|Year : 2019 | Volume
| Issue : 4 | Page : 307-311
Frequency of cesarean sections in female physicians and medical students in Babylon governorate
Safa Hadi Yassir1, Bushra J Al-Rubaey2
1 Department of Family and Community Medicine, College of Medicine, University of Babylon, Babylon, Iraq
2 Department of Obstetrics and Gynecology, College of Medicine, University of Babylon, Babylon, Iraq
|Date of Submission||09-Sep-2019|
|Date of Acceptance||22-Sep-2019|
|Date of Web Publication||23-Dec-2019|
Dr. Safa Hadi Yassir
Department of Family and Community Medicine, College of Medicine, University of Babylon, Babylon
Source of Support: None, Conflict of Interest: None
Background: Cesarean sections (CSs) defined as delivery of the fetus through abdominal incision. In certain condition, it is a life-saving surgical procedure for both mother and her fetus. Objectives: The aim of this study was to evaluate the frequency and causes of CSs in female Physicians and medical student in Babylon Governorate. Materials and Methods: It was a cross-sectional study conducted in Babylon. The duration of the study was over a period of 5 months, included a convenient sample of 345 female physicians and medical students delivered by CSs who worked at central and peripheral hospital mentioned who agreed to participate in this study, data were collected using a predesigned questionnaire by which female physicians and medical student were interviewed. Results: The mean age of female physicians whom delivered by CSs is (30.32 ± 4.38) years. More of them are para one CS (65.8%), no period of subfertility (92.5%), no history of miscarriage (78.6%), and delivered after 37 weeks of gestation (89.6%). Threatened miscarriage represented (47.3%) fallowed by anemia (14.2%) and preeclampsia (8.8%). The main indication of CSs was patient's wishes which represented (43.2%) of CS, (77.2%) of them had CS without any medical reason only afraid from the pain of normal vaginal delivery, (9.4%) had a history of primary subfertility, (6%) had bad obstetric history, (4.7%) had a history of pregnancy complications such as threatened miscarriage, gestational hypertension, and gestational diabetes mellitus. Conclusions: CSs rate in female physicians and medical student in Babylon Governorate were much higher than the optimal range recommended by the World Health Organization. In spite of their knowledge about the complications of CSs, more of them preferred CSs with no medical reason because of afraid from vaginal delivery pain.
Keywords: Cesarean sections, delivery, fetus
|How to cite this article:|
Yassir SH, Al-Rubaey BJ. Frequency of cesarean sections in female physicians and medical students in Babylon governorate. Med J Babylon 2019;16:307-11
|How to cite this URL:|
Yassir SH, Al-Rubaey BJ. Frequency of cesarean sections in female physicians and medical students in Babylon governorate. Med J Babylon [serial online] 2019 [cited 2020 Jan 28];16:307-11. Available from: http://www.medjbabylon.org/text.asp?2019/16/4/307/273783
| Introduction|| |
Cesarean sections (CSs) is a surgical procedure in which delivery of fetus through the abdominal wall. It is a life-saving surgical procedure when certain complications arise during pregnancy and labor. It is a major operation and associated with immediate maternal and neonatal risks and may have certain complications for further pregnancies.,
CS is often necessary when a vaginal delivery would put the fetus or mother at risk as obstructed labor, multiple pregnancy, complicated pregnancy by sever hypertension or preeclampsia, breech presentation, or problems with the placenta or umbilical cord., A trial of vaginal delivery after one CS may be possible.
The World Health Organization recommended that CS may be performed only when medically necessary. Some C-sections are performed without a medical reason on request of the mother.
The use of CS has increased dramatically worldwide in the last decade, especially in the middle and high-income countries, in spite of the lack of evidence supporting maternal and neonatal benefits with CS rates higher than a certain threshold, and some studies showing a link between increasing CS rates and poorer outcomes., The reasons for this increase are multifactorial and not well understood, changes in maternal characteristics and professional practice styles, increasing malpractice pressure, as well as economic, organizational, social, and cultural factors all have been implicated in this trend.,
CSs without indications, as compared to normal vaginal delivery (NVD) would bring many complications for both mother and fetus. In addition, the results of studies in the UK have shown that the risk of maternal death caused by cesarean delivery is three times more than that of NVD. The newborns health in case of CS studies had shown that the risk of death in newborns by CS is four times as much as newborns born by NVD. The most serious complications for the babies born by CSs are fetal respiratory problems such as transient tachypnea of newborn, respiratory distress syndrome, surgical blade cuts, and increased rates of newborns admission in the neonatal intensive care unit., CS rates are increasing globally. It doubled from 2003 to 2018 to reach 21%, and it is increasing annually by 4%. In the United States, as of 2017, about 32% of deliveries are by C-section., Wound infections occur after CSs at a rate of 3%–15%. The presence of chorioamnionitis and obesity predisposes the woman to develop a surgical site infection.
CSs have been classified in various ways by different perspectives, one way to discuss all classification systems is to group them by their focus either on the urgency of the procedure, characteristics of the mother or as a group based on other, less commonly discussed factors. It is most common to classify CS by the urgency of performing them. By urgency, CSs are classified as being either an elective surgery or an emergency operation. In UK, CSs are classified as a “Grade 4” sections (delivery timed to suit the mother or hospital staff) or as a “Grade 3” sections (no maternal or fetal compromise but early delivery needed) or as a “Grade 2” (delivery required within 90 min of the decision but no immediate threat to the life of the woman or the fetus) and “Grade 1” (delivery required within 30 min of the decision: Immediate threat to the life of the mother or the baby or both).
| Materials and Methods|| |
Study design, setting, and time
It was a cross-sectional study conducted in Babylon Maternity and Pediatrics Teaching Hospital, Al-Hilla General Teaching Hospital, Imam Al-Sadiq General Teaching Hospital, Marjan Teaching Hospital, AL-Mahaweel General Hospital, AL-Zahrah Maternity Hospital, AL-Eskandria General Hospital, AL-Hashymia General Hospital, and the primary health-care centers in Babylon Government. The duration of study was over a period of 5 months started from February 1, 2019, to July 1, 2019.
This study included a convenient sample of 345 female physicians and medical student delivered by CSs in Babylon Governorate who worked at the central and peripheral hospital mentioned above and in the primary health-care centers who agreed to participate in this study.
Any female physicians delivered by CSs in Babylon Governorate as senior, Permanente, junior doctors, and medical students.
Any female physicians and medical student delivered by vaginal delivery, and anyone refused to participate in the study.
Sample size determination
The sample size was estimated according to the following equation:
N = Z 2 P (1 − P)/D 2
Where: N = Sample size; Z = 1.96; P = The proportion = 34.4%, which is the prevalence of CSs in Babylon Governorate.
D = Relative precision = 0.05.
The total sample size required according to the equation is 345 female physicians and medical student delivered by CSs.
Any female physicians in the central and peripheral hospital and in the primary health-care center in Babylon Governorate whom agreed to participate in this study at the time of data collection were asked to give their verbal consent. Each one was interviewed for 10 min (any female physicians refused to participate was excluded, and the next one was interviewed).
Data collection tools
Data were collected using a predesigned questionnaire by which female physicians were interviewed.
Statistical analysis was carried out using SPSS version 21 (SPSS, IBM, USA). Categorical variables were presented as frequencies and percentages. Continuous variables were presented as (means ± standard deviation). Student's t-test was used to compare means between two groups. Pearson's Chi-square and Fisher's exact test were used to find the association between categorical variables. P ≤ 0.05 was considered statistically significant.
The study protocol was reviewed and granted permission by the Ethical Committee of Babylon University, College of Medicine. After explaining the objective of the study to the female physicians and medical student, verbal consent was obtained from them prior to interviewing. Names of the participant were replaced with identification codes to keep data confidential. To carry out the study, official agreement was obtained from Babylon Health Directorate.
| Results|| |
The distribution of patients according to study variables
[Table 1] shows the distribution of patients according to study variables included (age, parity, period of subfertility, number of miscarriage, and gestational age).
The distribution of patients according to study variables
[Table 2] shows the distribution of patients according to study variables included (type of conception, number and duration of ovulation induction, pregnancy complications, history of chronic medical illnesses, and history of the previous scar).
|Table 2: The distribution of patients according to study variables (n=345)|
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The distribution of patients according to the complications of cesarean sections
[Table 3] shows the distribution of patients according to the complications of CS. Wound infections represented the majority (65.9%) of CS complications.
|Table 3: Distribution of patients according to the complications of cesarean section|
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The distribution of patients according to the type of pregnancy complications
[Table 4] shows the distribution of patients according to the type of pregnancy complications. Threatened miscarriage represented the majority (47.3%) of pregnancy complications.
|Table 4: Distribution of patients according to the type of pregnancy complications|
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The distribution of patients according to the indication of cesarian sections
[Table 5] shows the distribution of patients according to the indication of CSs. The patient's wishes represented the majority (43.2%) of CSs.
|Table 5: Distribution of patients according to indication of cesarian sections|
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| Discussion|| |
CSs rate in Iraq was increasing globally, which was greater than the rate in some neighboring countries such as Jordan (18.5%). However, it is considerably lower than the rate in Iran (48%), and Turkey (47.5%). In Iraq, the recent global increase in the CSs rate can be largely attributed to different factors including advances in technologies to detect fetal distress and the attitudes of clinicians and women toward CSs such as the avoidance of labor pain. The CS rates were significantly higher in the governorates that had a larger number of private hospitals compared to those with a smaller number or no private hospitals. CS rates for all hospital births were Erbil (37.6%), Dohouk (26.6%), Al-Sulaimaniya (34.5%), Kurdistan (33.8%), Centre/South (34.9%), and total Iraq (34.7%).
This study is the study in Babylon Governorate was conducted on a sample of 345 female physicians to estimate the frequency and causes of CSs. After the distribution of patients according to the study variables the mean age of female physicians whom delivered by CSs is (30.32 ± 4.38) years. More of them are pervious one CS (65.8%) and no had period of subfertility (92.5%). In compare with study in Erbil mean of age was (28.1 ± 5.4) years, the majority (83.5%) of the mothers were multiparous, and (72%) of them had previous history of CS.
More female physicians no had a history of miscarriage (78.6%) and delivered after 37 weeks of gestation (89.6%). Regarding the type of conception more of them are concepted spontaneously (94.5%), small percentage are conceived by ovulation induction (5.2%) and highly present of them (72.2%) are needed more than 1-month ovulation induction to get their pregnancy. Regarding the pregnancy complications more of them had no complications (57.1%) and (42.9%) had complications. Threatened miscarriage represented (47.3%) followed by anemia (14.2%) and preeclampsia (8.8%).
The main indication of CS in female physicians was patient's wishes which represented the majority (43.2%) of CS, (77.2%) of them had CS without any medical reason only afraid from the pain of NVD, (9.4%) had history of primary subfertility, (6%) had bad obstetric history, (4.7%) had history of pregnancy complications, (2%) had history of secondary subfertility, and (0.7%) had history of assisted reproductions. The previous study in Baghdad hospital showed that CSs were conducted for nonmedical reasons such as the fear of vaginal delivery (45.7%), choosing the right timing for security reasons (31.4%) and performing a tubal ligation (8.6%).
Another indication of CS in this study was premature rupture of membrane (11%), failure of progress of labor and fetal distress (10.7%), preeclampsia (9.6%), meconium (6.4%), postdate and no sign of labor (5.8%), placenta previa (4.9%), cephalopelvic-disproportion (CPD) (3.8%), breech presentation (3.2%), and abruptio placentae (1.4%). In compare with a study done in Duhok city of Kurdistan region, the main indications of CS were repeated CS (50.7%), fetal distress (20.28%), breech presentation (17.95%), unknown cause (17.27%), emergency-risk to mother (13.12%), and exhaustion after long labor maternal distress (10.22%). Another study was done in Erbil the main indications of CS were mother's request which represented the majority (36.63%), CPD (17.32%), abnormal lie and presentation (16.83%), failure of labor to progress (10.89%), and bad obstetrical history with subfertility (10.39%), fetal distress (7.42%), multiple pregnancy (4.95%), previous AP repair (4.45%), preeclampsia/eclampsia (3.96%), placenta previa (2.47%), antepartum hemorrhage (0.99%), and cord prolapse (0.49).
In a Jordanian study, failure of progress of labor and fetal distress were the main indications of CS in the overall and primary indication of CS. Mean differences of age according to the indications of CS (patient wishes and other cause) there were significant differences between means of age according to study group (t = −6.374, P ≤ 0.001). After the distribution of patients according to study variable, more of CS are elective (65.5%) and (34.5%) are emergency, in compare with Erbil study (86.6%) of CS are elective and (13.4%) are emergency. Spacing between each CS in female physicians usually 1–3 years represented the majority (25.5%). All-female physicians had no history of vaginal delivery after cesarean vaginal birth after cesarean delivery represented (96.8%) but only (3.2%) delivered vaginally in spite of the National Institutes of Health, U.S. Department of Health and Human Services, and American College of Obstetrics and Gynecology all released statements in support of increasing Vaginal birth after CS.
| Conclusions|| |
CSs rate in female physicians and medical student in Babylon Governorate were much higher than the optimal range recommended by the World Health Organization. In spite of their knowledge about the complications of CSs more of them preferred CSs with no medical complaint because of afraid from vaginal delivery pain. Iraq witnessed a rapid upward trend in the CSs rate with a potential relationship between the expansion of the private health sector and the increasing CS rate.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: Whose risks? Whose benefits? Am J Perinatol 2012;29:7-18.
Huang X, Lei J, Tan H, Walker M, Zhou J, Wen SW. Cesarean delivery for first pregnancy and neonatal morbidity and mortality in second pregnancy. Eur J Obstet Gynecol Reprod Biol 2011;158:204-8.
Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: A systematic review. Am J Obstet Gynecol 2011;205:262.e1-8.
Lumbiganon P, Laopaiboon M, Gülmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al.
Method of delivery and pregnancy outcomes in Asia: The WHO global survey on maternal and perinatal health 2007-08. Lancet 2010;375:490-9.
Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al.
Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: The 2004-2008 WHO global survey on maternal and perinatal health. BMC Med 2010;8:71.
Zwecker P, Azoulay L, Abenhaim HA. Effect of fear of litigation on obstetric care: A nationwide analysis on obstetric practice. Am J Perinatol 2011;28:277-84.
Mi J, Liu F. Rate of caesarean section is alarming in China. Lancet 2014;383:1463-4.
Saeedi R, Ma'moori G, Ayati S, Rahmani SH, Robat Sangi MG. Neonatal complications in cesarean sections and vaginal delivery. Sabzevar Univ Med Sci J 2009;16:108-13.
Dosa L. Caesarean section delivery, an increasingly popular option. Bull World Health Organ 2001;79:1173.
Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001;138:92-100.
Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: A 7-year retrospective analysis of a national registry. Am J Obstet Gynecol 2010;202:250.e1-8.
Quiroz LH, Chang H, Blomquist JL, Okoh YK, Handa VL. Scheduled cesarean delivery: Maternal and neonatal risks in primiparous women in a community hospital setting. Am J Perinatol 2009;26:271-7.
Saeed KB, Greene RA, Corcoran P, O'Neill SM. Incidence of surgical site infection following caesarean section: A systematic review and meta-analysis protocol. BMJ Open 2017;7:e013037.
The Lancet. Stemming the global caesarean section epidemic. Lancet 2018;392:1279.
Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, et al.
Classifications for cesarean section: A systematic review. PLoS One 2011;6:e14566.
Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M, et al.
Urgency of caesarean section: A new classification. J R Soc Med 2000;93:346-50.
Hassain GS. Cesarean Section in Babylon Province, College of Medicine, Babylon University, Iraq. Int Res J Med Med Sci 2015;3:113-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]