professor Bernt Lindtjørn (RMMP advisor) for his relentless support to my thesis and has been generous with his time and knowledge constrictive comments and suggestion in this thesis.

I also acknowledge my wife w/rAbebechAnjuloand my children Baslel, Natinale, Dina and Bereket Zillo. Without your unreserved love, support and courage this thesis would not be possible.

My acknowledgment also goes to Gamo Goffa zone Health Department Arba Minch ,Chencha & Sawula Hospital, & Kemba, Laha, Gezesso, Beto,Selamber health center and Basketo special woreda health office Laska health center for your significant support and contribution in this work.

Table of Contents

Acknowledgment ...... i ABBREVIATIONS ...... v TABLES ...... vi FIGURES ...... vi ABSTRACT ...... vii 1. INTRODUCTION ...... 1 1.1 Back ground of the study ...... 1 1.2 Statement of the Problem ...... 2 1.3 Significance of the study ...... 3 2. LITERATURE REVIEW ...... 4 2.1 Caesarian Delivery ...... 4 2.2 The magnitude of caesarian delivery complications ...... 5 2.3 Factors associated with caesarian delivery complications ...... 5 3. OBJECTIVE ...... 8 4. METHOD ...... 9 4.1 Study Area ...... 9 4.2 Study Design and Period ...... 10 4.3 Study population ...... 10 4.4 Inclusion and Exclusion criteria ...... 10 4.5 Sample size ...... 10 4.6 Sampling Procedure ...... 11 4.7 Data collection procedures ...... 12 4.8 Operational definitions ...... 13 4.9 Study Variables ...... 13 4.10 Data Management /Processing/ ...... 14 4.11 Data Analysis Procedures ...... 14 4.12 Data quality assurance ...... 14 4.13 Ethical consideration ...... 14 5. RESULTS ...... 15 5.1 Socio-demographic characteristics of study participants ...... 15

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5.2 Obstetric characteristics of study participants ...... 15 5.3 The prevalence of maternal complication ...... 17 5.4 Factors associated with maternal complication ...... 18 6. DISCUSSION ...... 23 7. CONCLUSION ...... 26 8. RECOMMENDATION ...... 27 9.REFERENCES ...... Error! Bookmark not defined. ANNEXS ...... 31 Annex 1.Data Retrieving Form ...... 31 Annex 2. Information Sheet (For Hospital and health centers) ...... 35 Annex 3. ...... 37 Annex 4. Consent ...... 39 Annex 5. የስምምነት ቅጽ ...... 40 Declarations ...... 41

ABBREVIATIONS ANC Antenatal Care APH Ante Partum Hemorrhage APGAR Appearance, Pulse, Grimace, Activity, Respiration CI Confidence Interval C/S Cesarean Section DHS Demographic and Health Survey DVT Deep Venous Thrombosis E.C Ethiopian Calendar EMNOC Emergency Obstetric and Neonatal Care FMOH Federal Ministry of Health GA Gestational Age GP General Practitioner HCT Hematocrit HEW Health Extension Worker HIV Human Immunodeficiency Virus Hgb Hemoglobin HO Health Officer IESO Integrated Emergency Surgery Gynecology/Obstetrics MC Maternal Complication MD Medical Doctor MDG Millennium Development Goal MMR Maternal Mortality Rate/ratio NIC National Institute of International Excellence NLM Norwegian Lutheran mission RHB Regional Health Bureau RMMP Reduction of Maternal and infant Mortality Project SNNPR South Nation Nationality Peoples of Republic SPSS Statistical Packages for Social Science SAMM Severe Acute Maternal Morbidity VVF VesicoVaganl Fistula

TABLES Table 1 Sample size calculated by Open Epi version 2.3.1 for second specific objective of the study ...... 11 Table 2 Socio-demographic characteristics of mothers delivered by CS in Gamo Gofa zone and Basketo special woreda, 2012-2014 ...... 15 Table 3 Obstetric characteristics of mothers delivered by CS in Gamo Gofa zone and Basketo special woreda, 2012-2014 ...... 16 Table 4 Indications of CS in Gamo Gofa zone and Basketo special woreda, 2012-2014; ...... 17 Table 5 Proportion and associated factors of maternal Caesarian delivery complication in Gamo Gofa zone and Basketo special woreda, 2012-2014 ...... 19 Table 6 Factors associated with maternal complication of Caesarian delivery in Gamo Gofa zone and Basketo special woreda, 2012-2014 ...... 22

FIGURES Figure 1 Conceptual framework for analyzing the determinants of maternal morbidity and mortality ...... 7 Figure 2 Schematic presentation of the sampling procedure ...... 12 Figure 3 Trend of maternal caesarian delivery complication in Gamo Gofa zone and Basketo special woreda from 2012-2014 ...... 18

ABSTRACT Background : The rate of caesarian section is increasing across the world, its use seems to follow the health care inequity pattern of the world: under use in low income settings, and adequate or even unnecessary use in middle and high income settings. Caesarean sections can cause significant and sometimes permanent complications, disability or death. However, there was shortage of researches on caesarian section delivery complications especially in southern region.

Objective: To assess the prevalence of maternal complication and associated factors of caesarian section delivery at institutions carrying out Comprehensive Emergency Obstetric care in GamoGofa Zone, southern Ethiopia.

Method: A retrospective cross sectional study design was implemented in health facilities which provide comprehensive emergency obstetric care in Gamo Goffa zone Basketo special woreda. The data were abstracted from records of 1653 mothers who gave birth by caesarian section using data retrieving form. The data entered to Epi Info version 3.4.3 were analyzed by SPSS software performing descriptive statistics and bivariate and multivariate logistic regression.

Result: The prevalence of maternal complication of caesarian delivery was 24.6% with 95% CI of (20.5, 28.7).In comparison to <20yrs mothers those in age group 30-34 [AOR=2.14; 95% CI: (1.13, 4.07)] and ≥35 [AOR=2.11; 95% CI: (1.07, 4.17)] had showed 2.14 and 2.11 times higher complication, respectively. Two to three [AOR=0.63; 95% CI: (0.45, 0.88)] and ≥four ANC visits [AOR=0.37;95% CI: (0.26, 0.54)]showed a 37% and 63% protective effect respectively from caesarian delivery complications in comparison to zero visits. In operations performed by MD/ GP [AOR=1.61; 95% CI: (1.02, 2.52)] and at health center [AOR=7.11; 95% CI: (4.98, 10.16)] 1.61 and 7.11 times higher complication was observed in reference to operations done by specialists and at hospitals, respectively.

Conclusion and recommendation: Maternal complication prevalence 24.6% in mothers delivered by caesarian delivery was high. Some of identified factors of maternal caesarian complications were age, ANC visits, operations performed by MD/GP and CS deliveries at health centers. Therefore, it is important to increase the uptake of ANC visits and provide caesarian section service in higher or qualified facilities.

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1. INTRODUCTION 1.1 Back ground of the study

Pregnancy and parturition are events of considerable importance in life cycle of women. Pregnant women may delivery their children via normal spontaneous vaginal delivery or through cesarean section. Parturition or giving birth is physiological; however, it poses a significant risk to the life and well-being of both mother and fetus. Of all deliveries, however approximately 10% are considered as risk, some of these require cesarean section delivery [1]. The majority of cesarean deliveries are performed for condition that might pose a threat to both the mother and the fetus if vaginal delivery occurred. Cesarean section is the most common major surgical procedure in obstetrics and gynecology [1, 2].

Cesarean section first recommended in the late 16th century up on rare and desperate cases and the operation usually fatal. It was mainly performed upon dead on or nearly dying women in the last few weeks of pregnancy in the hope of saving the child [3]. The cesarean section delivery currently estimated more than 20millons occur each year in the world [4]. Rates of caesarean sections in more-developed countries have been rising since 1970, and vary greatly between less- developed countries[5].In United Kingdom women had cesarean section about 20%, united state 29.1% and Brazil highest in the world about 36.4% [6].However in Sub-Saharan Africa the trend of CS ranges from 4.1% to 16.8 % [7]. In Ethiopia the national cesarean section rate was 0.6% which varied from 9.9% in Harari to less than 1% in the large regions of Amhara, Oromiya, Southern Nations, and Tigray. However, the overall institutional rate was 18% which varied between 46% in private for profit sector and 15%in public sector [4].

The World Health Organization considers Cesarean section rates of 5 - 15% to be the optimal range to ensure the best outcome for mothers and children. Maternal morbidity related with cesarean section is 5 to 10 times greater than vaginal delivery. Therefore, rate of cesarean section higher than world health organization recommendation has negative effect for mother and fetus health worldwide. Very low caesarian section rate also means that doctors might not be as proficient in medical procedures, resulting in substandard care [5, 6].

To meet the millennium development goal (MDG)5 by 2015(to decrease MMR to 267/100000 ) , Ethiopia is implementing different strategies to overcome the three delays .Out of this

1 implementation strengthening health facilities , training health professionals at all level including health extension workers (HEW). So that at least each low and mid-level facility will be able to give basic emergency obstetric and neonatal care (CEmONC) at community level.

1.2 Statement of the Problem

Cesarean section is the most common major surgical procedure in sub-Saharan Africa [8]. Over the last decade, there has been a raising rate of cesarean section. This has been a source of major concern to health care providers in many developed and developing countries. The concern stems from the fact that cesarean delivery is associated with a significant higher risk of maternal morbidity and mortality than vaginal delivery [9].

According to studies done in Ethiopia 20% [10] and Lahore 15.5 % [11] overall complication were reported. The main complications reported in Ethiopia were wound infection, sepsis, and endometritis, hemorrhage and wound dehiscence [10]. Cesarean case fatality rate in a study from Malawi for72-hourpostpartum period was 1.06% [2]. Whereas in Ethiopia, 0.6% and 0.74%case fatality rates were reported in different studies [3, 12].

The majority of cesarean deliveries are performed for condition that might pose a threat to both the mother and the fetus if vaginal delivery occurred [13].The risk and safety of cesarean section differ from place to place in respect to structural development of health system. Although caesarean section is now safer than it has never been, it can never be entirely safe and therefore is not an alternate to vaginal delivery [9]. In Africa cesarean deliveries are still performed in harmful conditions for saving the mother and fetus. It has been shown that the risks of surgical complication are greater with emergency compared with elective cesarean section [7].

In Ethiopia three quarter of the cesareans were recorded as emergency [3].In our country where about 80% of the population lives in country side and the number of Hospitals are few and they are concentrated in urban areas, expansion of the practices of the cesarean section in rural health centers can reduce the death of mothers. Since there are poor infrastructures which connects rural households with urban areas in developing countries, like Ethiopia, moving the practice of cesarean section to rural health centers has a paramount importance in reducing maternal death.

With respect to this in Gamo Goffa zone and Basketo special woreda in addition to three hospital six health centers provides obstetrics and gynecological services including CS for rural and urban community in study area. But there is no study done to assess the caesarean section delivery complications and factors. So that this study aims to determine the prevalence of maternal complications of caesarian section and associated factors in Gamo Goffa zone.

1.3 Significance of the study

The findings of this study can be used by the government policy makers to formulate policies. Moreover concerned NGOs and others stake holders can use the result of this study and can help our country in expanding the practices of cesarean section in remote areas. Other researcher’s in this area also can use this paper as an input to carryout love striation on the practice of cesarean section.

2. LITERATURE REVIEW 2.1 Caesarian Delivery

The Millennium Development Goal five (MDG 5) plan was to reduce maternal mortality ratio by three-quarter from 1990 to 2015. In order to reach this goal, there needs to be an expansion in access to comprehensive emergency obstetric care (CEmOC) which includes safe Cesarean section [14, 15]. According to WHO recommendation, proportion of Caesarean births should range between 5 to 15%. The rate of Caesarean Sections below5% seems to be associated with gaps in obstetric care leading to poor health outcomes for mothers and child, whereas rates over 15% don’t seem to improve either maternal or infant health [12, 16].

The rate of CS is increasing across the world; its use seems to follow the health care inequity pattern of the world: underuse in low income settings, and adequate or even unnecessary use in middle and high income settings [17, 18]. The most recent data shows a CS global average of 14.8% with a range from 0.4% in Chad to 42.3% in Iran. In 67 (47.2%) countries analyzed, the CS rate was higher than 15%, in 39 (27.5%) between 5 and 15% and in 36 countries (25.3%) lower than 5%.Among 35 low-income countries in 23 (65.7%) the CS rate was less than 5%; but no country has the rare less than 5% in upper-middle and high income classes. In the Middle East, North Africa and sub-Saharan regions the percentages exceed 15% in only three countries (Iran, South Africa and Egypt) [17].

The trends of CS in Sub-Saharan Africa ranges from 4.1% to 16.8 %, one of the developing countries in Tanzania rate of cesarean section ranges from 29.9% to 35.5% [7, 19, 20]. In Ethiopia national population based survey for cesarean section delivery rate was 0.6%. The regional vary from 0.2% to 9%. The rate of institutional CS delivery was 15% in public, 21.6% in NGO and 46.1% in private [7].The most common indication of cesarean section are repeated cesarean section (previous CS scar), cesarean section on request, dystocia (non-progressive labor), abnormal fetal presentation e.g. breech, transverse, cord presentation and fetal distress [21, 22].

2.2 The magnitude of caesarian delivery complications In 2005, the World Health Organization (WHO) Global Survey on Maternal and Perinatal Health, in a multistage stratified sample obtained from 120 health facilities, comprising 24 geographic regions in 8 countries in Latin America, showed that the rate of cesarean section was associated with adverse outcomes such as postpartum antibiotic treatment and severe maternal morbidity ( admission to ICU, hysterectomy, blood transfusion or hospital stay greater than 7 days) and mortality, even after adjustment for risk factors[23]. In Finland, the prospective study looked at the complication rate among 2,500 women having a cesarean section during a 6 month time frame. The rate of serious complications (serious complications were defined as the following: more than 1,500 ml of blood loss, need for blood transfusion, hysterectomy, needing another surgery, septicemia (a serious infection), blood clots, pulmonary edema, and pneumonia) for all cesarean section was 10.4% [24].

The overall intra-operative complication rate of caesarian sectionin the study conducted in Lahore was 15.5%. In the same study 11% cervical tears,12% tears in body of uterus and extension of uterine incision,9% intra-operative hemorrhage of > 1000 cc and 1.3% bladder injury was observed[11].Cesarean case fatality rate in a study from Malawi for a 72-hourpostpartum period was 1.06% [2]. According to the study done in Jimma, the overall morbidity rate of caesarian delivery was 20%. The causes of morbidity were wound infection (27.1%), sepsis (21.4%), and endometritis (33.3%), hemorrhage (8%) and wound dehiscence (10%) [10]. In Ethiopia, 0.60% and 0.74%case fatality rates were reported in different studies [3, 12].

2.3 Factors associated with caesarian delivery complications According to the prospective study in Finland, women who were having an elective c/s had the lowest rate of serious complication 7.1%. As expected emergency c/s and crash c/s (ultra- emergency) had far higher serious complications rate: 11.7% and 25% respectively. Elective c/s by far has the lowest complication rate, because membranes are typically not ruptured lowering the infection risk. Also some of the serious problems that lead to an emergency c/s, such as severe bleeding, or fetal distress related to infection, will be their very nature of increase the risk of surgical complications [24].

The rate of all major morbidity was higher among General Practitioners’ patients than among specialists’ patients, 3.1% vs. 1.9% [OR= 1.6, 95% CI (1.1, 2.3); P=.009).In addition to this significantly shorter length of hospital stay for specialist surgeons’ patients (P=.006) also noted [25].This contradicts with the study done in Ethiopia [12] and Malawi [2] which showed no association between type of staff and cesarean delivery outcome. In Malawi, there was no significant difference in the number of days required for hospitalization in the two groups of surgeons [2].In Tanzania also no significant difference was noted between assistant medical officers and medical officers in the percentage of fatal outcomes for mother or child in these emergency operations [26]. A national review of cesarean delivery in Ethiopia reported that fetal outcomes werepooreramong women who underwent emergency cesarean (16%) than among women who had an elective cesarean (7%). Fetal outcomes were poorest among women whose indications for cesarean were breech or fetal distress [3]. Serious maternal morbidity increases with increasing number of cesarean deliveries. The majority of this risk is attributable to that associated with placenta accrete and/or the need for hysterectomy. Placenta accrete was present in more than 2% of patients having their fourth and in 6.7% of those undergoing their sixth or greater cesarean delivery. Almost 1 in 40(2.4%) women undergoing their fourth cesarean delivery required hysterectomy (compared with 0.65%of primary cesareans); the risk increased to 1 in 11(9%) having their sixth or greater procedure. In the absence of placenta accrete or the need for hysterectomy, there still was an association between maternal morbidity and increasing cesarean delivery number or all morbidities other than deep venous thrombosis[27].The main risk factors for intra operative complications recorded were low station of fetal head 27% and inexperienced surgeon 62% [11].

Socio demographic factors* ‹ Age ‹ Residence

Facility factors Obstetric history ‹ Referral status ‹ Gravida ‹ Parity ‹ ANC visits ‹ Stay in maternal ‹ Gestational age ‹ Previous CS village ‹ Operation facility Maternal type complication

Indications Operation related ‹ Obstructed labour factors ‹ Previous CS ‹ Type of c/s ‹ Fetal distress ‹ Surgeon (Profession ‹ Suspected uterine rupture of operator) ‹ Pre-eclampsia/Eclampsia ‹ Cord prolapse ‹ APH ‹ Breech in primigravida ‹ Malpresentation

* Socio-demographic factors were related with all other factors and the outcome variable.

Figure 1 Conceptual framework for analyzing the determinants of maternal morbidity and mortality Modified from- [trends in Maternal Health in Ethiopia In-depth Analysis of the EDHS 2000- 2011]

3. OBJECTIVE

3.1 General Objective:

‹ To assess the prevalence of maternal complications and associated factors of caesarian delivery at institutions carrying out Comprehensive Emergency Obstetric care in GamoGofa Zone and Basketo special woreda, southern Ethiopia,2014

3.2 Specific objectives:

• To measure the prevalence of maternal complications of caesarian delivery in GamoGoffa Zoneand Basketo special woreda, southern Ethiopia, 2014

• To determine associated factors of maternal complications of caesarian deliveryinGamoGoffa Zoneand Basketo special woreda, southern Ethiopia, 2014

4. METHOD 4.1 Study Area The study was conducted in GamoGofa zone and Basketo special woreda CEmOC services providing institutions. GamoGofa zone is one of the zones of South Nation Nationality of Peoples of Region which is located 505km and 275km far from Addis Ababa and Hawassa city of SNNPR, respectively. Whereas Basketo special woreda is located 540km from Addis Ababa and 340km far from Hawassa.Based on 2011 projected population of Ethiopia, GamoGofa administration (Urban and rural dwellers) has a total population of 2,019,687 and Basketo special woredahas 71,000 total populations.

There are three functional public hospitals (1 General and 2 primaries), 71 health Centers, 471 Health Posts and more than 120 different level private clinics in GamoGoffa zone and one new district hospitals (under construction), two health centers and 22 Health posts in Basketo special woreda which are actively providing health services. From these health facilities the study was implemented in three hospitals and six health centers which provide comprehensive emergency obstetric care services in the zone.

Arba Minch General Hospital is the only public hospital acting as referral hospital for the zone. It has a total capacity of 200 beds from which obstetrics and gynecology ward accounts for 72 beds. In the maternity ward there are 16 midwife nurses who interchangeably work for the whole 24hrs of a day, with 2 Obstetrics and Gynecology specialists who usually available for difficult cases by on call. Since the hospital is serving as a teaching site, especially for Integrated Obstetric and Emergency surgery program and short term training for CEmOC site, those students are valuably supporting the hospital on overall activities of the ward and working with Arba Minch university for teaching purpose. Chencha and Sawula primary hospital serving primarily comprehensive emergency obstetric care and all in and out patient activity according there levels.

The six health centers which are providing comprehensive emergency obstetric care service for the rural community at remote area are Laska from Basketo special woreda and Laha, Beto, Selamber, Kemba and Gazesso in the Gamo Gofa zone. The site was initiated by Reduction of

Maternal and infant Mortality Project(RMMP) Gamo Gofa zone and Basketo special woreda project from 2008 which is fully supported by Norwegian Lutheran mission (NLM).

4.2 Study Design and Period

A cross sectional study design was implemented using retrospective record review from Dec 03 to 23/2014 in health facilities which provide comprehensive emergency obstetric care.

4.3 Study population

All mothers who delivered by Caesarian Section in comprehensive emergency obstetric care health facility of study areas were source population of the study. From this source population those mothers who delivered by C/S in last three years from 2012 to 2014 constituted the study population.

4.4 Inclusion and Exclusion criteria

Inclusion criteria: All mother who give birth by C/S in selected health facility will be included

Exclusion : Patients whose charts cannot be retrieved and or with incomplete records will be also excluded from the study.

4.5 Sample size

The sample size was calculated manually for the first specific objective using a single population proportion formula and the following assumptions:-

• The overall morbidity rate in caesarian delivery (p) =20% [10]

• Confidence Level = 95%

• Margin of error (d)= 3%,

• Design effect = 2

2 2 • n= (Z α/2 ) *(p*q) = 1.96 *(0.2*0.8) = 684 d2 (0.03) 2

With design effect 2 and 10% contingency , n = 1505

Table 1Sample size calculated by Open Epi version 2.3.1 for second specific objective of the study

Variables Assumptions No. of (Repeated) No. of (Repeated) Profession of CS CS operator Two-sided confidence level 95% 95% 95% Power(% chance of detecting) 80 % 80 % 80 % Ratio of Unexposed to 4 2 1 Exposed Proportion of Unexposed with 1st CS 1st CS Specialists outcome =0.65% =0.65% =1.9% Proportion of Exposed with 6th CS 4th CS Medical officers outcome =9% [25] =2.4% [25] =3.1% [21] Least extreme Odds Ratio to be 15.12 3.74 1.65 detected 307 1833* 5668 Final n (n1 = 62, n2 = (n1 = 611, n2 = (n1 = 2834, n2 = 245) 1222) 2834)

As calculated above larger sample size was needed to show associated factors of caesarian delivery maternal complication, 1833 and 5668. So that in this study all 1653 mothers delivered by caesarian section in Gamo Goffa zone Basketo special woreda from 2012- 2014were studied.

4.6 Sampling Procedure

A two stage sampling method was used to select study units. So that first those health facilities which provides comprehensive emergency obstetric care services were selected and stratified in to two; Hospital and Health center. Then all 1653 mothers who gave birth by caesarian section in both strata (9 health facilities) from 2012 up to 2014 were included in the study.

Stratification

3Hospitals

All 1653 Mothers delivered by CS Health facility with CEmOC 2010-2014

6 HCs

Figure 2 Schematic presentation of the sampling procedure

4.7 Data collection procedures There is a registration format being filled and recorded for obstetrics and gynecology cases in comprehensive emergency obstetric care service providing hospitals and health centers in the zone, which is set by Reducing Maternal Mortality project (RMMP). This registration book and client’s cards were used as a source of data for the study. From this source of data socio- demographic and obstetric histories of mothers were extracted using the data retrieving form which was adopted from emergency cesarean delivery outcome tracing tools and from WHO research format tool(Annex 1).

The data retrieving form have two sections; socio-demographic and clinical characteristics sections. The socio-demographic section mainly inquires age, woreda, area of residence, operators’ profession and year of operation. Whereas, the clinical characteristics section retrieves information like parity, indications of C/S, type of operation, maternal complications and post- operative neonatal outcome.

The data was abstracted by 12 trained midwives as data collectors and the process was supervised by 6 public Health officers and the principal investigator. All data collectors and supervisors were attended a one day training on the data abstraction form and the procedure.

During supervision the collected data was checked for completeness, accuracy, and consistency by the supervisor before accepting from the data collectors.

4.8 Operational definitions

Maternal Caesarian delivery complication: means the mother undergone Caesarian Section suffered at least one of Peri-operative complications or Post-operative complications or stayed greater than 7 days after operation.

Peri-operative complication: includes one of the following; blood vessel injury, bladder injury, cervical tears, urethra injury, uterine tears, intra-operative hemorrhage (Blood loss >1000 cc) and anesthesia failure.

Post-operative complication: includes one of the following; wound infection, fever, need for reoperation, wound dehiscence and maternal death.

4.9 Study Variables Dependent variables:-

V Maternal Caesarian delivery complication status (Complicated or Not )

Independent Variables:-

V Socio-demographic variables: age, area of residence and year of operation V Obstetrics history: Gravida, parity, gestational age V Facility related variables: Referral status, ANC visits, Stay in maternal waiting village, Operation facility type V Indications for CS: Obstructed labour, Previous history of CS, Fetal distress, Suspected uterine rupture, Pre-eclampsia/Eclampsia, Cord prolapse, APH, Breech in primigravida, Malpresentation V Operation related variables: Profession of operator, Type of surgery/CS

4.10 Data Management /Processing/ Data were entered in to Epi Info version 3.4.3. After entry data quality was assured by checking the presence of any error doing descriptive statistics such as frequency and two-by-two tables. Then this cleaned and corrected data for possible errors were exported to SPSS version 20 to do analysis.

4.11 Data Analysis Procedures

The collected quantitative data was analyzed by using SPSS version 20.0. Descriptive analysis was carried out to explore the socio-demographic characteristics; magnitude of maternal complication following cesarean section was calculated. Bivariate analysis was carried out to examine the relationship between the outcome variable and the selected associated obstetric factors. After excluding variables which doesn’t fit for the model using P-value >0.05 in Likelihood ratio test multivariate analysis was performed to identify independently associated factors of maternal CS complication. For both COR and AOR significance was determined at P- value <0.05.

4.12 Data quality assurance To assure the quality of data training was given for data collectors and supervisors on data abstraction tool and procedure. During data abstraction also data retrieving forms were revised by the supervisor for being complete and appropriate. So in daily bases possible corrections were made.

4.13 Ethical consideration

The study was conducted after approval by ethical committee is obtained from Arba Minch University and Addis Continental Institute of Public Health. A legal letter was also written for health facilities where the study was done from Gamo Goffa zone health department, Basketo special woreda health office and RMM Project. Finally after taking permission from the facilities the data abstraction was conducted.

5. RESULTS 5.1 Socio-demographic characteristics of study participants

A total of all 1653 mothers charts were reviewed during the study period on whom Caesarian Section operations were performed in three hospitals and six health centers. The age of the mothers ranges from 16 to 45 years and the majority 29.32 %( 484) and 33.43% (552) were in age group 20-24 and 25-29, respectively. Those mothers who reside in rural area constituted 67.14 %( 1099). Out of 49.79 %( 814) referred mothers 78.010% were sent from health centers (Table 2).

Table 2 Socio-demographic characteristics of mothers delivered by CS in Gamo Gofa zone and Basketo special woreda, 2012-2014

Variables Category Frequency Percent Age of mother <20 118 7.15 (n=1651) 20-24 484 29.32

25-29 552 33.43

30-34 297 17.99 ≥35 200 12.11 Resident area Urban 538 32.86 (n=1637) Rural 1099 67.14 Referral status Not referred 821 50.21 (n=1635) Referred 814 49.79 Mother stayed in maternal No 1536 95.23 village (n=1613) Yes 77 4.77

5.2 Obstetric characteristics of study participants

Slightly above half 51.6% (849) of mothers did not followed ANC. Those mothers operated at term were88.4% (1403). Mothers with obstetric history of 2-4 pregnancies also account for 42.7% (700). Those with previous history of CS, VVF and pregnancy related diseases were 14.8% (244), 0.6% (9) and 1.3% (21), respectively. In performing emergency obstetric operations health officers take the first place by 51.0% (843) and followed by specialists with 32.3% (534) (Table 3).The most common indications of CS among these mothers were

15 obstructed labour 30.67% (507), fetal distress 24.50% (405) and failure to progress 19.84% (328) (Table 4).

Table 3Obstetric characteristics of mothers delivered by CS in Gamo Gofa zone and Basketo special woreda, 2012-2014

Variables Category Frequency Percent Follow ANC? 0 visits 849 51.61 (n=1645) 1 visit 78 4.74 2-3 visits 362 22.01 ≥4 visits 356 21.64 Gravida 1st Pregnancy 686 41.73 (n=1644) 2-4 Pregnancy 700 42.58 ≥5 Pregnancy 258 15.69 Parity No Parity 730 44.43 (n=1643) One Parity 343 20.88 ≥2 Parity 570 34.69 Gestational age Pre-term 105 6.61 (n=1588) Term 1403 88.35 Post-term 80 5.04 Has previous history of No 1406 85.21 CS (n=1650) Yes 244 14.79 Has history of VVF No 1606 99.44 (n=1615) Yes 9 0.56 Had previous No 1629 98.73 Pregnancy related Yes 21 1.27 disease (n=1650) Type of operation CS 1458 88.20 (n=1653) CS + Subtotal Hysterectomy 23 1.39 CS + Total Hysterectomy 35 2.12 CS + Repair of ruptured 23 1.39 Uterus CS + Bilateral tubal ligation 114 6.9 Profession of operator HO + surgical skill training 843 51.00 (n=1653) MD/GP + surgical skill training 188 11.37 Specialist 534 32.30 MSC/IESO 88 5.33 Health facility type Hospital 1357 82.09 (n=1653) Health center 296 17.91

Table 4 Indications of CS in Gamo Gofa zone and Basketo special woreda, 2012-2014;

Indications for CS Frequency Percent

CPD/ Obstructed labour 507 30.67 Previous CS 244 14.76 Fetal distress 405 24.50 Ruptured uterus 94 5.69 APH 92 5.57 Eclampsia/ Pre-eclampsia 60 3.63 Cord prolapse 38 2.30 Failure to progress 328 19.84 Breech in primigravida 86 5.20 Malpresentation 204 12.34 Others 48 2.90 No. of Indications One indication 1225 74.11 per mother Two indications 405 24.50 ≥Three indications 21 1.27 *n=1653

5.3 The prevalence of maternal complication

The prevalence of maternal complication of caesarian delivery was 24.6% (407) with 95% CI of (22.6, 26.7). Peri-operative complication prevalence was 7.08% (117),post-operative complication was 4.97% (82) and mothers who stayed longer than 7 days at health institutions after cesarean section were 19.4%(320). Mainly identified peri-operative complications were intra operative Haemorrhage 6.1% (100) and bladder injury 1.0% (16) while post-operative complications were fever 3.6% (59), wound infection 2.1% (34) and wound dehiscence 0.7% (11). Caesarian case fatality rate in this study was 0.4% (7). The highest maternal caesarian delivery complication (33.9%) among mother whom give in last three years in Basketo special woreda and Gamo Gofa zone the trend was observed in 2012 (Figure 3).

The highest complications were recorded among mothers of age group 30-34 (32.7%) and ≥35 (39.5%), rural areas (28.9%) and stayed in maternal villages (39.0%). A decrease from 30.0% in zero visits to 16.3% in ≥4 ANC visits was observed. Regarding their obstetric history mothers with ≥5 pregnancies (41.9%) and ≥2 deliveries (36.1%) suffered a lot. The complication was also

17 higher among mothers whose indication for surgery was suspected uterine rupture (63.8%), ante partum hemorrhage (48.9%) and cord prolapsed (36.8%). Having ≥3 indications also showed 47.8% complication. Moreover elective CS (20.4%), CS performed by specialists (17.4%) and at hospital level (18.3%) came up with lower complications (Table 5).

40.00% (170/502) 35.00%

30.00% (136/611) 25.00% (101/540) 20.00%

15.00%

10.00%

5.00%

0.00% 2012 2013 2014 * 33.90% 18.70% 22.30%

Figure 3 Trend of maternal caesarian delivery complication in Gamo Gofa zone and Basketo special woreda from 2012-2014 5.4 Factors associated with maternal complication

Binary analysis

Binary logistic regression analysis was conducted for factors that were identified as possible factors that could affect maternal complication secondary to CS. During Bivariate analysis from socio-demographic variables in age 30-34 and ≥35yrs mothers 2.88 [COR=2.88; 95% CI:(1.63, 5.09)] and 3.88 [COR=3.88; 95% CI: (2.16, 6.98)] times higher complication was observed respectively in reference to <20yrs mothers who delivered by CS. The complication also in mothers who were from rural resident 2.14 times [COR= 2.14; 95% CI: (1.64, 2.79)] and stayed in maternal waiting village 2 times [COR= 2.00; 95% CI: (1.25, 3.22)] higher than those from urban residents and not stayed respectively.

From obstetric characteristics having 2-3 and ≥4 ANC visits showed 41% [COR= 0.59; 95% CI: (0.44, 0.80)] and 55% [COR= 0.45; 95% CI: (0.33, 0.62)] protective effect from maternal caesarian delivery complications, respectively in comparison to mothers who have zero ANC visit.Pre-term and term gestations also associated with 4.31 [COR= 4.31; 95% CI: (1.99, 9.31)] and 2.32 [COR= 2.32; 95% CI: (1.18, 4.55)] times higher complications than post-term gestation, respectively. In comparison to mothers with first pregnancy 1.61 [COR= 1.61; 95% CI: (1.24, 2.09)]and 3.40 [COR= 3.40; 95% CI: (2.48, 4.66)] times higher complication were seen in mothers with 2-4 and ≥5 pregnancies, respectively. In mothers with ≥2 parity also 2.71 [COR= 2.71; 95% CI: (2.10, 3.51)] times higher complication was observed than mothers with no parity.

Mothers operated by indications of fetal distress [COR= 0.75; 95% CI: (0.57, 0.98)], suspected uterine rupture [COR= 6.16; 95% CI: (3.98, 9.55)], APH [COR= 3.17; 95% CI: (2.07, 4.85)], failure to progress [COR= 0.62; 95% CI: (0.45, 0.84)] and ≥3 indications per mother [COR= 2.73; 95% CI: (1.19, 6.25)] also indicated an association. In comparison to CS only, other types of operations were significantly associated with high maternal complications. in operations performed by MD/ GP [COR=1.63; 95% CI: (1.09, 2.42)]and at health center [COR=5.10;95% CI: (3.90, 6.65)] also 1.63 and 5.10 times higher complication was observed in reference to operations done by specialists and at hospitals, respectively (Table 5).

Table 5 Proportion and associated factors of maternal Caesarian delivery complication in Gamo Gofa zone and Basketo special woreda, 2012-2014

Maternal CS Complication Status Variables category COR (95% CI) Yes Not N (%) N <20 17 (14.41) 101 1.00 20-24 91 (18.80) 393 1.38 (0.78, 2.41) Age of Mother 25-29 123 (22.28) 429 1.70 (0.98, 2.96) 30-34 97 ( 32.66 ) 200 2.88 (1.63, 5.09)* ≥35 79 ( 39.50) 121 3.88 (2.16, 6.98)* Urban 86 (15.99) 452 1.00 Resident area Rural 318 ( 28.94 ) 781 2.14 (1.64, 2.79)* Mother stayed in Yes 30 ( 38.96 ) 47 2.00 (1.25, 3.22)*

maternal village No 371 (24.15) 1165 1.00 No visits 257 (30.27) 592 1.00 1 visit 16 (20.51) 62 0.59 (0.34, 1.05) No. of ANC visits 2&3 visits 74 (20.44) 288 0.59 (0.44, 0.80)* ≥4 visit 58 (16.29) 298 0.45 (0.33, 0.62)* Pre-term 40 (38.10) 65 4.31 (1.99, 9.31)* Gestation age Term 349 (24.88) 1054 2.32 (1.18, 4.55)* Post-term 10 (12.50) 70 1.00 1st Pregnancy 120 (17.49) 566 1.00 Gravida 2-4 Pregnancy 178 (25.43) 522 1.61 (1.24, 2.09)* ≥5 Pregnancy 108 (41.86) 150 3.40 (2.48, 4.66)* No Parity 126 (17.26) 604 1.00 Parity One Parity 74 (21.57) 269 1.32 (0.96, 1.82) ≥2 Parity 206 (36.14) 364 2.71 (2.10, 3.51)* Indications for CS Yes 84 (20.74) 321 0.75 (0.57, 0.98)* Fetal distress No 323 (25.88) 925 1.00 Yes 60 (63.83) 34 6.16 (3.98, 9.55)* Ruptured uterus No 347 (22.26) 1212 1.00 Yes 45 (48.91) 47 3.17 (2.07, 4.85)* APH No 362 (23.19) 1199 1.00 Yes 59 (17.99) 269 0.62 (0.45, 0.84)* Failure to progress No 348 (26.26) 977 1.00 One Indication 308 (25.14) 917 1.00 No. of Indications per Two Indications 88 (21.73) 317 0.83 (0.63, 1.08) mother ≥3 Indications 11 (47.83) 12 2.73 (1.19, 6.25)* Specialist 93 (17.42) 441 1.00 Profession MSC/IESO 17 (19.32) 71 1.14 (0.64, 2.02) of operator MD/GP+ surgical skill training 48 (25.53) 140 1.63 (1.09, 2.42)* HO + surgical skill training 249 (29.54) 594 1.99 (1.52, 2.60)* CS 298 (20.44) 1160 1.00 CS + Subtotal Hysterectomy 13 (56.52) 10 5.06 (2.20, 11.65)* Type of CS + Total Hysterectomy 30 (85.71) 5 23.36 (8.99, 60.71)* operation CS + Repair of ruptured Uterus 14 (60.87) 9 6.06 (2.60, 14.13)* CS + Bilateral tubal ligation 52 (45.61) 62 3.27 (2.21, 4.82)* Hospital 249 (18.35) 1108 1.00 Health facility type Health center 158 (53.38) 138 5.10 (3.90, 6.65)* *Statistically significant

Multivariable analysis

After excluding variables which doesn’t fit for the model using P-value >0.05 in Likelihood ratio test multivariate analysis was performed. In comparison to <20yrs mothers those in age group 30-34[AOR=2.14; 95% CI: (1.13, 4.07)] and ≥35 [AOR=2.11; 95% CI: (1.07, 4.17)] had showed 2.14 and 2.11 times higher complication, respectively. Mothers Stayed in maternity waiting village [AOR=2.10; 95% CI: (1.23, 3.60)] also showed 2.10 times complication than those who were not. Two to three[AOR=0.63;95% CI: (0.45, 0.88)] and ≥four ANC visits[AOR=0.37;95% CI: (0.26, 0.54)] had a 37% and 63% protective effect respectively from caesarian delivery complications in comparison to zero visits (Table 6).

Another difference in maternal complication was observed among mothers with pre-term gestation [AOR=2.98 (1.24, 7.12)] which was 3 times higher than that of post-term mothers. Maternal CS complication in mothers with APH indication was 2.26 times higher[AOR=2.26; 95% CI: (1.37, 3.71)].Mothers under gone CS with subtotal hysterectomy [AOR= 5.66; 95% CI: (1.78, 18.04)], CS with total hysterectomy [AOR= 46.51; 95% CI: (13.31, 162.44)], CS with ruptured uterus repair [AOR= 4.59; 95% CI: (1.76, 11.94)] and CS with bilateral tubal ligation [AOR= 2.43; 95% CI: (1.51, 3.92)] operations were strongly associated with high maternal complications than mothers operated CS only. Furthermore, in operations performed by MD/ GP [AOR=1.61; 95% CI: (1.02, 2.52)]and at health center [AOR=7.11;95% CI: (4.98, 10.16)] also 1.61and 7.11 times higher complication was observed in reference to operations done by specialists and at hospitals, respectively(Table 6).

Table 6Factors associated with maternal complication of Caesarian delivery in Gamo Gofa zone and Basketo special woreda, 2012-2014

Maternal CS Complication Variables Category Status COR (95% CI) AOR (95% CI) Yes Not Age of Mother <20 17 101 1.00 1.00 20-24 91 393 1.38 (0.78, 2.41) 1.37 (0.74, 2.55) 25-29 123 429 1.70 (0.98, 2.96) 1.77 (0.96, 3.26) 30-34 97 200 2.88 (1.63, 5.09)* 2.14 (1.13, 4.07)* ≥35 79 121 3.88 (2.16, 6.98)* 2.11 (1.07, 4.17)* Mother stayed in Yes 30 47 2.00 (1.25, 3.22)* 2.10 (1.23, 3.60)* maternal village No 371 1165 1.00 1.00 No. of ANC visits No visits 257 592 1.00 1.00 1 visit 16 62 0.59 (0.34, 1.05) 0.96 (0.51, 1.81) 2&3 visits 74 288 0.59 (0.44, 0.80)* 0.63 (0.45, 0.88)* ≥4 visit 58 298 0.45 (0.33, 0.62)* 0.37 (0.26, 0.54)* Gestation Pre-term 40 65 4.31 (1.99, 9.31)* 2.98 (1.24, 7.12)* Term 349 1054 2.32 (1.18, 4.55)* 1.60 (0.75, 3.40) Post-term 10 70 1.00 1.00 Have APH Yes 45 47 3.17 (2.07, 4.85)* 2.26 (1.37, 3.71)* indication No 362 1199 1.00 1.00 Type of CS 298 1160 1.00 1.00 operation CS + Subtotal Hysterectomy 13 10 5.06 (2.20, 11.65)* 5.66 (1.78, 18.04)* CS + Total Hysterectomy 30 5 23.36 (8.99, 60.71)* 46.51 (13.31, 162.44)* CS + Repair of ruptured 14 9 6.06 (2.60, 14.13)* 4.59 (1.76, 11.94)* Uterus CS + Bilateral tubal ligation 52 62 3.27 (2.21, 4.82)* 2.43 (1.51, 3.92)* Profession Specialist 93 441 1.00 1.00 of MSC/IESO 17 71 1.14 (0.64, 2.02) 0.64 (0.31, 1.32) operator MD/GP + surgical skill 48 140 1.63 (1.09, 2.42)* 1.61(1.02, 2.52)* training HO + surgical skill training 249 594 1.99 (1.52, 2.60)* 0.90 (0.63, 1.29) Health facility Hospital 249 1108 1.00 1.00 type Health center 158 138 5.10 (3.90, 6.65)* 7.11 (4.98, 10.16)* *Statistically significant

6. DISCUSSION

In this study, the all over that maternal complication prevalence secondary to caesarian delivery was found 24.6 %( 407). Factors which might have had an association with maternal complications also assessed by bivariate and multivariate analysis. With respect to this age, staying in maternal village, preterm gestation, APH indication and operation done by MD/GP and at health center were associated with higher maternal complication. However 2-3 and ≥4 ANC visits showed protective effect.

Maternal complication prevalence 24.6% indicated in this study was slightly higher than result found in Jimma 20.0% [10] and Lahore 15.5% [11]. Mainly identified peri-operative complications were intra operative Haemorrhage 6.1% (100/1653) and bladder injury 1.0% (16/1653) while post-operative complications were fever 3.6% (59/1651), wound infection 2.1% (34/1651) and wound dehiscence 0.7% (11/1651). Caesarian case fatality rate was 0.4% (7/1651) which is low in comparison to previous results, 0.6% and 0.7% in Ethiopia [3, 12] and 1.1% in Malawi [15].

Compared to <20 years mothers delivered by CS in 30-34 and ≥35 years mothers 2.14 and 2.11 times higher complication were indicated, respectively. Advanced maternal age can bring some pregnancy risks like high blood pressure, gestational diabetes, preterm babies, still births, low birth weight, C-section, congenital birth defects, and genetic birth defects [30]. The reason for age specific high maternal complications in our study may be due to their advanced age related medical conditions including obstetric history.

In both Gamo Gofa zone and Basketo special woreda, all three hospitals and five health centers which are included in this study have maternal waiting villages where mothers live until they give birth. In our study those mothers stayed in these villages were statistically associated with 2.10 times higher caesarian delivery complications than those who were not stayed. The reason may be those stayed in maternal villages were identified high risk mothers.

In preterm mothers also 3 times higher complication was observed in reference to post-term ones. However there is no difference between term and post-term mothers who gave birth by caesarian section. Having 2-3 and ≥4 ANC visits showed a 37% and 63% protective effect

23 respectively from caesarian delivery complications in comparison to zero visits. Whereas, there is no difference in maternal complications between mothers who have one ANC visit and zero visits. This could be explained by appropriate birth preparedness, early risk detection and referral.

From indications of CS, mothers with APH showed a statistical significant association with 2.26 times higher complications. The incidence of APH occurs in 2% to 5% of all pregnancies. In the non-pregnant state; the uterus receives approximately 1% of cardiac output. In the third trimester, it receives approximately 20%. Our result could be explained by uterine bleeding in the third trimester can be massive and can quickly result in a hemodynamically unstable woman. Furthermore advanced maternal age (>35 years)is a cause for APH [28].

Mothers under gone CS with subtotal hysterectomy, CS with total hysterectomy, CS with ruptured uterus repair and CS with bilateral tubal ligation operations were significantly associated with 5.66, 46.51, 4.59 and 2.43 times higher maternal complications, respectively than mothers operated CS only. This may be resulted due to the complexity of the procedures that potentially prone for injury to viscera or other structures and high time investing procedure. Beyond this those complex procedures takes more time and increases exposure to contamination and prone to develop infection.

CS operations performed by MD/GP indicated statistically 1.61 times higher maternal complications than that of specialists. This finding was supported by the result of previous study which was conducted to compare maternal outcomes of cesarean sections performed by GPs with the outcomes of those performed by specialists [25]. However, other studies in Ethiopia [12], Malawi [2] and Tanzania [26] reported no difference in maternal complications by type of staff/ operator.

We also found significantly 7.11 times higher maternal complications in caesarian operations conducted at health centers than hospitals. Lack of facilities and/or capacity to properly conduct safe surgery and treat surgical complications at health centers setting could be the reason [29].

Strengths and limitations of the study

Strengths

This study addresses both the peri-operative and post-operative maternal complication. Other similar studies only focus on either of the two. Thus this study provides comprehensive evidence both intra-operative and post-operative maternal complication.

Limitations

V The shortage of studies with similar methodological approach and on subjects with similar background characteristics to compare results. V There is no uniform definition of maternal complications following cesarean section so that comparison of the finding may be difficult. V Due to the secondary data utilized some variables mainly socio-economic characteristics of mothers were not observed. If they were included in this study, they may affect the outcome.

7. CONCLUSION

The findings of this study have shown that overall maternal complication level was 24.6% in mothers delivered by caesarian delivery in Gamo Gofa zone and Basketo special woreda. Socio- demographic factors that have associated with high maternal caesarian delivery complications were age ≥30 (30-34 and ≥35 years) and staying in maternal waiting villages. Other independently associated factors were ANC visits ≥2 (2-3 and ≥4 visits), preterm gestation, having Ante Partum Haemorrhage (APH),CS operations with other procedures such as subtotal/ total hysterectomy, ruptured uterine repair and bilateral tubal ligation, operations performed by MD/GP and CS deliveries at health centers.

8. RECOMMENDATION

Based on the findings of the present study, the following recommendations are forwarded:-

V Provide caesarian delivery service for mothers with identified predictors of maternal complications mainly age 30-34 and ≥35 years, preterm gestation, Ante Partum Haemorrhage (APH) and CS operations with other procedures at higher or qualified facilities with precautions. V Strength the services and work on increasing the uptake of ≥2 ANC visits. V Provide refreshment trainings to improve the skill of operators especially MD/GP. V Improve health centers’ facilities and capacity of providing CEmOC services.

9. REFERENCES 1. Cunningham GF, Kenneth LJ, Bloom SL, John HC, Larry GC, Wenstrom KD. 2005. Williams Obstetrics 22nd edition, New York Chicago: McGraw-Hill, 495-520. 2. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergström S. Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human Resources for Health. 2007; 5:17. doi:10.1186/1478-4491-5-17 3. Fesseha N, Getachew A, Hiluf M, Gebrehiwot Y, Bailey P. A national review of Cesarean delivery in Ethiopia. International Journal of Gynecology and Obstetrics. 2011. 115(1): (106–111), PMID: 21872239. 4. Gutema H, Shimye A. Caesarean Section and Associated Factors at MizanAman General Hospital, Southwest Ethiopia. Journal of Gynecology and Obstetrics. 2014. 2(3): 37-41. doi: 10.11648/j.jgo.20140203.12 5. Dumont A, Bernis L, Hélène M, Colle B, Bréart G, et.al (2001)for the MOMA study group* Caesarean section rate for maternal indication in sub-Saharan Africa: Lancet 2001; 358: 1328–334

6. Geidam AD, Audu BM, Kawuwa BM, Obed JY. Rising trend and indications of cesarean section. Annals of African Medicine2009. Vol.8, No2, 2009; 127-132 7. Choudhury AP, Dawson AJ. 2009. Trends in indications for cesarean sections over 7 years in a Welsh district general hospital. Journal of Obstetrics and Gynaecology, Vol. 29, No 8, (November 2009), pp. (714-717), PMID: 19821664. 8. Fenton P M, Whitty CJM, Reynolds F. Caesarean section in Malawi. Prospective study of early maternal and perinantal mortality. Brit Med J 2003; 27: 587-598. 9. Ezechi CO, Fasubaa OB, Kalu B., Nwokoro C, Obiesie LO. Caesarean delivery: Why the aersion? Trop J Obstet Gynaecol. 2004; 21: 164-167. 10. Ali Y. Analysis of caesarean delivery in Jimma Hospital, south-western Ethiopia. 11. Nisa M, Sadia,Riffat Nawaz. Intra-operative Maternal Complications of Emergency Cesarean Section Done in Advanced Labor . Annals vol 19, issue 1, Jan. – Mar. 2013

12. Gessessew A, Barnabas G, Prata N, Weidert K. Task shifting and sharing in Tigray Ethiopia to Comprehensive emergency obstetric care, Tigray Region Ethiopia. International journal of gynecology and obstetrics. 2010; 113(2011): 28-23 13. Gabbe, S. G., Neibyl, J. R., Simpson, J. L. Obstetrics: normal and problem pregnancies.5th ed Philadelphia: Churchill Livingstone publishing; 2002. 14. Berhan Y, Abdela A. Emergency obstetric performance with emphasis on operative delivery outcome: Does it reflect the quality of care? Ethiopian Journal of Health Development. 2004; 18(2 ) 15. Tadesse E, Adane M, Abiyou M. 1996. Caesarean section deliveries at TikurAnbessa Teaching Hospital, Ethiopia. East Afr Med Jor. vol. 73, No.9, pp:619-22 16. Chu K, Cortier H, Maldonado F, Mashant T, Ford N, et.al. (2012) Cesarean Section Rates and Indications in Sub Saharan Africa: A Multi Country Study from MedecinssansFrontieres; PLoSONE :7(9): e44484, doi:10.1371/journal.pone.0044484

17. Howell S., Johnston T., MacLeod S.-L. 2009. Trends and determinants of cesarean sections births in Queensland, 1997-2006. Australian and New Zealand Journal of Obstetrics andGynaecology, (2009), Vol. 49, No 6, pp. (606-611). PMID: 20070708. 18. Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report (2010) Background Paper, No 30

19. Zizza A, Tinelli A, Malvasi2, E. Barbone3, M. Stark4, A. 2011. Caesarean Section in the World: a new ecological approach. 20. Shah A, .F.Bukola b, M.James Machoki c, A.Faouzi d, N.Idi e,W.Jean-Joséf,M. Kidza g, N.Isilda h, N.Rosemary i,K.Marius j, Matthews Mathai Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynecol Obstet. 2009; doi:10.1016/j.ijgo.2009.08.013. 21. Emma L, Christian M, Edmund F, Jessica L. Contributing Indications to the Rising Cesarean Delivery Rate. Obstet Gynecol. 2011 July ; 118(1): 29–38. doi:10.1097/AOG.0b013e31821e5f65

22. Stanton C, Ronsmans C. 2008. Recommendations for routine reporting on indications for cesarean delivery in developing countries. Birth 35: 204–211. doi: 10.1111/j.1523- 536X.2008.00241.x 23. Villar J, Valladares E, Wojdyla D; WHO. 2005. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. The Lancet. 2006; 367(9525): 1819–1829 24. Pallasmaa N, Ekbland U, Aitokallio-Tallberq A, Raudaskoski Cesarean delivery inFinland: maternal complication and risk factors. Acta obstet Gynecolscand 2010; 89(7): 896-902. 25. Aubrey K, Newbery S, Kelly L, Weaver B, Wilson S. Maternal outcomes of cesarean sections.CanFam Physician. 2007; 53: 2132-2138 26. McCord C, Mbaruku G, Pereira C, Nzabuhakwa C, BergstromS. The Quality of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals. Health Affairs. 2009; 28(5): w876-w885 27. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et.al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries.Obstet Gynecol. 2006; 107: 1226–32 28. Adrien L, et al. CHAPTER 5: ANTEPARTUM HEMORRHAGE. FOURTH EDITION OF THE ALARM INTERNATIONAL PROGRAM. 2000 29. WHO Department of Reproductive Health and Research. WHO Statement on Caesarean Section Rates. 2015 30. Giri A, Srivastav VR, Suwal A, Tuladhar AS. Advanced maternal age and obstetric outcome. Nepal Med Coll J 2012; 15(2): 87-90

ANNEXS Annex 1.Data Retrieving Form Maternal complication and associated factors of Caesarian delivery in Gamo Gofa Zoneand Basketo special woreda, Southern Ethiopia

Part Zero: General Information

S.No Question Possible answers Code Skip 01 Form ID number , 02 Date of Data collection , 03 Name of data collector: 04 Name of supervisor: 05 Health facility Arba Minch Hosp. 1 ChenchaHosp. 2 SaulaHosp. 3 BetoHC 4 Selamber HC 5 KembaHC 6 GezzesoHC 7 Laska HC 8 Laha HC 9 06 Patient card number ,------

Part one: Socio-demographic

SUN Question Possible Response Code Skipping 101 Age ,

102 Name of kebele 103 Area of residence Urban 1 Rural 2 104 Referral status referred(yes) 1 If yes Go to105 Not referred(No) 2 105 Referred from Health center 1 Health post 2 Hospital 3 Private Health institution 4 106 Stayed in maternal village? Yes 1 No 2 107 Profession of Operator HO 1 MD/GP 2 Specialist 3 IESO 4 108 Date of Operation / / ,[dd/mm/yyyy]

Part Two: Clinical Characteristics

S.N Question Possible response Code Skipping 201 Parity Gravida ------Para ------202 History of ANC follows up ? Yes 1 No 2 Number of ANC visit ------

203 History of pregnancy Gestational Age ------

204 Previous History of C/S Yes 1 No 2 How many times previous C/S ------Previous History of VVF Yes 1 No 2 Previous History of Yes 1 pregnancy related diseases No 2 Which type of disease ------specify 205 Indication for Surgery CPD or obstructed labour 1 Previous caesarean section 2 Fetal distress 3 Suspected ruptured uterus 4 Ante-partumhemorrhage 5 Eclampsia 6 Cord prolapsed 7 Failure to progress 8 Breech in primigravida 9 Mal-presentation 10 Other specify______11 206 Type of Operation C/S 1 C/S + subtotal hysterectomy 2 C/S + total hysterectomy 3 C/S + repair of uteri rupture 4 C/S + bilateral tubal ligation 5 Other specify______6 207 Length of stay ,[days] 208 Peri-operative Yes 1 If no Go to Complication? No 2 ‰210

209 If yes, which Bladder injury 1 complication ? Blood Vessels 2 Cervical tear 3 Intra-operative hemorrhage (blood 4 loss>1000cc)

Due to anesthesia failure 5 Other specify______6 210 Postoperative Maternal Yes 1 If no Go complication No 2 to ‰212 211 If yes, which Wound infection 1 complication ? Fever 2 Need for re-operation 3 Wound dehiscence 4 Maternal death 5 Other specify______6 212 Was the child resuscitated ? 1 If yes Go Yes to ‰213 No 2 213 Postoperative neonatal Alive and well 1 outcome Alive and unwell 2 Stillbirth 3 Early neonatal death 4

Name of data collector: Signature:,

Name of supervisor: Signature:,

Annex 2. Information Sheet (For Hospital and health centers) Title of the Research Project: Maternal complication and associated factors of Caesarian delivery in Gamo Goffa zone and Basketo special woreda

Name of Principal Investigator: Zillo Zidda

Name of the Organization: AMU Department of Public Health College of Medicine and Health Sciences and Addis Continental Institute of Public Health

Name of the Sponsor: RMM-GG Norwegian Lutheran mission

Introduction: I am a student at Arba Minch University Department of Public Health College of Medicine and Health Sciences in collaboration with Addis Continental Institute of Public Health (ACIPH) in Masters of Public Health (MPH). As part of this degree I am undertaking a research project on maternal complication and associated factors of Caesarian delivery in Gamo Goffa zone and Basketo special woreda leading to a thesis.

Purpose of the Research Project: The aim of this study is to assess the maternal complication and associated factors of Caesarian delivery in Gamo-Goffa zone and Basketo special woreda, southern Ethiopia. And also the information gained from this research will be used to make recommendations to improve health service delivery.

Procedure: For this study CEmOC site, three Hospitals and six health centers (Arba Minch, Chencha and Sawla Hospitals, and Kemba, Beto, Selamber, Gezesso, Lask and Laha Health Centers) in Gamo Gafo zone and Basketo special woreda were selected. From these hospitals and health centers all necessary information will be abstracted by data retrieving form from delivery registration log books and client cards.

Risk and /or Discomfort: The study will be conducted by abstracting information from hospitals and health centers’ delivery registration log books and client cards, so it will not impose any harm on patients.

Benefits: The study has no direct benefit for those caesarian section delivery clients whose information is abstracted but indirectly beneficial if the result utilized by planners. Gamo Goffa

35 zone health department, and Basketo special woreda health office and selected three hospitals and six health centers will get the result of the study.

Confidentiality: During data abstraction the patients name will not be taken, instead they will be identified by their card number in the registration book. Therefore it will not be possible for them to be identified personally. All abstraction forms collected will be kept confidential and destroyed two years after the end of the project. The information abstracted will be used only for research purpose.

The thesis will be submitted for marking to Arba Minch University Department of Public Health College of Medicine and Health Sciences and Addis Continental Institute of Public Health (ACIPH) and deposited in the University Library. It is intended that one or more articles will be submitted for publication in scholarly journals.

Right to Refusal or Withdraw: Approval of the manager of the hospitals and head of health centers will be required to start data abstraction. Therefore if you agree please sign the consent form to express your approval. During data abstraction also you can supervise and stop the process at any time you feel necessary.

Person to contact: If you have any further questions or would like to receive further information about the project, please contact:

1. Name: (Supervisor), Cell Phone: +251 2. Name: Zillo Zidda (Principal Investigator), Cell Phone: +251 9168776456 Email: [email protected] 3. Name: Honelegn Nahusenay (Advisor), E-mail: [email protected] Cell Phone: + 251912138221

Thank you for reading the Information Sheet, and asking any questions that you might have had.

Date: DD/MM/YYYY

Annex 3. የምርምሩ ርዕስ፡ በቀዶ ጥገና ወሊድና ድህረ ወሊድ ጊዜ እናቶች ያጋጠ Nˆቸው ችግሮች እና ተያያዥ ምክንያቶች በጋሞ ጎፋ ዞን እና ባስኬቶ ልዩ ወረዳ፤ ደቡብ ኢትዮጲያ

የዋናየዋናየዋና ተመራማሪ ስም፡ስም፡ስም፡ ዚሎ ዚዳ

የድርጅቱ ስም፡ስም፡ስም፡ የአርባ ምንጭ ዩኒቨርሲቲ ህክምናና ጤና ሳይንስ ኮልጅ ከአዲስ ኮንቲነንታል የህብረተሰብ ጤና አጠባበቅ እንስቲቲዩት ጋር በመተባበር

ለምርምሩ የገንዘብ ድጋፍድጋፍድጋፍ ያደረገው፡ያደረገው፡በኖርዌጂያን ሉትራንሚሽን(RMMP GG)

መግቢያ፡ እኔ የዚህ የምርምር ፅሁፍ አዘጋጅ ከላይ በተገለጸውዩኒቨርሲቲየሁለተኛድግሪዬንበህብረተሰብጤናአጠባበቅ እየተማርኩእገኛለሁ፡፡ የማዘጋጀው የምርምር ጽሁፍም በጋሞጎፋ ዞንእና ባስኬቶልዩወረዳ፤ በቀዶ ጥገና ወሊድና ድህረወሊድጊዜእናቶችያጋጠ Nˆቸው ችግሮችእናተያያዥ ምክንያቶችን የተመለከተይሆናል፡፡

የጥናቱ አላማ፡ የዚህጥናትዋናአላማበጋሞ ጎፋ ዞን እና ባስኬቶ ልዩ ወረዳ ባሉእናቶች ላይ በቀዶጥገናወሊድና ድህረወሊድጊዜያጋጠሙ ችግሮች ሥርጭት እናተያያዥ ምክንያቶችን መለየትነው፡፡ ከጥናቱ የሚገኘው ውጤት ለእናቶች የሚሰጠውን የጤና አገልግሎት ለማሻሻል ጭምር ይውላል፡፡

አተገባበር፡ ጥናቱን ከዳር ለማድረስ በጋሞጎፋዞንእናባስኬቶልዩ ወረዳ የCEmOC ሳይት የሆኑ ሦስት ሆስፒታሎችእና ስድስት ጤናጣቢያዎች (አርባምንጭሆ/ል፤ ጨንቻ ሆ/ል፤ ሳውላ ሆ/ል፤ ካምባ ጤ/ጣ፤ ገዜሶጤ/ጣ፤ ባቶጤ/ጣ፤ ሰላምበርጤ/ጣ፤ ላስካጤ/ጣቢያናላሃጤ/ጣ) ተመርጠዋል፡፡ በመሆኑምባለፉትአምስትዓመታትከሰኔ 20/2001ዓ.ም እስከሰኔ 20/2006ዓ.ም ድረስ በነዚህ ጤና ተቋማት በቀዶ ጥገና የወሊድ አገልግሎት ሲያገኙ ስለነበሩትወላዶችበወላድመዝገቡላይየተያዘውመረጃበተዘጋጀውየመረጃመሰብሰቢያቅጽአማካኝነትይሰበሰባል፡፡

ሊገጥም የሚችል ችግርችግርችግር/ችግር / አለመመቸት፡

ጥቅሞች፡ በጥናቱውስጥየሚካተቱትበቀዶጥገናየወሊድአገልግሎትያገኑእናቶችምንምዓይነትቀጥተኛጥቅምአያገኙም፡፡ ነገርግንጥናቱከተጠናቀቀበኃላየጥናቱዉጤትንመሰረትአድርጎበሚዘጋጁእቅዶችበተዘዋዋሪተጠቃሚሊሆኑይችላሉ፡፡ የጋሞጎፋዞንጤናመምሪያ፤ የባስኬቶልዩወረዳጤና ጽ/ ቤትናየተመረጡጤናተቋማትየጥናቱዉጤትእንዲደርሳቸውይሆናል፡፡

ሚስጢራዊነት፡ ታካሚዎችበግለሰብደረጃእንዳይለዩሲባለከመዝገቦቹላይመረጃውበሚሰበሰብበትወቅትየታካሚዎቹ

የመከልከልየመከልከል// የማቁዋረጥ መብት፡መብት፡መረጃውንለመሰብሰብ የሆስፒታሎቹ ስራ አስኪያጅና የጤና ጣቢዎቹ ኃላፊፈቃድያስፈልጋል፡፡ ስለሆነምየምርምሩንአላማተረድተውከፈቀዱተያይዞያለውየስምምነትቅጽላይበመፈረም መፍቀዶን ያረጋግጡ፡፡ መረጃውበሚሰበሰብበትወቅትሂደቱንበቅርበትመከታተልናአስፈላጊሆኖሲያገኙየማስቆምመብቶየተረጋገጠ መሆኑን ልንገልጽሎ እንወዳለን፡፡

ሊያገኙዋቸው የሚችሉ ሰዎች፡ሰዎች፡ስለምርምሩጥያቄካሎትወይምተጨማሪማብራሪያካስፈለጎትየሚከተሉትንአድራሻዎች ይጠቀሙ፡፡

1. ስም : (ተቆጣጣሪ ), ሞባይልስልክ : +251 2. ስም : ዚሎዚዳ (ዋናተመራማሪ), ሞባይልስልክ : +251 916877645 ኢ-ሜይል :[email protected] 3. ስም : ሆነልኝናውሰናይ (አማካሪ), ሞባይልስልክ : + 251 912138221 ኢ-ሜይል : [email protected]

ጊዜሰጥተውስላነበቡናስለሚኖሮትማንኛውምጥያቄበቅድሚያእናመሰግናለን፡፡

ቀን፡ DD/MM/YYYY

Annex 4. Consent Title of the Research Project: Maternal complication and associated factors of Caesarian delivery in Gamo Goffa zone and Basketo special woreda

I have been given and have understood the information sheet of this research project. I have had an opportunity to ask questions and have them answered. I understand that any information abstracted from delivery log books and clients’ card will be kept confidential to the research team.

Therefore, to confirm my approval for data abstraction from hospital/ health centre delivery registration log books and clients’ card I signed this consent form.

Name: ,

Position: ,

Signature: ,

Date: ,

Annex 5. የስምምነት ቅጽቅጽቅጽ የምርምሩ ርዕስ፡ በቀዶ ጥገና ወሊድና ድህረ ወሊድ ጊዜ እናቶች ያጋጠ Nˆቸው ችግሮች እና ተያያዥ ምክንያቶች በጋሞ ጎፋ ዞን እና ባስኬቶ ልዩ ወረዳ፤ ደቡብ ኢትዮጲያ

የምርምሩ የመረጃ ቅጽ ተሰጥቶኝ ያነበብኩና የተረዳሁ ሲሆን ለነበሩኝም ጥያቄዎች ተገቢውን ምላሽ ማግኘት ችያለሁ፡፡ የሚሰበሰበውም መረጃ ሚስጢራዊነቱ ተጠብቆ ለዚሁ ጥናት ብቻ አገልግሎት ላይ እንደሚውል አረጋግጫለሁ፡፡ ስለሆነም በተዘጋጀው መረጃ መሰብሰቢያ ቅጽ መሰረት አስፈላጊውን መረጃ ከሆስፒታል/ ጤና ጣቢያ የወሊድ መዝገብና የተገልጋይ ካርድ ላይ እንዲወስዱ መፍቀዴን በፊረማዬ አረጋግጣለሁ፡፡

ስም : - .

የስራ ድርሻ : - .

ፊርማ : - .

ቀን : - .

Declarations I, the undersigned declare that this thesis is my original work in partial fulfillment of the requirement for the degree of Master of Public Health. I also declare that it has never been presented in thisor any other university and that all resources and materials used in the thesis have been duly acknowledged.

Student Name: Zillo Zidda

Signature: ______

Place of submission: ______

Date of submission: ______

This thesis has been submitted with my approval as a university advisor.

Advisor Name: Honelgn Nahusenay

Signature: ______

Date of submission: ______