What Factor Is Least Likely to Affect Any Emergencyã¢â‚¬â€¹ Response?
Keywords
Cesarean section; Jordan; Neonatal; Mortality
Introduction
WHO) that the rate of cesarean section (CS) should not exceed 10% to 15% in whatsoever land [ane]. In recent years, the rate of caesarean deliveries increased dramatically worldwide and many countries had exceeded the WHO recommended charge per unit [2].
Many factors have been identified to be associated with CS across the world such as premature rupture of the amniotic membrane, cephalo-pelvic disproportion, fetal distress, multiple pregnancy, breech presentation, place of birth (private or public infirmary), maternal preference, birth weight, parity, maternal pinnacle and antenatal care use [3-10]. The main indications for cesarean delivery are previous cesarean commitment, breech presentation, and fetal distress [11]. Although CS is a safe performance, when it is performed without medical need it puts mothers and their babies at risk of short- and long-term wellness problems. Most complications of CS, notwithstanding, come up from the crusade which leads to CS. Factors that make some women more probable to accept complications include: obesity, large baby size, prolonged labor, multiple pregnancy, and premature labor. In the absence of a clear medical indication, the excess risk associated with the performance itself must be considered. Short- and long-term maternal and infant problems associated with constituent caesarean section are higher than those associated with vaginal birth [12-xiv].
In Jordan, a study conducted between 2002 and 2012 showed that the rate of CS increased from 18.two% in 2002 to 30.3% in 2012 with the about common reason for CS existence "absence of a articulate indication" [three]. In Jordan, equally in many Arab countries, at that place is a preference for relatively large families. As CS limits the number of children a female parent can give nascency to, it becomes of paramount importance to perform such operation only when clear medical indications exist.
This study aimed to decide the rate of CS in Jordan and its causes, associated factors, and neonatal outcomes, using a huge sample size representing the different regions and health sectors in Jordan. This information is necessary for alerting health authorities and provides a baseline for future policies and strategies against this rapidly increasing problem.
Methods
Study blueprint
The study is a part of a comprehensive national report of perinatal mortality which was conducted betwixt 2011 and 2012 in Jordan. Details of the study blueprint were described elsewhere [15]. In cursory, a sample of 18 hospitals with maternity departments was selected to stand for the 3 regions of Hashemite kingdom of jordan (South, Middle, and Northward) and the different medical sectors (Ministry of Wellness, Purple Medical Services, Individual sector, and University Hospitals). Sample pick was guided by the Technical Commission of the study that included experts from the Ministry building of Wellness, General Department of Statistics, and a number of international agencies (UNICEF, WHO, and Health System Strengthening (HSS)). All deliveries with a gestational age ≥ xx week that took place in any of the 18 hospitals during the study period (March 2011- Apr 2012) were invited to participate in the study. Consenting women were interviewed by the trained midwives in these hospitals using a structured questionnaire prepared for the purpose of this report. Additional data was also nerveless based on the concrete examination past the midwife and the obstetrician at access and at discharge. Information on the newborn were besides collected by the pediatric nurses and the neonatologists in these hospitals. The study instrument included the interview questionnaire as well as data sheets to be completed past the midwife and the pediatric nurse under the supervision of the obstetrician and the neonatologist who were required to sign all data forms. The condition of new borns (expressionless or live) was ascertained 28 days afterward delivery. Midwives were required to phone call mothers by telephone for this purpose. If the new born has died in hospital before 28 days the cause of decease was ascertained by the neonatologist. If expiry occurred at abode, a verbal autopsy was performed to notice out the crusade of death. A total of 21,928 women delivering in these hospitals during the study period were included in the study with a response rate of about 99%. The study was approved past the Jordanian Institutional Review Lath (IRB). An informed consent was obtained from all participating women. Every effort was made to protect the confidentiality and the identity of participants.
Data Collection
All-encompassing data were collected on each woman included in the study and her new built-in through interview and by brainchild of relevant data from medical records. Data obtained included socio-demographic variables, obstetric history, antenatal care, mode of commitment, complications of delivery, new built-in status (expressionless or live), Apgar score, birth weight, nascence injuries and complexity etc. Data on cesarean delivery including crusade, whether the CS was planned or emergency, and the occurrence of any complications were ascertained by the obstetrician. The study team consisted of 126 persons including hospital obstetricians and neonatologists, midwives, and pediatric nurses. A 2-24-hour interval workshop was conducted to train all the study team and a 1- day pilot study was carried out in each of the participating hospitals.
Variable definitions
Stillbirth was defined as whatsoever fetus built-in without a heartbeat, animate, and pulsation of umbilical string or definite motion of voluntary muscles. The stillbirth rate was calculated equally the number of stillbirths per ane,000 live births plus fetal deaths (stillbirths). Neonatal death was divers as a death of a live born babe within the first 28 days of life. Neonatal bloodshed rate (NNMR) was calculated every bit the number of deaths during the first 28 completed days of life per 1,000 alive births. A baby who was born with a weight of less than ii,500 g was considered low nativity weight babe. A premature infant was divers as a infant who was built-in before 37 completed weeks of pregnancy. The baby is scored for Apgar score at 1 and 5 minutes after birth. Apgar score was classified every bit: A score of eight-10 is considered normal, 4-vii is intermediate, 0-3 is poor and the infant requires firsthand resuscitation.
Preeclampsia was defined co-ordinate to International Society for the Study of Hypertension in Pregnancy (ISSHP). Obesity was defined according to torso mass index (BMI) and it was calculated as pre-pregnancy women weight in Kg divided by height in meters square. A adult female with BMI >thirty kg/mii was considered as obese.
Statistical Analysis
Information were analyzed using the Statistical Package for Social Sciences (SPSS IBM 20). The rate of CS, overall and by relevant variables were calculated. The differences in CS rates according to studied variables were tested using Chi-square test. Multivariate analysis using logistic regression was conducted to determine the factors associated with CS. The outcomes of cesarean delivery for the baby were obtained and compared with the balance of the deliveries in bivariate and multivariate models. The frequency of the unlike causes for CS was besides obtained. CS were classified into emergency and planned and the frequency of each, overall and past relevant variables were obtained. A pvalue of less than 0.05 was considered statistically significant.
Results
Participants' characteristics
This report included a full of 21,928 women. Their age ranged from fourteen to 55 with a mean (SD) of 27.nine (vi.0). Of all women, 28.1% gave nascence in private hospitals, 48.8% in public hospitals, 19.2% in military hospitals, and 3.nine% in teaching hospitals. About ii.9% of women gave birth to ii or more fetuses. Merely 13.1% of women were employed, 28.5% were overweight, 9.six% were obese, v.0% had high blood pressure, 1.3% had preeclampsia, 1.ii% had gestational diabetes, and 0.half-dozen% had pre-gestational diabetes. About eight.two% of women had a history of preterm or low birth weight commitment, and 5.iii% had a history of neonatal death or stillbirth.
Rate of cesarean section
The overall rate of CS was 29.ane% (13.2% for emergency CS and xv.nine% for planned CS). Table ane shows the mode of commitment according to socio-demographic characteristics. CS was significantly higher among women who were older than 35 years and in highly educated women (44.four%, 35.7%, respectively). The charge per unit of CS was significantly lower in women delivering in south of Hashemite kingdom of jordan (23.6%), compared to that in the middle and the north (31.7%, 30.8%, respectively). Planning of CS was significantly more common among Christian Jordanian women than that amongst Muslims (33.3% vs.16.6%) and amongst women who fume compared to that among nonsmokers (20.7%, 16.5%, respectively). CS rate in Jordanian and non-Jordanian women was virtually the same (30.v% vs. 30.6%). CS charge per unit was significantly higher among women who delivered in didactics and private hospitals (42.5%, 37.6%, respectively) compared to women who delivered in military and public hospitals (31.3%, 25.2%, respectively) (Effigy 1). CS rate was significantly higher in employed women (39.6%), compared to the rate of CS in housewives (29.1%). It was obvious that the CS rate is higher when fathers are educated >fourteen years compared with poor educated fathers (36.2% vs. 26.6%).
Figure 1:The rate of caesarean section according to health sector, Jordan 2011-2012.
| Variable | Mode of delivery | Total | P-value | ||
|---|---|---|---|---|---|
| Planned N (%) | Emergency N (%) | Vaginal N (%) | |||
| Age (yr) | |||||
| <twenty | 69 (5.iv) | 171 (xiii.three) | 1046 (81.3) | 1286 | 0.000 |
| 20-35 | 2619 (15.6) | 2310 (xiii.7) | 11890 (70.seven) | 16819 | |
| >35 | 764 (29.4) | 388 (15.0) | 1443 (55.six) | 2595 | |
| Occupation | |||||
| Housewife | 2848 (15.9) | 2374 (xiii.ii) | 12718 (lxx.nine) | 17940 | 0.000 |
| Employee | 593 (21.9) | 480 (17.vii) | 1636 (60.4) | 2709 | |
| Region | |||||
| North | 1166 (16.2) | 1056 (14.vi) | 4997 (69.ii) | 7219 | 0.000 |
| Middle | 1971 (17.v) | 1607 (14.3) | 7695 (68.3) | 11273 | |
| South | 319 (14.iv) | 206 (9.3) | 1696 (76.4) | 2221 | |
| Organized religion | |||||
| Muslim | 3439 (xvi.6) | 2862 (thirteen.9) | 14361 (69.5) | 20662 | 0.000 |
| Christian | 17 (33.3) | 7 (13.7) | 27 (52.9) | 51 | |
| Sector | |||||
| Private | 1292 (22.two) | 901 (15.5) | 3633 (62.four) | 5826 | 0.000 |
| Public | 1395 (xiii.viii) | 1147 (11.4) | 7560 (74.8) | 10102 | |
| Military machine | 565 (14.ii) | 681 (17.1) | 2730 (68.7) | 3976 | |
| Didactics | 204 (25.two) | 140 (17.iii) | 465 (57.5) | 809 | |
| Nationality | |||||
| Jordanian | 3221 (sixteen.15) | 2728 (14.0) | 13536 (69.five) | 19485 | 0.007 |
| Others | 235 (nineteen.ane) | 141 (11.5) | 852 (69.4) | 1228 | |
| Mother'southward pedagogy | |||||
| <12 | 964 (14.2) | 820 (12.1) | 4988 (73.7) | 772 | 0.000 |
| 12-14 | 1679 (17.eight) | 1249 (xiii.2) | 6521 (69.0) | 9449 | |
| >14 | 796 (18.0) | 783 (17.7) | 2842 (64.3) | 4421 | |
| Father'due south education | |||||
| <12 | 1055 (14.four) | 893 (12.2) | 5389 (73.4) | 7337 | 0.000 |
| 12-14 | 1611 (17.i) | 1330 (fourteen.1) | 6494 (68.8) | 9435 | |
| >fourteen | 762 (xix.9) | 625 (sixteen.3) | 2446 (63.8) | 3833 | |
| Smoking | |||||
| Yes | 142 (20.7) | 104 (15.i) | 441 (64.2) | 687 | 0.000 |
| No | 3312 (16.5) | 2764 (13.8) | 13945 (69.7) | 20021 | |
Table 1: Style of delivery of Jordanian women according to socio-demographic, characteristics, 2011-2012.
Table two shows the mode of delivery in Jordanian women according to clinical, anthropometric, obstetric and other relevant characteristics. Women who had diabetes mellitus, preeclampsia, fever, anemia, hypertension, overweight and obesity and past history of stillbirth were more likely to deliver via CS. Breech or presentations other than cephalic, history of CS in previous deliveries, past history of early onset of labor, being transferred from other hospitals, and being hospitalized during the index pregnancy were significantly associated with college rate of CS delivery. Breech presentation and other noncephalic presentations (such every bit transverse and cord presentation) were associated with a very high rate of CS (91.2% and 98.2%, respectively) equally compared to cephalic presentation (26.4%). Mothers who had past history of CS had a loftier charge per unit of CS (74.9%) as compared to mothers who didn't have a past history of CS (twenty.iii%). Mothers who were transferred from other hospitals had a very high rate of CS (61.ii%) as compared to mothers who didn't have a history of transfer from other hospitals (29.9%). Mothers with history of hospitalization during the electric current pregnancy had a very high rate of CS (47.2%) as compared to mothers without history of hospitalization (29.4%).
| Variable | Mode of delivery | Full N (%) | P-value | ||
|---|---|---|---|---|---|
| Planned Northward (%) | Emergency N (%) | Vaginal N (%) | |||
| Preeclampsia | |||||
| Yep | 72 (25.9) | 101 (36.iii) | 105 (37.viii) | 278 | 0.000 |
| No | 3382 (16.half dozen) | 2767 (13.five) | 14281 (69.ix) | 20430 | |
| Diabetes mellitus | |||||
| No Diabetes | 3286 (sixteen.2) | 2800 (13.8) | 14249 (lxx.1) | 20335 | 0.000 |
| Gestational diabetes | 105 (41.3) | 48 (18.nine) | 101 (39.8) | 254 | |
| Pre-gestational diabetes | 63 (52.9) | 20 (xvi.eight) | 36 (xxx.three) | 119 | |
| Anemia | |||||
| Yes | 729 (20.4) | 494 (thirteen.viii) | 2350 (65.8) | 3573 | 0.000 |
| No | 2725 (15.ix) | 2374 (13.9) | 12036 (lxx.ii) | 17135 | |
| High blood pressure | |||||
| Yes | 254 (24.six) | 281 (27.two) | 499 (48.3) | 1034 | 0.000 |
| No | 3200 (xvi.iii) | 2587 (13.i) | 13887 (70.half-dozen) | 19674 | |
| Body mass index | |||||
| Normal | 1524 (13.2) | 1488 (12.nine) | 8528 (73.ix) | 11540 | 0.000 |
| Overweight | 1071 (18.i) | 837 (14.2) | 4001 (67.7) | 5909 | |
| Obesity | 527 (26.5) | 326 (16.4) | 1137 (57.1) | 1990 | |
| History of stillbirth | |||||
| No | 3121 (15.9) | 2727 (13.nine) | 13743 (70.1) | 19591 | 0.000 |
| Yes | 332 (30.ii) | 137 (12.five) | 630 (57.3) | 1099 | |
| Antenatal visits | |||||
| None | 22 (ix.6) | 28 (12.3) | 178 (78.1) | 228 | 0.000 |
| ane-8 | 860 (fourteen.ane) | 719 (xi.8) | 4520 (74.1) | 609 | |
| >8 | 2530 (17.8) | 2093 (14.vii) | 9610 (67.5) | 14233 | |
| Birth weight | |||||
| ≥2500 | 3033 (16.1) | 2462 (xiii.0) | 13378 (70.9) | 18873 | 0.000 |
| <2500 | 422 (23.0) | 405 (22.i) | 1004 (54.8) | 1831 | |
| Apgar score | |||||
| Poor (0-iii) | 27 (22.7) | 48 (40.3) | 44 (37.0) | 119 | 0.000 |
| Intermediate (4-seven) | 1747 (xix.7) | 1610 (18.i) | 5515 (62.ii) | 8872 | |
| Normal (8-10) | 1573 (xiv.one) | 1132 (10.2) | 8420 (75.7) | 11125 | |
| Fetus presentation | |||||
| Cephalic | 2770 (xiv.3) | 2357 (12.1) | 14302 (73.half dozen) | 19429 | 0.000 |
| Breech | 465 (52.4) | 345 (38.9) | 78 (8.8) | 888 | |
| Other | 209 (55.0) | 164 (43.two) | seven (1.8) | 380 | |
| Gestational age | |||||
| ≤31 | 64 (19.half-dozen) | 81 (24.8) | 181 (55.v) | 326 | 0.000 |
| 32-36 | 345 (27.ix) | 268 (21.half-dozen) | 625 (l.5) | 1238 | |
| ≥ 37 | 3046 (fifteen.9) | 2518 (thirteen.two) | 13576 (seventy.ix) | 19140 | |
| History of C-department | |||||
| Yeah | 2304 (59.half dozen) | 592 (xv.three) | 968 (25.1) | 3864 | 0.000 |
| No | 1149 (6.8) | 2272 (13.five) | 13405 (79.seven) | 16826 | |
| History of stillbirth | |||||
| Yes | 332 (30.two) | 137 (12.five) | 630 (57.3) | 1099 | 0.000 |
| No | 3121 (fifteen.ix) | 2727 (thirteen.9) | 13743 (70.1) | 19591 | |
| History of early on onset of labor | |||||
| Spontaneous | 538 (3.8) | 1465 (ten.iii) | 12164 (85.9) | 14167 | 0.000 |
| Induced | 130 (four.1) | 910 (28.5) | 2155 (67.iv) | 3195 | |
| Planned C-section | 2730 (87.half-dozen) | 382 (12.3) | iii (0.ane) | 3115 | |
Table 2: Mode of delivery of Jordanian women co-ordinate to clinical, anthropometric, and obstetric characteristics, 2011-2012.
Multivariate analysis of factors associated with CS
Multivariate assay (Table 3) showed many factors to be associated with CS. Health sector was significantly associated with the charge per unit of CS. Compared to those who gave birth in individual hospitals, women who gave birth in Ministry of Health hospitals (OR=0.four) and Armed services hospitals (OR=0.6) were less likely to deliver via CS. The rate of CS increased significantly with increased age. The odds of delivering via CS among women aged ≥ 30 years was iii.vii times that odds among women anile <20 years. Income of >350 vs. ≤ 350 JD, <12 years of teaching, increased gestational age at delivery, primiparity, previous CS (OR=23.8), baby's male gender, overweight, obesity, pre-gestational and gestational diabetes, not-cephalic presentation, multiple pregnancy, preeclampsia, anemia, smoking, history of neonatal death/stillbirth, and hospitalization during electric current delivery were all associated with increased odds of CS in the multivariate analysis.
| Variable | OR | 95% confidence interval | P-value | |
|---|---|---|---|---|
| Sector | ||||
| Private | 1 | - | - | - |
| Public | 0.4 | 0.4 | 0.5 | 0.000 |
| Armed forces | 0.6 | 0.6 | 0.vii | 0.000 |
| Teaching | 0.8 | 0.vii | one.0 | 0.057 |
| Age (year) | ||||
| xiv-19 | 1 | - | - | - |
| twenty-24 | one.6 | i.iii | 1.9 | 0.000 |
| 25-29 | two.four | 2.0 | iii.0 | 0.000 |
| = thirty | 3.seven | 3.0 | 4.7 | 0.000 |
| Gestational age | ||||
| <28 | 1 | - | - | - |
| 28-32 | vii.ane | 3.5 | 14.four | 0.000 |
| 32-37 | 7.3 | three.9 | thirteen.5 | 0.000 |
| >37 | 4.vi | 2.five | 8.3 | 0.000 |
| Number of deliveries | ||||
| 1 | ane.8 | 1.5 | 2.1 | 0.000 |
| ii | 1.1 | 1.0 | 1.3 | 0.148 |
| = iii | one | - | - | - |
| Inter-delivery interval | ||||
| First delivery | 7.five | half dozen.iii | viii.8 | 0.000 |
| <2 years | 0.ix | 0.eight | ane.0 | 0.046 |
| >2 years | 1 | - | - | - |
| Diabetes mellitus | ||||
| No Diabetes | 1 | - | - | - |
| Gestational diabetes | three.1 | 2.2 | 4.4 | 0.000 |
| Pre-gestational diabetes | 2.viii | ane.7 | 4.nine | 0.000 |
| Presentation at commitment | ||||
| Cephalic | 1 | - | - | - |
| Breech | 52.0 | 39.seven | 68.ii | 0.000 |
| Other | 342.ii | 138.half-dozen | 844.7 | 0.000 |
| Trunk mass alphabetize | ||||
| Normal | 1 | - | - | - |
| Overweight | 1.four | one.3 | ane.6 | 0.000 |
| Obesity | 1.9 | 1.6 | 2.2 | 0.000 |
| Mother'southward education | ||||
| <12 years | one.2 | 1.0 | 1.4 | 0.016 |
| 12-xiv | 1.1 | 1.0 | one.2 | 0.159 |
| >xiv | one | - | - | - |
| Region | ||||
| Northward | 1 | - | - | - |
| Heart | 0.8 | 0.7 | 0.9 | 0.000 |
| Due south | 0.6 | 0.5 | 0.7 | 0.000 |
| Baby's gender (Male vs. Female) | 1.1 | ane.1 | 1.2 | 0.001 |
| Number of fetuses (Multiple vs. Single) | 3.three | 2.5 | four.ii | 0.000 |
| Preeclampsia | 3.2 | 2.3 | 4.v | 0.000 |
| Anemia | 1.iii | 1.1 | 1.four | 0.000 |
| Income (JD) (>350 vs. ≤350) | i.2 | i.1 | 1.3 | 0.000 |
| Smoking | one.4 | 1.2 | 1.8 | 0.002 |
| History of depression delivery/preterm delivery | 0.8 | 0.7 | 0.nine | 0.003 |
| History of neonatal death/stillbirth | 1.3 | 1.0 | 1.5 | 0.018 |
| Previous cesarean section | 23.8 | 21.3 | 26.5 | 0.000 |
| Hospitalization during current delivery | ane.5 | one.three | i.8 | 0.000 |
Table 3: Multivariate analysis of factors associated with cesarean section. Jordan 2011- 2012.
Reasons for planned and emergency CS
Tabular array 4 shows the various reasons for planned CS co-ordinate to wellness sector. The most frequent reason was scarred uterus (59.iv%). The second about common reason was abnormal presentation like breech or presentations other than cephalic (seven.nine%). Other relatively mutual reasons included multiple pregnancy (6.eight%), medical problems (half dozen.ii%), and mothers' want for CS (5.6%). The distribution of these reasons varied significantly according to sector. Table 5 shows the various reasons for emergency CS co-ordinate to wellness sector. The near frequent reason was prolonged fetal distress (30.0%) followed by obstructed labor (24%), abnormal presentation (15.6%), and eclampsia or sudden astringent high blood pressure level or seizure (eight.i%). The distribution of these reasons varied according to health sector.
| Variables | Total N (%) | Sector | |||
|---|---|---|---|---|---|
| Private Northward (%) | Public N (%) | Military N (%) | Pedagogy North (%) | ||
| Scarred uterus | 2056 (59.5) | 770 (59.6) | 937 (67.2) | 254 (45.0) | 95 (46.six) |
| Abnormal presentation | 274 (7.9) | 81 (6.3) | 87 (6.2) | 94 (sixteen.half-dozen) | 12 (5.9) |
| Multiple fetuses | 234 (6.eight) | 58 (4.5) | 74 (5.iii) | 77 (13.6) | 25 (12.iii) |
| Special medical Condition | 215 (half-dozen.two) | 110 (8.5) | 77 (five.5) | 21 (iii.7) | 7 (3.four) |
| Female parent's desire | 192 (5.half-dozen) | eighty (6.two) | 35 (2.v) | 38 (6.seven) | 39 (xix.1) |
| Placenta previa or Placenta malposition | 76 (ii.two) | 30 (2.3) | 24 (1.7) | fourteen (2.5) | viii (3.9) |
| Big fetus | 69 (2.0) | 26 (2.0) | 20 (1.4) | 22 (3.ix) | 1 (0.5) |
| Precious fetus | 65 (1.9) | 26 (2.0) | 21 (ane.5) | 16 (2.viii) | 2 (1.0) |
| Post date | 46 (1.3) | 16 (1.2) | 27 (ane.9) | 3 (0.5) | 0 (0.0) |
| Quondam primi | 25 (0.seven) | 2 (0.2) | 22 (1.half dozen) | 1 (0.2) | 0 (0.0) |
| Cephalo-pelvic disproportion | 25 (0.7) | x (0.8) | thirteen (0.9) | 0 (0.0) | ii (1.0) |
| Bad obstetric history | 17 (0.five) | 11 (0.9) | 3 (0.2) | 2 (0.4) | i (0.5) |
| Oligohydramnios | 17 (0.v) | 8 (0.6) | 5 (0.4) | 4 (0.7) | 0 (0.0) |
| Infection of vaginal tract | xi (0.iii) | 3 (0.2) | 7 (0.5) | 1 (0.2) | 0 (0.0) |
| Inductive posterior vaginal repair | 11 (0.3) | 5 (0.four) | 3 (0.two) | 1 (0.two) | 2 (1.0) |
| Built anomaly | ten (0.3) | 3 (0.2) | iv (0.3) | ane (0.2) | 2 (ane.0) |
| IUGR | x (0.iii) | 5 (0.four) | 0 (0.0) | 5 (0.9) | 0 (0.0) |
| Others | 103 (3.0) | 48 (3.7) | 36 (2.half dozen) | 11 (1.9) | 8 (3.ix) |
| Total | 3456 (100.0) | 3456 (100) | 1395 (100) | 565 (100.0) | 204 (100.0) |
Table 4: Reported reasons for planned cesarean section in Jordanian women co-ordinate to sector, 2011-2012.
| Variables | Total Northward (%) | Sector | |||
|---|---|---|---|---|---|
| Private N (%) | Public Due north (%) | Military machine N (%) | Teaching N (%) | ||
| Prolonged fetal distress | 862 (30.0) | 246 (27.3) | 230 (20.i) | 335 (49.two) | 51 (36.iv) |
| Obstructed labor | 700 (24.4) | 274 (30.4) | 231 (xx.one) | 149 (21.9) | 46 (32.9) |
| Abnormal presentation | 447 (15.6) | 87 (9.7) | 253 (22.1) | 87 (12.eight) | xx (fourteen.3) |
| Eclampsia or sudden sever high claret pressure or seizure | 231 (8.one) | 52 (5.8) | 142 (12.4) | 33 (4.viii) | 4 (2.9) |
| Heavy persistent vaginal bleeding | 113 (3.ix) | 30 (three.three) | 68 (5.ix) | 15 (2.two) | 0 (0.0) |
| Cephalopelvic disproportion | 76 (2.half-dozen) | 17 (1.nine) | 47 (4.ane) | eleven (1.6) | ane (0.7) |
| Mother exhaustion | 60 (ii.1) | 17 (1.9) | xl (3.5) | 3 (0.iv) | 0 (0.0) |
| Cord prolapse | 44 (1.5) | 10 (1.1) | 14 (i.ii) | 15 (2.two) | 5 (3.six) |
| Premature labor hurting | 35 (ane.2) | 22 (2.iv) | 9 (0.viii) | 4 (0.half dozen) | 0 (0.0) |
| Failed vacuum or forceps delivery | 31 (1.1) | eight (0.9) | nine (0.8) | 10 (one.5) | 4 (2.9) |
| High floating fetal head | 29 (1.0) | 26 (2.ix) | iii (0.3) | 0 (0.0) | 0 (0.0) |
| Abnormal intra uterine fetal eye nonstress test | 15 (0.v) | xi (ane.2) | two (0.2) | ane (0.1) | 1 (0.7) |
| Failed labor induction | 10 (0.iii) | 0 (0.0) | nine (0.8) | 0 (0.0) | one (0.7) |
| Rupture of uterus | four (0.1) | four (0.4) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Other mother reasons | 148 (v.2) | 63 (7.0) | 70 (half dozen.1) | thirteen (1.nine) | two (ane.4) |
| Other fetal reasons | 64 (two.2) | 34 (iii.8) | xx (1.7) | 5 (0.7) | v (3.6) |
| Total | 2869 (100.0) | 901 (100.0) | 1147 (100.) | 681 (100.0) | 140 (100.0) |
Table 5: Reasons for emergency cesarean section in Jordanian women co-ordinate to sector, 2011-2012.
Association betwixt CS and neonatal bloodshed
The neonatal death rate was significantly higher (p=0.000) for planned CS (2.1%) and emergency CS (2.5%) equally compared to vaginal delivery (0.9%). After adjusting for important predictors of neonatal bloodshed including gestational historic period, history of neonatal death/stillbirth, birth weight, and baby'south gender (Table 6), style of delivery was significantly associated with neonatal mortality. The rate of neonatal bloodshed for babies born via CS was 1.3 times higher than for babies born by normal delivery.
| Variable | OR | 95% confidence interval | P-value | |
|---|---|---|---|---|
| Style of commitment (cesarean section vs. vaginal) | 1.3 | 1.0 | 1.7 | 0.041 |
| Gestational age (<37 vs. ≥ 37) | 7.2 | v.1 | 10.2 | 0.000 |
| History of neonatal death/stillbirth (yes vs. no) | 1.viii | 1.2 | 2.7 | 0.004 |
| Birthweight (<2500 vs. ≥ 2500) | eleven.3 | seven.eight | 16.2 | 0.000 |
| Infant's gender (Male vs. Female) | 1.four | 1.1 | ane.eight | 0.011 |
Tabular array 6: Neonatal mortality by way of delivery and other relevant variables using multivariate logistic regression, Jordan 2011-2012.
Discussion
This study demonstrated a markedly high rate of CS of 29.ane% in Jordan. The observed rate of CS in this study was higher than the previously reported rate of 27.7% from the higher population Council maternal morbidity study in Jordan (2007-2008) [16], and the charge per unit of 18.5% from the 2007 Jordan Population and Family Health Survey [17]. The figure becomes more hitting when compared to the previously reported data from seven military machine hospitals across the country revealing a rate of merely 8% for the period 1990-1992 which increased to 10.nine% for the catamenia 1999-2001 [18]. In fact, an increasing trend in cesarean deliveries has been observed almost everywhere during the past few decades. In Egypt, CS charge per unit increased from four.half dozen% to ten% between 1992 and 2000 [nineteen]. Ba'aqeel [20] reported that over the menstruation between 1997 and 2006, CS delivery rate increased from 10.6% to xix.1% in Saudi arabia.
The high rate of CS has well surpassed the recommendations of the WHO health experts who considered the ideal charge per unit for CS to be between 10% and 15% [i]. The trouble is serious in Jordan and most Arab countries which prefer relatively larger families. Limitation of the number of children a woman can give nascence to due to repeated CS may expose her to family problems such as divorce or polygamy. Information technology has been claimed that many reasons may have led to this high rate of CS. One reason is performing unnecessary CSs for preparation purposes past some residents. This is supported by the finding that the highest CS rate was in instruction hospitals (42.5%). Even so, the kind of women delivering in teaching hospitals may differ from women delivering in other hospitals which may explicate such higher CS rates in teaching hospitals. Another reason for the high rate is financial since hospitals accuse more coin for CS than normal vaginal delivery. This is supported by a college charge per unit of CS in the private sector (37.6%) equally compared to the public sector (25.2%). Like findings were also reported from a national study of 57 out of 230 hospitals in Syria, where the CS charge per unit was 12.7% in public hospitals compared to 22.9% in the private sector [21,22].
The study showed that increased age was significantly associated with CS. CS rate was higher among women who were older than 35 years (44.iv%). Peipert and Bracken [23] observed that women whose age is >30 years had a seventy% increase in risk for caesarean commitment compared with women <30. A lot of other studies showed that increased maternal age is associated with an increment in CS rate [24]. There is no satisfactory explanation for this linear association between age and CS charge per unit. However, pelvic rigidity and over care for premium babies in this group might be behind this increase. Moreover, we found a significantly higher CS rate amongst highly educated women. Highly educated women tend to be older than low educated women, because usually they get married and pregnant at an older age. However, controlling for historic period in the present study did not remove the outcome of education.
This study showed that women with preeclampsia had a significantly increased CS rate. Preeclampsia is known to be associated with intrauterine growth brake, fetal distress and prematurity [25]. Because of that a lot of mothers with preeclampsia programme to evangelize via CS. Similar findings were reported from another study [26]. Moreover, our study showed that CS rate was significantly higher in both mothers with gestational diabetes (sixty.2%) or pre-gestational diabetes (69.7%). It has been recently observed that women with diabetes accept "impaired uterine contractility". Obesity in the nowadays study was associated with a higher charge per unit of CS (42.9%). Like findings were reported past others [27,28] and a linear relationship between BMI and cesarean delivery has been reported [29].
One study showed that obese women were 6 times more likely to have CS due to cephalo-pelvic disproportion or failure to progress than non-obese women [30]. In the present written report, 45.iii% of all cesareans were performed on emergency basis and 55.7% were planned. This finding is not consistent with other studies which showed that emergency CS far exceeds planned CS. [31,32]. Consistent with another written report [33], the about mutual reasons for emergency CS in the current study were prolonged fetal distress, obstructed labor, and aberrant presentations such as breech or transverse presentations. The most frequent reason cited for planned CS was scarred uterus, which mostly reflects previous CS. Among the proposed factors contributing to the increase in cesarean is patient desire. Female parent desire in the current study was one of the main reasons for planned CS accounting for 5.vi% of all planned CS. The reason provided past participating women for preference of CS was simply to avoid pain of vaginal delivery. On the other mitt, in a previous study of maternal morbidity in Jordan (2007-2008), female parent desire deemed for less than one% of cesarean deliveries [17].
The increase in cesarean delivery rates overtime has not been associated with improvements in neonatal outcomes [34]. In the present report, the neonatal death rate was significantly college in planned CS and emergency CS, every bit compared to vaginal commitment. The current study and many other international studies support an increment in neonatal expiry in women undergoing CS. A possible caption is that mothers undergoing CS, and newborns that are products of CS, may have serious medical conditions like preeclampsia, diabetes mellitus, scarred uterus, fetal distress, congenital anomalies, heart diseases, etc. In other words, information technology is very difficult to attribute the backlog in neonatal bloodshed to CS as information technology may be resulting from the causes for which CS was performed. The nowadays written report is a national study utilizing a huge sample size (about 15% of all deliveries in a year) representing the different regions and wellness sectors in Jordan. The study assessed comprehensively all women during their admission and followed them prospectively to ascertain the status of their newborns and decide the causes of any deaths inside 28 days afterward birth. The principal limitation of this study is that the reasons for CS were provided by the obstetrician who is probable to provide legitimate reasons for performing CS. Provided reasons may non be the actual reasons; it is unlikely that an obstetrician would formally confess that he performed CS for illegitimate reasons such as training of residents, convenient timing, or financial reasons. Therefore, the reasons stated in this study are those reported by the obstetricians; studying the actual reasons needs a dissimilar design.
Determination
Futurity research is needed to explore the nonclinical causes of CS like attitudes, behaviors, and skills of obstetricians equally well as the social, economic, and legal environment in the country. We need also to sympathize the preferences of women in this regard. As much of the offered causes for cesarean delivery in this study are to an extent subjective and dependent on the judgment of the physician, inquiry may be directed to uncover the true causes for this alarming wellness trouble. To maintain an acceptable caesarean section rate, a multidisciplinary quality assurance programme should be established in all facilities in which delivery occurs. Every bit most CSs are currently based on physician's judgment, it may be extremely useful to develop and strictly implement national guidelines for performing CSs.
Acknowledgements
We would like to thank UNICEF for funding the study and for providing the needed administrative and technical help. John Snow Inc. (JSI) was the contracting torso and worked closely with the local squad to have this project successfully achieved. We warmly acknowledge the Higher Population Council in Jordan for their great role in facilitating and coordinating this written report and providing all necessary back up. We would like besides to thank our field researchers of neonatologists, pediatricians, and nurses for their marvelous try in collecting the data. Finally, we give thanks all participating mothers for their cooperativeness, without which the study couldn't accept come to a successful conclusion.
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