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Caesarean Section: Sixteen-Years' Trend, Risk Factors and Attitudes Of 183 KUWAIT MEDICAL JOURNAL June 2020 Original Article Caesarean section: Sixteen-years’ trend, risk factors and attitudes of females delivered at King Abdulaziz University Hospital, Jeddah, Saudi Arabia Nahla Khamis Ibrahim1,2, Khadeja Ayoub3, Sara Ali Sawan3, Maha Saleh Al-Jdani3, Nedaa Mohamed Bahkali4 1Department of Community Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia 2Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt 3Interns, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia 4Department of Obstetrics & Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Kuwait Medical Journal 2020; 52 (2): 183 - 190 ABSTRACT Objective: To determine sixteen-years’ trend of cesarean Results: An increasing CS trend was obvious (129.5% section (CS), risk factors and attitudes towards it among increase); from 13.86% (2000) to 31.81% (2015). CS delivery females delivered at King Abdulaziz University Hospital was significantly associated with high income, increased (KAUH), Jeddah weight, smoking, gestational diabetes mellitus, and previous Design: Two study designs were conducted during 2016. A CS(s). Non-cephalic (breech and shoulder) presentation, retrospective study was done through reviewing of delivery multiple pregnancies, preterm delivery, fetal distress and records (2000-2015). The second design was a matched case- low Bishop Score were important risk factors of CS. The most control study. frequent CS indications were history of previous CS, fetal Setting: Obstetrics & Gynecology Department of KAUH distress and maternal emergencies. CS was done according Subjects: For the retrospective study, females delivered to mother’s opinion for 3.7%. Regarding attitudes, females during the 16 years were scrutinized. For the case-control delivered by CS perceived it as a safer and more convenient study, 300 postpartum randomly selected females were delivery than controls. recruited (150 cases delivered by CS, and an equal number Conclusion: Increasing rates of CS prevailed at KAUH. of controls with vaginal delivery) matched by age and parity. Females with high risk factors require adequate antenatal Intervention: Reviewing delivery records, an interviewing follow-up. Implementation of programs such as labor questionnaire with females, and clinical record abstraction induction in low-risk pregnancies is recommended. forms. Descriptive and inferential statistics were done. Increased awareness about CS complicity and advantage of Main outcome measures: Trend, risk factors and attitudes vaginal delivery is needed. towards CS KEY WORDS: attitudes, cesarean section, risk factors, trend INTRODUCTION Dominican Republic (56.4%) from South America and The increasing rates of cesarean section (CS) the Caribbean, Egypt (51.8%) from Africa, Iran and represents a worldwide escalating epidemic[1,2]. The Turkey from Asia (47.9% and 47.5%, respectively), number of babies delivered by CS is rapidly growing Italy (38.1%) from Europe, United States (32.8%) from both in developed and the developing countries. The Northern America, and New Zealand (33.4%) from rate of CS ranged from 12% - 86% in the industrialized Oceania[4]. CS is a common obstetric procedure[5] and countries[3]. In the developing nations, CS rates ranged the reasons behind its continuous increasing rates between 2 - 39%[3]. The countries with the highest appeared to be multiple, complex and, may be in many CS rates as reported in 2016 were Brazil (55.6%) and cases, specific to the country[1,2]. The increasing trend Address correspondence to: Nahla Khamis Ibrahim, M.B.B.Ch, MPH, Dr.PH (Epidemiology), DHPE (Medical Education), JMHPE (Maastricht/SCU), King Abdulaziz University, Jeddah, Box: 42806, Postal code: 21551, Kingdom of Saudi Arabia. E-mail: [email protected] June 2020 KUWAIT MEDICAL JOURNAL 184 of CS may be attributed to maternal, foetal, obstetric SUBJECTS AND METHODS and organizational factors[6,7]. In some cases, women Two study designs were conducted: may request cesarean delivery without medical need[8]. 1. A retrospective record review study There are many concerns regarding the escalating (16-years’ trend of CS): All records of deliveries done rise in CS rates due to potential maternal and perinatal in the Obstetrics & Gynaecology Department of the risks, the probability of obstetric complications University Hospital during a 16 year period (2000 - in upcoming pregnancies and financial issues[9]. 2015) were reviewed. The increased rates of CS lead to increased scar Data was collected through a pre-constructed pregnancies, which can have lethal consequences clinical data abstraction sheet. It was used to collect and may affect infant immune system[2]. Females information about the numbers and methods of previously delivered by CS may be more liable to deliveries (CS or VD). The types of CS such as upper postpartum haemorrhage and retained placenta. segment, transverse and lower segment CS (LSCS) Uterine rupture and placenta previa are well-known were also recorded. Similarly, the types of VD such as and potentially life-threatening complications spontaneous VD (SVD), breach and assisted deliveries of previous CS, but are fortunately still rare (ventouse and forceps) were also noted. conditions[10]. 2. A matched case-control study: Eligibility The World Health Organization has stated that criteria for enrolment in this part of the study included maximum CS percentage should be 15%, and that all females in the reproductive age, who attended no region in the world is justified with having a the Gynaecology and Obstetrics Department of the caesarean rate greater than 10% to 15%[9]. Although University Hospital for labour during the year 2016, the rate of CS is escalating, no adequate studies were mentally sound, who were willing to participate in the done about the trend, risk factors and attitudes of study, and to write the informed written consent. mothers towards CS in university hospitals in Jeddah, Cases: Females who fulfilled the eligibility criteria Saudi Arabia. Therefore, such a study is needed. and delivered by CS. The study was done to determine the 16 years’ Controls: Females who fulfilled eligibility criteria trend of CS (2000 - 2015), and to identify the risk and had a VD. factors and attitudes towards CS among females who A systemic random sample method was used. delivered by both CS and vaginal delivery (VD) in Every 7th file of the postpartum females, who fulfilled the University Hospital from Jeddah. the eligibility criteria were included. For each selected Percentage Fig 1: Sixteen years’ trend of vaginal and caesarean section deliveries among females delivered at King Abdulaziz University Hospital from year 2000 to 2015 185 Caesarean section: Sixteen-years’ trend, risk factors and attitudes of females delivered at King Abdulaziz ... June 2020 Table 1: Sixteen-year trend of types of deliveries between females delivered at the University Hospital (2000 to 2015) Vaginal deliveries CS Total All Year deliveries SVD Assisted vaginal delivery Breach vaginal No % SVD % Ventouse % Forceps % Breach. % % 2000 3145 2625 83.46 24 0.03 1 0.03 59 1.88 86.14 436 13.86 2001 3790 3127 82.50 41 0.08 3 0.08 59 1.56 85.22 560 14.78 2002 4165 3337 80.12 53 0.02 1 0.02 48 1.15 82.57 726 17.43 2003 4927 3960 80.37 83 0.12 6 0.12 55 1.12 83.3 823 16.7 2004 4717 3725 78.96 106 0.04 2 0.04 55 1.17 82.43 829 17.57 2005 3899 3084 79.09 92 0.05 2 0.05 29 0.74 82.25 692 17.75 2006 3834 3000 78.25 96 0.10 4 0.10 29 0.76 81.61 705 18.39 2007 3919 2967 75.71 92 0.10 4 0.10 43 1.10 79.25 813 20.75 2008 4398 3315 75.38 96 0.2 12 0.27 46 1.05 78.88 929 21.12 2009 4243 3165 74.59 90 0.09 4 0.09 52 1.23 78.03 932 21.97 2010 4238 3108 73.34 94 0.04 2 0.04 45 1.06 76.66 989 23.34 2011 4760 3424 71.93 131 0.06 3 0.06 44 0.92 75.67 1158 24.33 2012 4599 3331 72.43 113 0.04 2 0.04 35 0.76 75.69 1118 24.31 2013 4319 3039 70.36 88 0.07 3 0.07 51 1.18 73.65 1138 26.35 2014 3724 2426 65.15 105 0.03 1 0.03 107 2.87 70.86 1085 29.14 2015 3323 2146 64.58 73 0.15 5 0.15 42 1.26 68.19 1057 31.81 Total 66,000 49779 75.42 1377 2.1 55 0.08 799 1.2 78.8 13990 21.20 SVD: spontaneous vaginal delivery female delivered by CS (case), one female delivered by present). It is based on the consistency, effacement, VD (control) was taken and matched by age and parity. dilation, and position of cervix. It assessed also the The sample size for the case-control part was foetal station (how far up the birth canal the baby’s calculated through EpiTools epidemiological head is)[12]. calculators[11]. It was assumed that expected proportion of Statistical analysis exposure among the control group was 60%, odds ratio Data was analysed using SPSS 20 (SPSS Inc., (OR) was 2, the power of the sampling equals 80%. At Chicago, IL). The rate of CS was calculated as the 1.96 confidence level, the calculated sample size was number of caesarean births divided by total live births. 300, divided into 150 in each group. Bishop score[12] was calculated and categorized into those having a score of ≥6 (labour is likely to start A data collection sheet was used for the case-control without induction), and those who obtained a score ≤ 5 study and it contained: (labour is unlikely to start without induction).
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