Magnitude of Maternal Complication and Associated Factors Among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Original Research Article

Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

Tsigereda Tesfaye1, Dr, Dejene Hailu2, Niguse Mekonnen3, Raheal Tesfaye4

1Medical Surgical Coordinator, Sawla, General Hospital 2Associate Professor of Public Health, School of Public and Environmental Health, College of medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia 3Lecturer, School of Public Health, College of Health Sciences, Wolaita Sodo University, Wolaita Sodo, Ethiopia 4Lecturer, Arbaminch Health Science College

Corresponding Author: Niguse Mekonnen

ABSTRACT

Background: Cesarean section is a major surgical procedure in obstetrics worldwide. It saves the life of the mother as well as the fetus by use of advanced technique, use of antibiotics and blood transfusion. However, its complications during and after cesarean section pose higher maternal morbidity and mortality compared to other modes of deliveries in many developed and developing countries. Maternal complications during and after cesarean sections and associated factors at Yirgalem General Hospital was not studied. Objective: To assess magnitude of maternal complications and associated factors among mothers undergone cesarean section at Yirgalem General Hospital, Southern Nation Nationalities Peoples Region. Methods: Institution based cross-sectional study was conducted by reviewing charts of 469 mother who were operated by cesarean section from July 8/2013 to July 7/2015. The sample was estimated based on specified assumptions and by using Epi Info. Data were collected by 2nd year Integrated Emergency Surgical Officers (IESO) from September 1-20/2015.and were analyzed using SPSS version 20.0. Both bivariate and multivariable analysis was carried out to identify factors associated maternal complications. Results: The overall maternal complication rate was 30.1 % (95%CI 25.9%-34.1%). Living in rural setting (AOR=3.37, 95% CI:1.68,6.77); maternal age 20-34 years (AOR= 3.98, 95% CI:1.64,9.67); mothers referred from other institutions (AOR= 2.23, 95%,CI: 1.37,3.65); multi gravid (AOR= 4.99, 95%CI: 2.75, 9.13); grand multi gravid (AOR= 21.03, 95%CI: 9.30,47.50 ), have no history of ANC follow up (AOR=3.19,95%CI:1.79,5.65) and operation done with general anesthesia (AOR=2.811,95%CI:1.73,4.57) were found to be significantly associated with maternal complication. Conclusions: Maternal complication was found to be high. Living in rural setting, maternal age 20-34 years and use of general anesthesia were associated with high maternal complication. Use of appropriate anesthesia will reduce the occurrence of complications. Keywords: Maternal complication, cesarean section, Yirgalem.

INTRODUCTION section could be performed as an elective Cesarean section serves as a salvage procedure when there is a predictable risk to surgical procedure facilitating rapid delivery the mother or fetus during labor or in the of the fetus when prolongation of the presence of an identifiable indication for the pregnancy is deemed undesirable. Cesarean procedure. The procedure is however

International Journal of Health Sciences & Research (www.ijhsr.org) 264 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia undertaken as an emergency when a increased delivery costs, future pregnancies complication of pregnancy or labor warrants are more likely to be complicated because quick intervention to deliver the fetus. [1,2] of a primary cesarean section. [10] Cesarean section is the most July, 2003 American College of common major surgical procedure Obstetricians and Gynecologist (ACOG) performed in sub-Saharan Africa countries. news release reported that cesarean birth [3] Over the last decade, there has been a significantly increased a woman's risk of a raising rate of cesarean section. This has pregnancy related fatality (35.9 deaths per been a source of major concern to health 100,000 deliveries with a live-birth care providers in many developed and outcome) compared to a woman who developing countries. The concern stems delivered vaginally (9.2 deaths per from the fact that cesarean section is 100,000). [11] significantly associated with higher risk of The risk and safety of cesarean maternal morbidity and mortality compared section differ from place to place in respect to vaginal delivery. [4] to structural development of health system. Aseptic and antiseptic methods with Although caesarean section is now safer antibiotics therapy, use of blood transfusion than it has never been, it can never be and improved anesthesia have all entirely safe and therefore, is not an contributed to the dramatic decrease in alternate to vaginal delivery. [12] mortality seen during the last. [5] Despite In Africa, cesarean sections are still these improved results, considerable care is performed in harmful conditions for saving still required to maintain and improve the the mother and fetus. It has been shown that rate of maternal and prenatal morbidity and the risks of surgical complication are greater mortality. The majority of cesarean with emergency compared with elective deliveries are performed for condition that cesarean section. [13] might pose a threat to both the mother and In Ethiopia, the overall institutional the fetus if vaginal delivery occurred. [6] rate of cesarean section was 18%, which Cesarean sections are potentially various between 46% in the private for morbid procedures with overall infectious profit sector and 15% in the public sector morbidity rates as high as 25%. [7] In among this three quarter of cesareans were addition to the increased risk for infections recorded as an emergency and thus, the with cesarean section, women are exposed magnitude of maternal complication is to complications such as excessive blood expected to be high. Prophylaxis antibiotics loss and damage to pelvic organs. Future were given in 94% of reviewed cases; pregnancies may also be affected. There is nevertheless, 12% of the cases reported an increased risk of uterine rupture, placenta wound infection there were two maternal accretes, and placenta previa associated with deaths. [14] a previous cesarean section. [8] Post- Different studies in Ethiopia indicate operative complications include that the magnitude of maternal complication endomyometritis, wound infection, fascial following cesarean section were high and dehiscence, urinary tract infections, bowel associated with various obstetric factors like dysfunction, thromboembolic prolonged or obstructed labor. [15,16] To the complications, and pelvic thrombophlebitis. level of researcher‟s knowledge, maternal [9] complications during and after cesarean In many developed countries, section and associated factors at Yirgalem women are not allowed to VBAC and must General Hospital (YGH) are not studied. re-sign to a repeat cesarean section with Therefore, this study was carried out to each successive pregnancy, exposing them determine maternal complications during to greater risks with each procedure and and after cesarean section and associated subsequent pregnancy. Aside from the factors as the knowledge of the study results

International Journal of Health Sciences & Research (www.ijhsr.org) 265 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia will help to increase awareness among hospital of 20%, [18] an absolute precision of health care professionals for the prevention 4% and 5% level of significance. of this problem in this hospital. n = (z )2 p (1-p) = (1.96) 2 0.2(1-0.2)/ (0.04) 2n=384 α/2 d2 METHODOLOGY

Study setting Where n represents sample size, P This study was conducted in represents proportion of maternal Yirgalem General Hospital which is found complication after caesarean section, d, in Yirgalem town, Sidama Zone, Southern represents margin of error and CI represents Nation Nationalities Peoples Region, confidence interval 95%. Ethiopia. It is located 318 kilometers south Hence, the initial estimated sample of Addis Ababa, capital city of Ethiopia, size was 384 Women. Fifteen percent of the and 45 Km far from regional city. The sample was added as a contingency Yirgalem General Hospital is serving as a considering possible loss due to teaching hospital, with a catchment incompleteness of some cards. Therefore, population of more than 4 million. [17] The the total sample size determined was 384 hospital has seven departments; Obstetrics +15%*384 was 442. Sample size for the and Gynecology is one of the Departments second objectives was also calculated using where greater than 820 operations are maternal age variable greater than 30 and conducted annually. prevalence is 13.0, OR, 2.1, power of Study design and Population test,80% and p-value of 5% the same Institution based cross-sectional formula was used and 15% contingency was study was employed so as to assess the added the final sample size is 497 It was magnitude of maternal complication and calculated using Epi-Info associated factors among mothers Therefore, by comparing sample size undergone cesarean section at Yirgalem calculated for two objectives that is General Hospital, SNNPR, Ethiopia, 2015. determining the magnitude of maternal The maternity records of all patients who complication among mothers‟ undergone delivered by cesarean section in Yirgalem cesarean section and identifying factors General Hospital from July 8/2013 to July associated with maternal complication 7/2015 were reviewed. All cesarean sections among mothers undergone cesarean section attended in the hospital from July 8/2013 to at Yirgalem General Hospital, SNNPR, July 7/2015 were taken as source and Ethiopia. The largest sample size (n = 432) randomly selected charts of mothers considering 15% contingency which added undergone cesarean sections July 8/2013 to to a total of 497 sample size was used for July 7/2015 in Hospital were considered the study. study population respectively. Sampling technique Inclusion and Exclusion criteria: All The registration numbers of mothers women who had undergone cesarean who gave birth by cesarean section from deliveries during the study period were July 8/2013- July 7/2015 were traced from included where as those with incomplete logbooks. The sampling interval or „k‟ was records, those re-admitted 7days after calculated by dividing the total number of discharge or those with lost chart were eligible mothers (1219) to the final sample excluded. Stitch abscess and Episiotomy site size (497) and the calculated k -value was infection were also excluded. approximated and taken as 2. The first chart Sample size calculation was randomly selected using lottery method The sample size was computed for and the subsequent charts were selected by magnitude of maternal complication after systematic random sampling method using cesarean section based on the estimation of sampling interval of two. the proportion of maternal complication in Data collection methods International Journal of Health Sciences & Research (www.ijhsr.org) 266 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

Data were collected through injury, prolonged catheterization, febrile document review (reviewing mothers‟ cards maternal morbidity and death in hospital. and operation records). Two Integrated Venous thromboembolic: Formation of a Emergency Surgical officer (IESO) year II clot of deep veins, usually of the lower limb, students were initially trained and later with swelling, warmth, and erythema, collected the data being supervised by the frequently a precursor of pulmonary investigator. The structured data abstraction embolism. format was pre-tested outside the study area Postpartum hemorrhage: Is defined as before one week then the main data estimated blood loss of >= 1000ml, fall in collection process was commenced. HCT >10%, post-operation HCT <25%. Variables Elective cesarean section: Defined as Dependent variables operation that was done at prearranged time Maternal complications during and after during pregnancy to ensure the best quality cesarean section in the first week of post- of obstetrics, anesthesia, neonatal operation. resuscitation and nursing services. Independent variables Emergency cesarean section: Defined as Age, residence, parity, gestational age, operation that was done immediate, ANC, medical disease, obstetric unplanned or unscheduled termination of complications, presentation, indication, pregnancy via cesarean section for the prophylaxis antibiotics, qualification of ultimate purpose of saving the life of both surgeons, type of anesthesia and type of the parturient and her offspring. cesarean section. Prophylactic antibiotic: Refer to a very Operational definitions brief course of antimicrobial agent initiated Maternal complications: Are complications just before an operation begins with an (with at least one of such complications like attempt to sterilize the tissue, but a critically Intra-operative or post operative surgical timed adjunct used to reduce the microbial complications, febrile maternal burden of intra-operative contamination to a complication, postpartum hemorrhage and level that can not overwhelm host defense. venous thromboembolism which occur Data analysis and processing during and after cesarean section or dead The data were coded, entered, within 7 days of postoperative day‟s cleaned and analyzed by using SPSS version cesarean section). 20.0. Descriptive analysis was carried out to Intra-operative surgical complications: explore the socio-demographic Include any damage occurring to adjacent characteristics; magnitude of maternal organs, including bladder, urinary tract or complication after cesarean section was bowel, as well as unintentional damage to calculated. Bivariate analysis was carried the uterus or cervix. out to examine the relationship between the Febrile maternal complication: Are outcome variable and selected obstetric complications that have a body temperature factors. of greater than or equal to 38oC. Some of Factors for which P-value < 0.25 the complications are wound infection, were retained for subsequent multivariable endomyometritis, septicemia, puerperal analysis using multiple logistic regression morbidity. and those factors which had P-value <0.05 Severe maternal complication: Includes in the final model were taken as statistically one of the following hemorrhage, blood significant. transfusion, hysterectomy, thromboembolic, Quality control measures and intensive care unit admission, The data abstraction format was postpartum length of stay, postpartum revised for being complete and appropriate antibiotics treatment, adjacent internal organ before commencement of data collection. Possible corrections were made at every end

International Journal of Health Sciences & Research (www.ijhsr.org) 267 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia of the days to check if there were seven mothers (86.8%) delivered by unnecessary or missing variables. emergency cesarean section. Ethical considerations The study protocol was approved Table 1.Socio-demographic characteristics of mothers delivered by cesarean section in Yirgalem General Hospital, and ethically cleared by the Institutional July 8/2013 to July 7/2015. Review Board of Hawassa University, Variables Frequency ( n=469) Percent (%) Age College of Medicine and Health Sciences. <20 74 15.8 Official letter of permission was written to 20-34 366 78.0 >=35 29 6.2 the hospital. Information on the studies was Residence given to the hospital officials and team Urban 146 31.1 leaders of the respective departments about Rural 323 68.9 Referral status the purposes and procedures. In order to Referred 254 54.2 protect the confidentiality of the Self-referral 215 45.8 information, name or identification number Table 2: Obstetric characteristics of mothers delivered by was not included in data abstraction format. cesarean section at Yirgalem General Hospital, July 8/2013 to Identification of the client was only possible July 7/2015. Variables Frequency(n =469) Percent (%) through numerical codes. Parity One 201 42.9 Two-five 222 47.3 RESULTS >Five 46 9.8 Socio-demographic characteristics of the ANC follow up mothers Yes 373 79.5 No 96 20.5 During the study period, a total of Medical illness during pregnancy 4519 deliveries were attended in Yirgalem Hypertension 39 8.3 HIV/AIDS 15 3.2 General Hospital, out of which 1219 Diabetes mellitus 15 3.2 (26.9%) women delivered by cesarean Labor status(n=469) section. Out of the 497charts reviewed, 469 Started 395 84.2 Not started 74 15.8 (94.3%) were eligible for analysis. The Duration of labor remaining 28 charts (27 with incomplete <24hr 373 94.4 ≥24hr 22 5.6 information and 4 lost charts) were excluded Status of membrane from analysis. Out of the 469 mothers for Ruptured 324 69.1 whom cesarean sections were performed, Not ruptured 145 30.9 146 (31.1%) were from urban and 323(68.9%) were from rural areas. Two hundred fifty four (54.2%) of the mothers were referred from other health facilities and 215(45.8%) were self-referred. The mean (±SD) age of the mothers‟ was 25.3(±4.8) years and majority of the mothers (78.0%) were in the age group of 20-34 years [table1].

Maternal obstetric and medical history Three hundred seventy-three (79.5%) mothers visited health facilities for ANC for the recent pregnancy. Most of the Figure 1, Intra-operative surgical complications of mothers women, 222(47.3%) were Para 2 to 5.The delivered by cesarean section in Yirgalem General Hospital, leading medical diseases were hypertension, SNNPR, July 8/2013 to July 7/2015. 39(8.3%), HIV/AIDS, 15(3.2%) and diabetes mellitus, 15(3.2). four hindered MATERNAL COMPLICATION

International Journal of Health Sciences & Research (www.ijhsr.org) 268 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

The overall rate of complications extension 40(28.4%) (Fig 1). And the major among mothers who delivered by caesarean postoperative complications were surgical section were 141(30.1%) with 95% CI wound infection 34(43.0%) and febrile (25.9%-34.1%). The leading surgical morbidity 45(57.0%) details are presented in complications during intra-operative (Table 3). included; hemorrhage, 91(64.5%), incision

Table 3: Post-operative maternal complications of the mothers delivered by cesarean section in Yirgalem General Hospital, SNPPR, July 8/2013 to July 7/2015 Variables Frequency (n=469) Percentage (%) Status of women after operation Alive 459 97.8 Dead 4 0.9 Referred 6 1.3 Postoperative maternal complications wound infection 34 43.0 Febrile morbidity 45 57.0 Post-operative blood transfused Yes 83 17.7 No 386 82.3 Amount of blood transfused (n=32) One unit 45 54.2 Two and above 38 45.8 Length of hospital stay after operation <5 days 267 57.7 5-7 days 156 33.7 >7 days 40 8.6

Factors associated with maternal analysis in which living in rural setting Complications (AOR= 3.37, 95%CI: 1.68, 6.77); age group Bivariate analysis showed that there 20- 34 years (AOR=3.98, 95%CI: 1.64, was association between maternal 9.67); referral status (AOR= 2.23, 95% CI: complications and living in rural setting, age 1.37,3.65); multi gravid (AOR= 4.99, 95% group (20- 34 years), referral status, CI: 2.75, 9.13); grand multi gravid (AOR= gravidity, had no ANC follow up ,operation 21.03, 95%CI: 9.30,47.50 ); had no ANC done under general anesthesia, duration of follow up (AOR= 2.23, 95%CI: 1.79,5.65) operation and emergency cesarean section and operation done under general anesthesia (Table 4). Those variables which has (AOR=2.81, 95% CI: 1.73, 4.57) were association at bivariate with maternal found to be significantly associated with complication were undergone multivariable maternal complications (Table 4).

Table 4: Factors independently associated with maternal complications who delivered by cesarean section in Yirgalem General Hospital, SNNPR, Ethiopia, July 8/2013 to July 7/2015. Variables(n=469) Maternal complications Yes No COR(95%C.I) AOR(95%C.I) Residence Urban 18 128 1 1 Rural 123 200 4.37(2.54,7.52)* 3.36(1.67,6.77)** Age <20 6 68 1 1 20-34 127 298 6.02(2.54,4.26)* 3.98(1.64,9.67)** >=35 8 21 4.32(1.35,13.86)* 2.14(0.62,7.34) Referral status Referred 93 161 2.01(1.33,3.03)* 2.23(1.37,3.65** Self referral 48 167 1 1 Gravidity Primigravida 179 22 1 1 Multigravida 118 70 4.83(2.83,8.22)* 4.99(2.75,9.13)** Grandmultigravid 31 49 12.86(6.84,24.18)* 21.03(9.30,47.0)** ANC Follow up Yes 86 287 1 1 No 55 41 4.48(2.80,7.17)* 3.19(1.79,5.65)** Types of anesthesia Spinal anesthesia 87 270 1 1 General anesthesia 54 58 2.89(1.86,7.50)* 2.81(1.73,4.57)** *p<0.25 in bivariate, ** p<0.05 multivariable. International Journal of Health Sciences & Research (www.ijhsr.org) 269 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

DISCUSSION in urban areas. Rural women are less likely In this study, the overall maternal to utilize a health facility than their urban complications were 30.1% with 95% CI counterparts and this could reflect that (25.9%-34.1%).This is high compared to cesarean section facilities are either not other studies conducted in developing available or too far away. Mothers who countries. Bamako, Mali Hospital, reported come from rural setting usually come after 13.2% [19] and Jimma Hospital, West prolonged labor which renders the mother Ethiopia reported 20%. [16] This variation for complications. may be due to the nature of obstetric The present finding showed that emergency including accidental internal referral mothers from other health organ injury and blood transfusion and also institutions had 2.23 times higher odds of the services provided for most referred maternal complication relative to those self patients or complicated deliveries yield high referred. The reason for this high maternal maternal complication. complication could be a gap in provision of This study revealed that a number of quality obstetric care during intrapartum important socio-demographic, obstetric and period. In addition to this, majority of the delivery characteristics were found to have a mothers came from outside Yirgalem town significant influence on maternal after they developed obstetrics complication of cesarean delivery. These complications and thus, were subjected to include living in rural setting, age group 20- cesarean section. 34 years, referral status, gravidity, those In this study, mothers who had no mothers who did not follow ANC for the ANC follow ups for the most recent recent pregnancy and use of general pregnancy had 2.23 times more anesthesia during the procedure. These complications compared to those who had findings are consistent with other studies attended ANC. This might be due to low conducted different countries in Africa. [9,20- health seeking behavior and delay to reach 23] health institutions. Even though more The present study showed that should be done to lower maternal mothers in the age group of 20-34 years complications by providing better antenatal were four times more likely to develop care services, basic EmOC at the health maternal complications compared with facility level is critical to achieve safe those less than 20 years of age (AOR=3.98, motherhood. 95% CI: 1.64, 9.67). Contrary to this In this study, it was observed that finding, a report from Bamako G Point mothers for whom operations were done Hospital revealed that there is no association under general anesthesia were 2.81 times in age difference. [19] more likely to have maternal complications In this study, grand multiparty has compared to mothers for whom operations 21.03 times more risk of developing were done under spinal anesthesia. This maternal complications than primgravida finding is in line with a study done in (AOR=21.03, 95% CI: 19.30, 47.50). This is Gondar Teaching Hospital. [22] Another consistent with the study done in Sub- studies conducted in African countries Saharan Africa. [21] These complications indicated that complicated labor and use of could be reduced by increasing access to general anesthesia increase the risk of family planning and reducing unmet need accidental internal organs injury and for contraception which reduces mortality in hemorrhage due to uterine atony. this group. [16,19,20,23,24] These might be due to majority The result of this study further of the cesarean section done after the revealed that mothers living in rural settings development of complicated labor, and also are 3 times more likely to have risk of majority of the operations performed were maternal complications than those who live on emergency bases either labor started or

International Journal of Health Sciences & Research (www.ijhsr.org) 270 Vol.7; Issue: 5; May 2017 Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia complications occurred. and guidance given me to write this research thesis. CONCLUSION AND Also, I am very much grateful to my advisor Dr. RECOMMENDATION Dejene Hailu (PhD) for his unreserved guidance The magnitude of maternal and constructive suggestions and comments on the stage of research topic selection and thesis complication following cesarean section at writing. Yirgalem General Hospital was high. This I am also grateful to Hawassa University study identified that living in rural setting, College of Medicine and Health Sciences, referral status, maternal age and use of School of Public and Environmental Health for general anesthesia as important predictors of giving me the chance to prepare this research maternal complication. Thus, due attention thesis and for their support by assigning the has to be given for closeness of health research advisors. I would like to extend my facilities as international standards, referral gratitude to Yirgalem General Hospital status, as well maternal age and the management, staffs and data collectors for their consultation of senior before giving general cooperation in providing and capturing the anesthesia from providers more over necessary information. Lastly, I would like to thank my friends who clinician must consider these factors in have given their important inputs during the maternal care settings. preparation of this research thesis.

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How to cite this article: Tesfaye T, Hailu D, Mekonnen N et al. Magnitude of maternal complication and associated factors among mothers undergone cesarean section at Yirgalem general hospital, SNNPR, Ethiopia. Int J Health Sci Res. 2017; 7(5):264-272.

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