183 KUWAIT MEDICAL JOURNAL June 2020

Original Article : 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 & 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 , preterm delivery, fetal distress and records (2000-2015). The second design was a matched case- low 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 . 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 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). Ø An interviewing questionnaire: A validated, Apgar score was categorized. Descriptive and anonymous, interviewing questionnaire with females inferential statistics were done. Body mass index was used. Two experts examined the face and content was calculated. Chi square, OR and 95% confidence validity. The internal constituency reliability was intervals (CIs) were calculated. All p-values <0.05 was assessed by Cronbach’s α test and was 0.82. considered significant. Post-partum females from both the case and control groups were asked about the personal and socio- RESULTS demographic information. History of chronic diseases For the retrospective study, the sixteen years’ trend was taken. Gynecological, obstetric history and of all deliveries is presented in Table 1 and Figure 1. The history of the current were determined. In total cumulative numbers of deliveries done during addition, the attitudes of all females towards delivery the period was 66,000. The rate of VD decreased from by CS were assessed. 86.14% during 2000 to 68.19% in 2015. On the other Ø Clinical record abstraction form: It was hand, the rate of CS increased from 13.86% to 31.81% fulfilled through reviewing the hospital files of the during the same years, respectively (129.5% increase). selected females for collecting data about the weight, CS accounted for 21.2%, and SVD with cephalic height, (GA), presence of gestational presentation represented 75.42% of all deliveries done diabetes mellitus (GDM) and hypertension. The types during the 16-year period. SVD with babies in breach of CS or VD were taken. Data about the presentation presentation accounted for 1.2%. Assisted VDs were and child’s Apgar score (after one minute) was also done by ventouse and forceps for 2.1% and 0.08% of collected. Bishop Score was recorded (if data was females, respectively. June 2020 KUWAIT MEDICAL JOURNAL 186

Table 2: Comparisons between females delivered by caesarean section and by vaginal deliveries according to personal, socio-demographic factors, obstetric history and measurements

Case Control Variable (Caesarean Section) (Vaginal delivery) X2 p-value OR 95% CI No. Percentage No. Percentage Mother’s age 0.32 0.573 0.85 0.49 -1.48 < 35 116 49.2 120 50.8 ≤ 35 34 53.1 30 46.9 Education 0.00 1.000 1.00 0.64 – 1.57 < University 78 52 78 52 ≥ University 72 48 72 48 Occupation 0.56 0.456 0.80 0.45 – 1.44 Professional 25 16.7 30 20 Non-Professional 125 83.3 120 80 Income 6.36 0.012 0.41 0.21 – 0.83 Not enough 13 8.7 28 18.7 Enough or more 137 91.3 122 81.3 Smoking 4.23* 0.040 3.17 1.01 - 10.08 Yes 12 75.0 4 25.0 No 138 48.6 146 51.4 BMI 7.17 0.007 2.25 1.23 – 4.10 Overweight & obese 123 54.2 104 45.8 Normal 20 34.5 38 65.5 Current gestational age 4.80* 0.029 3.88 1.06 -14.19 ≤ 32 weeks 11 78.6 3 21.4 > 32 weeks 139 48.6 147 51.4 Follow-up regularly during this pregnancy 0.37 0.542 1.21 0.66 - 2.19 Yes 126 50.8 122 49.2 No 24 46.2 28 53.8 Gravidity 3.76 0.05 0.55 0.31-1.01 Primigravida 21 38.2 34 61.8 Multigravida 129 52.7 116 47.3

* Fisher’s exact test OR: odds ration; CI: confidence interval Regarding case-control part of the study, the mean - 4.10). Smokers had higher rates of CS compared to age of all 300 females was 30.09 ± 5.16 years. Based others, with statistically significant difference (p <0.05). on matching criteria, there is no statistical significant Shorter GA at birth (≤ 32 weeks) was associated with difference between cases and controls regarding age or more CS delivery (p <0.05) parity (p >0.05). Regarding types, LSCS was the most Table 3 revealed that females who delivered by common type of CS (97.3%). Only two cases (1.3%) previous CS had an increased risk of delivery by the were delivered through transverse CS incision, and same method in the current pregnancy (X2 = 116.15, one case (0.7%) had complication and delivered by p <0.001). Furthermore, mothers who suffered from emergency caesarean hysterectomy. GDM in the current pregnancy were about three times Results revealed that all cases of placenta previa more at risk of having CS delivery (current) compared (8 cases), preeclampsia (5 cases), cord prolapse and to others (OR = 2.79; 95% CI: 1.13 - 6.88). Hypertensive placenta were delivered by CS (4 cases females had a higher rate of delivery by CS compared for each). It was found that 18.3% of females were to others (p <0.05). primigravida. The cephalic presentation represented Regarding foetal presentation, CS was done for 88%, while non-cephalic (breech and shoulder) 97.2% of women who had their foetus in the non- accounted for 12% of all presentations. GDM occurred cephalic presentations compared to only 43.6% for among 8.3% of all females from both groups. females whose foetus was in the Table 2 illustrates that there is no statistically (OR = 45.35; 95% CI: 6.12 - 335.95). Mothers who significant association between the type of delivery delivered twins were about eight times more liable to and each females’ occupation and education (p >0.05). CS delivery (OR = 8.22; 95% CI: 1.8 5- 36.62). Those who However, females who had enough income delivered delivered a distressed baby (confirmed by first minute more frequently by CS compared to others, with a Apgar score ≤ 6) had higher rate of CS compared to statistically significant difference (p <0.05). Overweight others. Females who had a pre-term delivery (GA ≤32 and obese mothers were 2.25 times more prone to CS weeks) had a higher susceptibility to CS compared to delivery compared to others (OR = 2.25; 95% CI: 1.23 others (p <0.05). 187 Caesarean section: Sixteen-years’ trend, risk factors and attitudes of females delivered at King Abdulaziz ... June 2020

Table 3: Comparisons between females delivered by caesarean section and by vaginal deliveries regarding current obstetric history

Case Control Variable (Caesarean Section) (Vaginal delivery) X2 p-value OR 95% CI No. Percentage No. Percentage Mode of previous deliveries (245 had previous deliveries) All deliveries were by CS 65 95.6 3 4.4 116.15* 0.000 67.56 22.46-260.9 Both CS & vaginal deliveries 34 82.9 7 17.1 17.16 6.91-42.59 All deliveries were vaginal RC 30 22.1 106 77.9 1 Gestational diabetes mellitus 5.28 0.02 2.79 1.13 - 6.88 Yes 18 72.0 7 28.0 No 132 48.0 143 52.0 Hypertension 4.23* 0.04 3.17 1.01 - 10.08 Yes 12 75.0 4 25.0 No 138 48.6 146 51.4 Presentation 36.49* 0.000 45.35 6.12–335.95 Non-cephalic (breech & shoulders) 35 97.2 1 2.8 Cephalic 115 43.6 149 56.4 Current gestational age 4.80* 0.02 3.88 1.06 - 14.19 ≤ 32 weeks 11 78.6 3 21.4 > 32 weeks 139 48.6 147 51.4 Multiple pregnancies 10.54* 0.001 8.22 1.85 - 36.62 Twins 15 88.2 2 11.8 Single 135 47.7 148 52.3 Foetal distress (Apgar score after 1 minute) 20.22 0.000 7.25 2.73 - 19.26 ≤ 6 30 85.7 5 14.3 <6 120 45.3 145 54.7 History of taking drugs 3.34 0.068 1.62 0.96 - 2.72 Yes 47 58.8 33 41.2 No 103 46.8 117 53.2 Exaggerated pregnancy symptoms 0.40 0.53 1.17 0.72 - 1.93 Yes 47 52.8 42 47.2 No 103 48.8 108 51.2 Bishop score (done for 92 cases only) 24.68* 0.000 25.87* 4.97–134.76 < 6 9 81.8 2 18.2 ≥ 6 12 14.8 69 85.2

* Fisher’s exact test RC: Referent Category; OR: odds ratio; CI: confidence interval

The most common indications for CS (Table 4) were Table 4: Indication of cesarean section delivery among females having a history of previous CS (26%), foetal distress attended labour at King Abdulaziz University Hospital (24.7%) and mother’s emergency (22.3%). Furthermore, opinions of doctors and mothers accounted for 14% Causes of caesarean section No. Percentage and 3.7%, respectively. Maternal & foetal causes Previous CS 78 26.0 Table 5 demonstrates the attitudes of females in Foetal distress 74 24.7 both case and control groups towards CS. A higher Mother's emergency 67 22.3 percentage of females who delivered by CS agreed Opinion of doctor 42 14.0 Baby in breech 31 10.3 that CS is a safer method of giving birth than others Precious baby 30 10.0 (X2 =13.79, p <0.01). Similarly, there is a statistically Mechanical impendence 20 6.7 significant difference between opinions of both Dilation problems 15 5.0 Cephalo-pelvic disproportion 12 4.0 groups concerning CS as a more convenient method Opinion of mother 11 3.7 of delivery (p <0.05). Obstetric causes Multiple pregnancy 11 3.7 Placenta previa 8 2.7 DISCUSSION Preeclampsia 5 1.7 CS is one of the most frequently performed Cord prolapse 4 1.3 surgical obstetric operations[13]. Results of the placental abruption 4 1.3 Pregnancy after infertility 4 1.3 retrospective part of our study showed an increasing Genital herpes 1 0.3 CS trend overtime. The rate was 13.86% during 2000 CS: caesarean section and increased to 31.81% in 2015 (129.5% increase). NB: Each item was separately collected June 2020 KUWAIT MEDICAL JOURNAL 188

Table 5: Opinions of females delivered by cesarean section or vaginal delivery towards cesarean section

Agree No opinion Disagree X2 Question No. Percentage No. Percentage No. Percentage (p) CS is an easier way of giving birth 3.09 (0.14) CS 41 27.3 15 10.0 93 62.0 VD 34 22.7 8 5.3 108 72.0 CS is a more convenient way of birthing 6.16 (0.04) CS 33 22.0 17 11.3 100 66.7 VD 17 11.3 20 13.4 113 75.3 CS is safer than vaginal delivery 13.79 (0.001) CS 24 16 17 11.3 109 72.7 VD 5 3.3 19 12.7 126 84.0 CS is no longer seen as major surgery 5.03 (0.07) CS 61 40.7 24 16 65 43.3 VD 43 28.7 24 16.0 83 53.3 CS is portrayed by media as a better way of delivery than the vaginal 3.99 (0.14) CS 55 36.7 36 24 59 39.3 VD 41 27.3 70 46.7 39 26

CS: caesarean section; VD: vaginal delivery Similarly, several other studies have reported to persistence of the indication for conduction. This increasing CS trends[1,13-17]. On the other hand, Costa result agrees with many other findings[3,7,14,20,22]. et al[9] conducted a retrospective study at a teaching Our results showed that females with shorter GA hospital from Portugal and revealed decreasing CS (preterm labour) were significantly at an increased risk rates overtime; from 30.9% in 2005 to 27.6% in 2011. for CS, which agrees with the results of Patel et al from The cause behind this discrepancy may be attributed UK[20]. Furthermore, most of the cases with multiple- to their implementation of departmental policies as pregnancies (twins) in our study were delivered by CS, external fetal version program, labor induction after which coincides with other researches[3,23]. the 41 gestational weeks in pregnancy with low-risk, Concerning child presentation, our results found etc.[9]. that mothers whose babies were in the non-cephalic In the current study, the cumulative 16-years CS presentation were about 45 times more prone to CS rate was 21.2%, which agrees with 16-years rate (1997- delivery compared to others, which agrees with two 2012) of Lurie et al[18]. UK studies[20,24]. Regarding our case control study, 97.3% of females Results of the current study showed that overweight in CS group delivered by LSCS, which agrees with and obese mothers had higher susceptibility to CS results of Gupta et al from India[19]. In addition, history delivery. It was found from results of a meta-analysis of previous CS was the first indication of its current from 2014 that obese women are more likely to have conduction, followed by foetal distress and mother’s macrosomic babies, and therefore more likely to have emergency. We found that all cases of maternal CS[25]. This finding may be because obesity can be emergencies (placenta previa, pre-eclampsia, cord associated with other pregnancy problems such as prolapse and placenta abrrtion) were delivered by CS. pre-eclampsia, diabetes mellitus and GDM[14]. Similar These results are aligned with findings of one-year findings were reported from Peru[1], Oman[14] and retrospective study carried out by Abebe et al from China[26]. Furthermore, our findings illustrated that Ethiopia in 2016[3]. mothers with GDM had about a threefold increase in In the current study, older women had a slightly risk of CS delivery compared to others. Similar results higher rate of CS delivery, which agrees with a were obtained from the studies of Oman[14], UK[20] and study from the UK[20]. Older females are more likely Portugal[27]. Hypertension was also associated with CS to have pregnancy complications[7]. However, there in our study, which coincides with the Omani study[14]. was no significant difference between the age of In the current work, CS rate increased among females delivered by CS or VD in our study, which smokers compared to non-smokers, which coincides agrees with results of Dias et al from Brazil[21] and with the results of another study done by Lurie et al[28]. Chanthasenanont et al from Iran[22]. Furthermore, we They concluded that foetal compromise can occur found that increasing family income was associated during labour, leading to increased rates of operative with increased CS delivery, which agrees with results delivery among female smokers. of Al Busaidi et al from Oman[14]. Our results revealed presence of significant In our study, previous CS was associated with association between low Bishops score and CS, which much increased risk of current CS, which may be due agrees with results from Iran[12] and Turkey[29]. 189 Caesarean section: Sixteen-years’ trend, risk factors and attitudes of females delivered at King Abdulaziz ... June 2020

Low Apgar score (≤ 6) was significantly associated 3. Abebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. with CS delivery in our study, which coincides with Factors leading to cesarean section delivery at results from another study done by Gasim in Al- Felegehiwot referral hospital, Northwest Ethiopia: a Khobar, KSA, which indicated that CS was conducted retrospective record review. Reprod Health 2016; 13:6. 4. Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, more in foetal distress[23]. Torloni MR. The increasing trend in caesarean section Regarding attitudes, a higher percentage of females rates: Global, regional and national estimates: 1990- delivered by CS in our study agreed that CS is an 2014. PloS one 2016; 11(2):e0148343. easier, safer and more convenient way of giving birth 5. Mhaske N, Agarwal R, Wadhwa RD, Basannar DR. compared to the control group. Women who preferred Study of the risk factors for cesarean delivery in CS from another Saudi study done by Gari et al[30], and induced labors at term. J Obstet Gynaecol India 2015; those from an Iranian ethnographic study reported 65(4):236-240. that they preferred CS as it is less painful[31]. Ashimi 6. Al Rowaily MA, Alsalem FA, Abolfotouh MA. Cesarean et al found that a majority of their Nigerian pregnant section in a high-parity community in Saudi Arabia: clinical indications and obstetric outcomes. BMC females are willing to undergo and repeat CS if it is [32] Pregnancy 2014; 14:92. indicated . However, a study of Adageba et al from 7. Cnattingius R, Höglund B, Kieler H. Emergency Ghana showed that the majority of women in their cesarean delivery in induction of labor: an evaluation of study preferred VD unless CS is necessary[33]. risk factors. Acta Obstet Gynecol Scand 2005; 84(5):456- 462. CONCLUSION 8. Tully KP, Ball HL. 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