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I CESAREAN SECTION DELIVERY in INDIA

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I CESAREAN SECTION DELIVERY in INDIA CESAREAN SECTION DELIVERY IN INDIA: AN ANALYSIS OF MATERNAL FACTORS AND INFANT OUTCOMES by Tamala Gondwe BS, University of Maryland, College Park, 2007 MPH, Tulane University, 2010 Submitted to the Graduate Faculty of the Department of Epidemiology Graduate School of Public Health in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2017 i UNIVERSITY OF PITTSBURGH GRADUATE SCHOOL OF PUBLIC HEALTH This dissertation was presented by Tamala Gondwe It was defended on October 30, 2017 and approved by Dissertation Advisor: Catherine L. Haggerty, PhD, MPH Associate Professor of Reproductive Epidemiology Department of Epidemiology Graduate School of Public Health University of Pittsburgh Dissertation Committee Members: Clareann H. Bunker, PhD Associate Professor Emeritus Department of Epidemiology Graduate School of Public Health University of Pittsburgh Hyagriv Simhan, MD, MS Professor Department of Obstetrics, Gynecology and Reproductive Science School of Medicine University of Pittsburgh Gong Tang, PhD Associate Professor Department of Biostatistics Graduate School of Public Health University of Pittsburgh ii Copyright © by Tamala Gondwe 2017 iii Catherine L. Haggerty, PhD, MPH CESAREAN SECTION DELIVERY IN INDIA: AN ANALYSIS OF MATERNAL FACTORS AND INFANT OUTCOMES Tamala Gondwe, PhD University of Pittsburgh, 2017 ABSTRACT Cesarean section (CS) delivery is increasing globally, in many countries exceeding the World Health Organization recommended upper limit of 15% of births in all regions. The CS rate is also increasing nationally in India, where the factors and outcomes associated with CS have not previously been explored. We sought to determine maternal factors and infant outcomes associated with mode of delivery in India from two data sources. First, we assessed the independent association of several maternal factors with mode of delivery in the Longitudinal Indian Family Health (LIFE) study cohort. Second, we assessed whether mode of delivery in the LIFE study was associated with diarrhea and respiratory infection in infants. Lastly, we assessed the maternal, socioeconomic, and healthcare factors, and infant outcomes associated with mode of delivery in the 2005-2006 India National Family Health Survey. Of the 1,164 singleton births in the LIFE study between 2010 and 2015, 46% were delivered by CS. Prior pregnancy complications, history of prior CS, pre-pregnancy body mass index, and labor and delivery complications contributed to the high CS rate. In regards to infant outcomes, after adjusting for pre-delivery maternal factors, mode of delivery was not associated with infants having diarrhea or respiratory infection at six months in the LIFE study. In the India national data, 12% of the 35,601 most recent singleton births in the 2005 and 2006 survey were iv delivered by CS. Factors associated with CS nationally were high wealth index, high level of maternal education, maternal receipt of >5 antenatal care visits, and delivery at a private care facility. After adjusting for these factors, mode of delivery was not associated with infant diarrhea and acute respiratory infection, but an association was found with neonatal death. Our studies yield public health significance in showing that a range of maternal factors are associated with mode of delivery in India, and that mode of delivery is not a determinant of some adverse infant health outcomes. Further research is needed on the effect of CS delivery on infant and maternal outcomes in India and other countries as the CS rates continue to increase. v TABLE OF CONTENTS PREFACE ................................................................................................................................. XIII 1.0 INTRODUCTION ........................................................................................................ 1 1.1 BACKGROUND .................................................................................................. 1 1.2 RESEARCH AIMS .............................................................................................. 2 2.0 BACKGROUND AND SIGNIFICANCE .................................................................. 4 2.1 MODE OF DELIVERY ...................................................................................... 4 2.1.1 Current Issues .................................................................................................. 4 2.1.1.1 Increasing Rate of Cesarean Sections ................................................. 4 2.1.1.2 Comparing Cesarean Section Rates .................................................... 5 2.1.1.3 Vaginal Birth after a Previous Cesarean ............................................ 6 2.1.2 Global Epidemiology of Cesarean Section Delivery ..................................... 7 2.1.2.1 National and Regional Estimates of Cesarean Section Prevalence in India ................................................................................................................. 8 2.1.3 Review of Risk Factors for Cesarean Section Delivery Globally .............. 11 2.1.3.1 Medical Indications ............................................................................. 11 2.1.3.2 Maternal Characteristics .................................................................... 12 2.1.3.3 Health Care .......................................................................................... 17 2.1.3.4 Summary of Risk Factors for Cesarean Section Delivery ............... 19 2.1.4 Adverse Outcomes Associated with Cesarean Section Delivery ............... 23 2.1.4.1 Adverse Infant Outcomes ................................................................... 23 2.1.4.2 Maternal Health Outcomes ................................................................ 25 vi 2.1.5 Conclusion ...................................................................................................... 25 2.2 THE LONGITUDINAL INDIAN FAMILY HEALTH STUDY................... 27 2.2.1 Original Study Design and Population ........................................................ 27 2.3 THE NATIONAL FAMILY HEALTH SURVEY.......................................... 30 2.3.1 Data Collection ............................................................................................... 30 2.3.2 Reliability of NFHS Data to Assess Cesarean Section Delivery Rates ...... 30 3.0 MANUSCRIPT 1: FACTORS ASSOCIATED WITH MODE OF DELIVERY IN A PERI-URBAN INDIAN POPULATION .............................................................................. 32 3.1 ABSTRACT........................................................................................................ 32 3.2 INTRODUCTION ............................................................................................. 33 3.3 METHODS ......................................................................................................... 34 3.4 RESULTS ........................................................................................................... 36 3.5 DISCUSSION ..................................................................................................... 38 3.6 FIGURE AND TABLES ................................................................................... 42 4.0 MANUSCRIPT 2: MODE OF DELIVERY AND SHORT-TERM INFANT HEALTH OUTCOMES IN A PERI-URBAN INDIAN POPULATION .............................. 48 4.1 ABSTRACT........................................................................................................ 48 4.2 INTRODUCTION ............................................................................................. 49 4.3 METHODS ......................................................................................................... 51 4.3.1 Study population ............................................................................................ 51 4.3.2 Exposure and Outcome variables ................................................................ 52 4.3.3 Statistical Analysis ......................................................................................... 52 4.3.4 Propensity Score Analysis ............................................................................. 52 vii 4.3.5 Regression Analysis ....................................................................................... 53 4.4 RESULTS ........................................................................................................... 54 4.4.1 Population characteristics ............................................................................. 54 4.4.2 Propensity Score Analysis ............................................................................. 55 4.4.3 Regression Analysis ....................................................................................... 55 4.5 DISCUSSION ..................................................................................................... 56 4.6 TABLES.............................................................................................................. 59 5.0 MANUSCRIPT 3: ADVERSE INFANT OUTCOMES ASSOCIATED WITH CESAREAN SECTION DELIVERY IN INDIA: A RETROSPECTIVE ANALYSIS OF NATIONAL SURVEY DATA ................................................................................................... 65 5.1 ABSTRACT........................................................................................................ 65 5.2 INTRODUCTION ............................................................................................. 67 5.3 METHODS ........................................................................................................
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